Speech Therapy: An Overview One of the not so noticed areas of rehabilitation medicine is Speech Therapy. In fact, a lot of people may not even know that something like this existed. It may be the case that this is your first time to encounter the field or you may have heard it somewhere, but don't fully understand what the practice is all about. The sad truth about Speech Therapy is that you may not encounter it unless the situation calls for it. However, getting to know what the practice is can be very beneficial information. What Is Speech Therapy? As the name suggests, speech therapy deals with speech problems that an individual may encounter. However, the field of Speech Pathology doesn't only tackle speech, but also language and other communication problems that people may already have due to birth, or people acquired due to accidents or other misfortunes. Speech therapy is basically a treatment that people of all ages can undergo through, to fix their speech. Although speech therapy alone would focus on fixing speech related problems like treating one's vocal pitch, volume, tone, rhythm and articulation. Goals Of Speech Therapy Speech Therapy aims for an individual to develop or get back effective communication skills at its optimal level. Recovery mainly depends on the case and severity of your problem, especially if your speech problem is acquired, meaning you had normal speech skills before then you had an accident or abrupt incident that caused your current speech problem; thus, you may or may not get back your old level of speech function. Speech Problems Speech problems are mainly categorized into three namely: Articulation Disorders, Resonance or Voice Disorders and Fluency Disorders. Each disorder deals with a different pathology and uses different techniques for therapy. Articulation Disorders Articulation Disorders are basically problems with physical features used for articulation. These features include lips, tongue, teeth, hard and soft palate, jaws and inner cheeks. If you have an Articulation Disorder, then you may have a problem producing words or syllables correctly to the point that people you communicate to can't understand what you are saying. Resonance or Voice Disorders Resonance, more popularly known as, Voice Disorders mainly deal with problems regarding phonation or the production of the raw sound itself. Most probably, you have a Voice Disorder when the sound that your larynx or voice box produces comes out to be muffled, nasal, intermittent, weak, too loud or any other characteristic not pertaining to normal. Fluency Disorders Fluency Disorders are speech problems with regard to the fluency of your speech. There are some cases that you talk too fast, in which people can't understand you, thus, you have a Fluency Disorder of Cluttering. The most common Fluency Disorder however, is Stuttering, which is a disorder of fluency where your speech is constantly interrupted by blocks, fillers, stoppages, repetitions or sound prolongations. Who Gives Speech Therapy? A highly trained professional, called a SLP or a Speech and Language Pathologist, gives Speech Therapy. Speech and Language Pathologists are informally more popularly known as Speech Therapists. They are professionals who have education and training with human communication development and disorders. Speech and Language pathologists assess, diagnose and treat people with speech, communication and language disorders. However, they are not doctors, but are considered to be specialists on the field of medical rehabilitation. Therapy Procedures for Speech Disorders 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. 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. Teaching Hearing Impaired Children at the Nonverbal Level 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. Toys As Materials For 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. The Role of Speech Therapy In Traumatic Brain Injury 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 Voice Training For The Laryngectomee 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. Speech Therapy Of Hearing Impaired Children at the Verbal Level 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. Speech Therapy Management For Fluency Disorders 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 1/2- 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. Speech Therapy for the Hearing Impaired Hearing is conversely associated with speech in that initial communication and hence understanding, arises primarily from learning spoken language through listening and building up symbolic thinking processes. This is why speech therapy is a must for people with hearing impairment. Developing Auditory Awareness Auditory awareness is the ability to be conscious of the fact that sound is present. During this period, the child is to learn to wear appropriate amplification. Therapy involves playing with toys that make sounds and listening to music. Developing Auditory Attention or Listening Auditory attention is the ability to give some real notice or interest to the sound that is heard. The clinician focuses the child's attention to the sound by saying two or three times: "Listen, I hear something. What is that?" The clinician pats his ears, but does not show the source of the sound until the child is listening. The clinician rewards the child's attention by showing the source of the sound. Developing Auditory Localization and Distance Hearing Auditory localization is the ability to recognize the direction from which the sound is coming from. Distance hearing, on the other hand, is the ability to hear the sound even from afar. The therapist shows the child how to respond whenever he hears a sound. Some of the activities are opening the door when someone knocks, dancing to music, clapping to music, building blocks when a sound is heard, marching to a drum and picking the phone up when it rings. Developing Vocal Play Vocal play is the ability to use the speech structures to produce various sounds that are not necessarily meaningful but are sound productions nonetheless. This stage requires making lots of sounds when playing with toys, especially animal and vehicle noises: growl for the teddy bear, meow for the cat, or click tongue for the horse. Developing Auditory Discrimination Auditory discrimination is the ability to identify one sound from another. Activities include reviewing vowel sounds and varying pitch, loudness and rhythm: oo--- vs. oo-oo. For example, the therapist can build a train with blocks and say oo-oo or oo---, as the train is being pushed on the table. For older infants, they can look at books, making similar sounds for the pictures. Developing Auditory Discrimination and Short-Term Memory Activities include teaching discrimination of noise makers in audition and incorporation of phonemes into words in use. Developing Auditory Processing Auditory processing is the ability to associate sounds with memories of past events. Activities include naming of abstract ideas like sadness and joy. The therapist also starts to teach the child to call the names of the people that he has constant contact with. Developing Auditory Processing of Patterns and Auditory Memory Span Activities for the child's audition include testing the child's recognition of words and testing of auditory memory span. Auditory memory span is the ability of the child to remember in sequence the things that he has heard. An example would be the sequence of the instructions that the therapist gave to him. Developing Auditory Figure-Ground Discrimination Auditory figure-ground discrimination is the ability to choose among the sounds that are present in the environment and to focus on that one sound alone without being distracted by the rest of the surrounding sounds. Activities for the child's auditory skills include clapping or dancing to different rhythms, learning to count from one to ten, saying the alphabets, days of the week, nursery rhymes, holiday songs, prayers, his own address or telephone number, and also remembering two or three directions at a time. Auditory Tracking Auditory tracking is the act of listening closely to a material to be able to follow what is being stated in the said material. Auditory tracking using a tape recorder is included in the activities. Also included are reading aloud, practicing using the telephone, listening for information and using internal repetition. Speech Therapy For Intermediate Stuttering There are different techniques used for the treatment of intermediate Stuttering. Such techniques are a mix of fluency shaping and stuttering modification techniques. Here are some of the commonly used techniques for treating intermediate stuttering. Flexible Rate Flexible rate is slowing down the production of a word, especially the first syllable. This technique is thought to allow more time for language planning and motor execution. In here, only those syllables on which stuttering is expected are slowed, not the surrounding speech. Flexible rate is taught by having the clinician model production of words in which the first syllable and the transition to the second syllable are said in a way that slows all of the sounds equally. Vowels, fricatives, nasals, sibilants, and glides are lengthened, and plosives and affricates are produced to sound more like fricatives, without stopping the sound or airflow. After the clinician's model, the child produces the word with flexible rate, and successive approximations of the target are reinforced. Easy Onsets Easy onsets refer to an easy or gentle onset of voicing. Teaching easy onsets is like teaching flexible rate. The clinician models the target behavior by the use of a lot of different sounds and then he makes the child imitate the models. After the child tries to imitate, the therapist should reinforce the child's successive approximations. Some children, particular younger ones, may be helped to get the concept by performing an action, such as bringing their hands together slowly, as they produce an easy onset. Light Contacts Producing consonants with light contacts prevents the stoppage of airlow and/ or voicing that can trigger stuttering. Light contacts are taught by modeling a style of producing consonants with relaxed articulators and continuous flow of air or voice, depending on the consonant. Plosives and affricates should be slightly distorted so that they sound like fricatives but are still intelligible. Modeling a variety of words with initial consonants and reinforcing the child's successive approximations of the target accomplish teaching a child to use light contacts. The clinician can use a variety of games to make the concept of light contact more interesting. Proprioception Proprioception refers to sensory feedback from mechanoreceptors in muscles of the lips, jaw, and tongue. The effectiveness of teaching proprioception may be that it promotes conscious attention to sensory information from the articulators, perhaps bypassing inefficient automatic sensory monitoring systems and thereby normalizing sensory-motor control. Children can be taught to use proprioception by having a child first hold a raisin in his mouth and report on its taste, shape, size, and other attributes. Children can also learn proprioception by picking a word from a list and then closing their eyes and silently moving their articulators for this word and being rewarded when the clinician guesses the word. Children can be coached to feel the movements of their lips, tongue, and jaw as they say a word. Proprioceptive awareness can also be enhanced by using masking noise or delayed auditory feedback to interfere with self-hearing. In this, the clinician must look for slightly exaggerated, slow movements to verify that a child is trying to feel the movement of his articulators. Scaffolding It is useful with some children to "scaffold" their use of superfluency by letting the listener/s know that we are working on our speech and sometimes by coaching the child in that fluency-friendly environment. This can be exhibited for example telling a stranger in a mall that the child and the clinician are working on their speech and would like to ask him some questions, another example would be when the child makes telephone calls. Speech Therapy Fluency Shaping: A Different Approach There is a lot of fluency shaping techniques used in speech therapy for fluency disorders. However, due to the advancements of technology, a new kind of fluency shaping approach is now available. This is possible by the use of biofeedback mechanisms. Fluency Shaping At A Glance In fluency shaping therapy, motor skills are acquired. But in order to have a successful therapy the client needs to have feedback. Since it involves physically learned behavior, the client should know if what he is doing is right or wrong. For example, a therapist asks his patient to use diaphragmatic breathing. The client and the speech therapist knows if the client is doing it right or wrong because they could observe it by putting a hand in the patient's stomach. On the other hand if the therapist asks the client to execute air with vocal tension, and he does so, and then therapist asks the client to do it faster; it would be hard to observe and see the difference between the two actions. That's why biofeedback devices were invented. Biofeedback Mechanisms A biofeedback mechanism is an instrument that shows the user's physiological activity's display and measurement. It is very helpful to increase the awareness of the client. The client has an increased control of the activity too. It provides real time feedback that is more reliable and precise than human observation. It is able to measure what can't be seen or heard by human senses. It is also helpful with to that SLP so that he can concentrate on the other behaviors of the client. If the client is a visual learner, it would benefit him very much and it may speed up his way to successful fluency therapy. There are devices that can be used not only in the clinic but at home too, so the client can practice even at home. Some examples of this kind of devices are CAFET or the Computer-Aided Fluency Establishment And Trainer, Dr. Fluency, EMG (Electromyograph) and Vocal Frequency Biofeedback. The Dr. Fluency and CAFET are computer based biofeedback systems. They make use of a microphone to monitor the user's vocal fold activity. A chest strap is also used to monitor breathing. The change in vocal fold activity and breathing is displayed on the computer display. Instructions and error messages are also seen. The device trains a lot of fluency skill behaviors such as: continuous breathing, relaxed diaphragmatic breathing, pre-voice and gradual exhalation, gentle onset, continuous phonation, adequate support of breath, and phrasing. In a study of CAFET, 197 teenagers and adults used the program reported that just after six months of finishing the program, eighty-two percent met the fluency criteria. After twelve months, eighty-nine percent were fluent. Lastly, in two years of post-therapy, ninety-two percent were fluent. EMG and Vocal Frequency Biofeedback is a device using an EMG working with a DAF (Delayed Auditory Feedback) mechanism. The EMG monitors muscle activity and if it detects something wrong a red light would turn on and the DAF would automatically play. The use of biofeedback mechanisms can be considered to a breakthrough in the realm of speech therapy and fluency disorders. However, not every one can have access through it, since getting such devices can be very expensive. Nonetheless, other fluency shaping approaches are still viable and have been proven effective already from years of practice. Speech Therapy Diagnosis: Autism Before a child could undergo speech therapy with the diagnosis of Autism, he should pass a criteria of characteristics first that is given by the DSM-IV. So here are the criteria for a child to be diagnosed with such conditions. Autistic Disorder Criteria: Social Interaction First off, a child should have impairment in social interaction. This could be manifested by at least two of the following behaviors. First is a marked impairment with the use of different non-verbal behaviors like facial expression, eye-to-eye gaze, and body posture. Second is the child's failure to develop peer relationship that is appropriate for his developmental level. In this case the child may seem to have difficulty gaining friends, or even just relating to other children within his age. The child may also have the lack of spontaneity to share his emotions and thoughts. He may not share enjoyment, achievements, or interests to other people. In this case, the child doesn't usually bring or point to objects that interest him. The lack of emotional reciprocity is also possible. No matter how hard you try to connect or show your emotions and feelings to the child, he wouldn't care less. Autistic Disorder Criteria: Communication The child also has communication impairment. Having at least one of the following conditions manifests this. First is having a delay, or even total lack of spoken language development or expressive language. In this case, the child doesn't even try to use of compensatory strategies to communicate or other means of communication like gestures. For children that have adequate speech, the communication impairment is manifested by not being able to initiate or sustain a conversation with other people. The child can also have stereotyped and repetitive use of language. This phenomenon is actually called idiosyncratic language, where what the child keeps on saying seems to me meaningless. He may keep on saying the word "blue" for countless of times, even for the whole duration of the day. He can also lack the ability to have varied, spontaneous make-believe play or social imitative play that is appropriate for his developmental level. Play is one of the notable things that differentiate a child with Autism with normal children. For an Autistic child, play does not exist. The main concern is that play is an important factor for language development since it is a prerequisite or co-requisite of inner language. Autistic Disorder Criteria: Repetitive And Stereotype Behavior Patterns An Autistic child also manifests repetitive behavior. This criteria is judged by having at least one of the following conditions. The child may have an encompassing preoccupation with one or more restricted and stereotyped patterns of interests that may seem abnormal in respect to focus and intensity. For example the child can sit and look at the ceiling fan for the whole day, and doesn't care what is happening in his environment, all that matters is the fan. The child also has fetish with routines and rituals. If he passes by a certain way to school, it has to be the same way. If you use the main stairs going to his classroom, then taking a different route like the elevator would definitely agitate him, make him angry and have tantrums. The child may also have repetitive behaviors or mannerisms. Hand flapping, finger twisting, and complex body movements are examples of these. Lastly, he can also be preoccupied with object parts like buttons, screws and other small details. Speech Therapy Assessment Tips For Fluency Disorders During the assessment of an individual with suspected fluency disorder, there are some things to remember to make the assessment more comprehensive and useful. Here are some of those critical points to take note of during assessment. Benefits Of Obtaining Both Reading and Conversation Sample It is more beneficial to obtain both reading and conversation sample from school children and adults because this would give more reliability and credibility to the samples taken. Since stuttering varies in different situations, a reading and conversation sample would allow the clinician to see the behaviors of the person in two different tasks. A conversational speech sample is likely to have more variability, while a reading passage would likely have less variability. Information To Assess Motivation Through interview, a therapist can learn a lot from his client. In fact, insight about the client's motivation could be seen by asking the following questions like "What do you believe caused you to stutter?", "Has you stuttering changed or caused you more problems recently?, "Why did you come in for help at the present time?", " Are there times or situations when you stutter more? Less? What are they?". Benefits Of Continuing Evaluation No individual could be understood in an hour or two; that's why continuing of evaluation is recommended. The clinician might overlook an important element at times and some times a vital clue will not be present in the samples of behavior taken from the limited time of the evaluation period. Note The Difference When Assessing Feelings and Attitudes Assessing a school-age child's feelings and attitudes would require the clinician to establish rapport and to get to know the child much better after some time, because the clinician's judgment is also a fair measurement in the case of school-age children. Talking to the child and observing his behaviors would be necessary. When the clinician has known the child much better, he could administer the A-19 Scale to the child. Other methods could also be used such as "Worry Ladder" and "Hands Down" that could be found in the workbook, The School-Age Child Who Stutters: Working Effectively with Attitudes and Emotions. For adults and adolescents assessment of feelings and attitudes are usually done by administering tools such as, the Modified Erickson Scale of Communication Attitudes, the Stutterer's Self-Rating of Reactions to Speech Situations, the Perceptions of Stuttering Inventory and the Locus of Control of Behavior Scale. Remember The Role Of The IEP Team An Individualized Education Program (IEP) team is appointed to a child to be the ones to consider reports by the clinician and other information. They decide if the child meets the state's eligibility standards and if the child's stuttering has a negative effect on his education. If a child is eligible for services measurable, the IEP team sets goals and short-term objectives for the child. They also provide services needed by the child for improvement in the educational setting. Goals Of Trial Therapy Trial therapy for a school-age child is done to understand what approach might work and what might be difficult for him. This could increase the child's motivation and positive outlook for the treatment. In the case of adults and adolescents, trial therapy is done for 3 main reasons. First, is to get an idea of how a client would respond to different therapy approaches. Second, is to make a differential diagnosis between developmental, neurological or psychological stuttering. Third, it gives a preview to the client of what to expect during therapy sessions, in effect it would give them motivation to go on their treatment. Speech Therapy Activities For Aphasia To begin with, the primary cause of aphasia should be stabilized or treated. After doing so, that's the only time that a therapist can work on the rehabilitation of the patient. To recover a person's language function, he or she should begin undergoing therapy as soon as possible subsequent the injury.
Speech Therapy: As A Treatment For Aphasia Since there are no surgical or medical procedures that are currently available to treat Aphasia, conditions that result from head injury or stroke can be improved through the treatment of speech therapy. For majority of Aphasic patients though, the main emphasis is placed upon optimizing the use of the person's retained language skills and being able to learn to use other ways of communication to be able to compensate for their permanently lost language abilities. Therapy Activities The formulation of what activities to use during a speech therapy session is critically done and would highly depend on the therapists' assessment and diagnosis results on the individual. However, there are some general activities that are done to treat Aphasia. Exercise Since most types of Aphasia would include right-sided weakness of the body and sensory loss, it is important for the patient to be able to exercise their body. Regular exercise and practice is needed to strengthen the weak muscles and prevent it from further degeneration. The exercise activities do not have to be exhilarating. For the purpose of speech function, the therapist can exercise the patient's weakened muscles through repetitive speaking of certain words, and projecting facial expressions, like smiling and frowning. The use of food too is helpful, since the patient is able to exercise articulators needed for speech production like the tongue and jaw, which may be weakened due to the condition. Picture Cards One of the tools used for therapy are picture cards. Pictures of daily living and everyday objects can be used to improve and develop word recall skills. Picture cards can act as a visual cue to increase the learning process of an Aphasic. These can also help increase the vocabulary of the patient. By showing the picture cards and repetitively saying aloud the names of the objects in the picture, the patient will be able to exercise weak muscles and practice vocalization. Picture Boards Another tool for therapy are picture boards. Since aphasia can bring about difficulty in recalling names of activities, objects and people, use of material to help recall these names is very helpful. By making use of a board where the therapist places pictures of different everyday activities and objects, the patient can point to specific pictures to express ideas and communicate with other people. Workbooks The use of workbooks is also important in the treatment of Aphasia. Since reading and writing skills are affected, this is one way to exercise them. Workbook exercises can be used to sharpen an Aphasic's word recalling skills and recover reading and writing abilities. By reading aloud, hearing comprehension can also be exercised and redeveloped through workbook exercises. Computers With the development of technology, there are now computer programs that are used to treat Aphasia. Such computer programs can be used to improve an Aphasic's reading, speech, recall, and hearing comprehension. In fact, the use of computers can bring about optimal results, since it can stimulate senses of vision, and hearing at the same time, helping speed up the learning process. Speech Therapy: PROLAM-GM Approach PROLAM-GM is an acronym for the various intervention and transfer strategies used in the management of stuttering. PROLAM, which stands for physiological adjustments, rate manipulation, operant controls, length and complexity of utterance, attitude changes, and monitoring, are the intervention strategies. GM, which stands for generalization and maintenance, are the transfer strategies. Physiological Adjustments Physiological adjustment strategies include tactics that manipulate bodily components known or thought to be involved in the production of stuttered speech. An example of this would be the attempt to use gentle contact between the articulators when talking. The rationale behind this approach is that the physiological components necessary for the production of normal fluent speech are in some way used inappropriately when stuttering occurs. Therefore, the therapy tactics used will result in a "readjustment" of the disordered component, or in use of compensatory behaviors and strategies. Rate of Speech Manipulations Use of a reduced speech rate to modify stuttering operates in the belief that: (a) reduction of rate results in simplification of the physiological speech processes, thus allowing easier synchronization or; (b) reduction in the rate of speech prevents the stutterer from anticipating feared stimuli that result in the production of the stuttering response. The rate of the stutterer's speech may be reduced by: prolongation, combining prolongation with continuous phonation, and using an instructional rate control method. Operant Controls Use of operant controls in the management of stuttering believes that if stuttering is an operant behavior (behaviors whose frequency or probability of occurrence are influenced by the consequences they generate), then its frequency will increase if it is reinforced, and its frequency of occurrence will decrease if it is punished. Two of the most frequently used operant procedures for treating stuttering are positive reinforcement of fluency and punishment of stuttering. Length and Complexity of Utterance Controlling the length and complexity of the stutterer's utterance reduces stuttering and increases fluency. This technique is often used to increase fluent speech. Most of the approaches utilizing this technique combine manipulation of length and complexity of the client's language with operant controls (punishment of stuttering and reinforcement of fluency). Attitude There are two components of stuttering namely: the feelings accompanying it and the speaking behaviors that are resulted from it. It is believed by some that to have a successful therapy, a balance of treating both factors should be done. That's why attitude manipulation is done in some approaches while in other approaches it can be optional depending on the case of the client. Monitoring In the science of Speech Pathology, especially in the field of stuttering, there are a lot of meanings for the term 'monitoring'. Some say it's a process in which the PWS becomes aware of what he is doing at the time he is doing it. Some say it is a specific form of consciousness where the act of speaking is raised from an automatic level to a purposeful level. Basically, it has three key components: self-awareness, deliberate control and self-feedback. Generalization The technical term for generalization is "the occurrence of a relevant behavior under different nontraining conditions." The term generalization is usually interchanged with 'transfer' or 'carryover'. Maintenance Sometimes, when clients are able to achieve fluency, they think the fight is over. They forget to maintain their skills and in result they have a relapse with their stuttering. Maintenance refers to different after-treatment activities to help clients keep the skills they learned from therapy intact. Some activities to help maintain skills are daily self-monitoring activities, regular clinic contacts, refresher programs and having self-help groups. Speech Therapy: An Overview On Fluency Disorders One of the main categories of speech problems in need for speech therapy are fluency disorders. However, there are different types of fluency disorders, even though they may all seem the same. Each type has its own cause, and defining characteristics that make them stand out from one another. There are basically six main types of fluency disorders, while some are considered to be other conditions that are related to fluency disorders. Normal Developmental Disfluency Normal developmental disfluency, is a fluency disorder that is a lot of times mistaken to be stuttering. This condition occurs with children from ages 1:6- 6 years old, although the peak of the condition is considered to be 2-4 years of age. A lot of parents may be concerned of the way their child speaks, but in reality, this is a normal condition that every child goes through. Normal developmental disfluency is a normal part of a child's development. So there is really no need to worry at all. A child would normally get over this stage as his speech skills develop. However, a proper environment, and interaction is needed for that to happen. If a child is pressured by his parents or people around him about his speech, the higher the probability that his disfluency would become a problem in the future and could develop to stuttering. Stuttering Stuttering is a disorder of childhood (developmental) that is characterized by an abnormally high frequency or duration of stoppages in the forward flow of speech. Although normal developmental disfluency has its own share of stoppages, stuttering on the other hand has some extra characteristics that normal developmental disfluency doesn't have. What makes stuttering different, from normal developmental disfluency, is that stuttering has escape behaviors, avoidance behaviors, and other secondary behaviors. These so called behaviors are also called physical concomitants. Some examples are eye blinks, head nods, jaw tremors and total body gyrations. Neurogenic Disfluency This kind of disfluency is a result of an identifiable neuropathology in a person that has no history of fluency problems prior to occurrence of the pathology. People who have accidents that caused brain problems, which induced their disfluency, fall into this category. Neurogenic disfluency has similar characteristics as stuttering, including the physical behaviors like eye blinks and tremors. The thing is that, the main problem in conditions like these is not fluency at all, but the lesser control of muscles needed in speech production. Psychogenic Disfluency A disfluency with no found evidence of neurological dysfunction and no history of developmental stuttering. It is of sudden onset and attributed to an identifiable emotional crisis. Can be grouped into three categories namely: emotionally based, manipulative, and malingering disfluencies An example of this kind of disfluency is when a person starts to stutter when a specific other is around. For instance, a student who is afraid of her teacher, starts to stutter every time her teacher is around but speaks fluently when around her friends and family. Language Bases Disfluency This is a disfluency that is attributed to the development of linguistic sophistication. The main root of the problem here would be language problems, which would require language based therapy rather than fluency-based therapy. Mixed Fluency Failures These are fluency failures that are characterized by overlapping causative factors. Speech pattern observed is the result of a blend of two or more factors/disfluency. Cluttering This is a condition that is related to fluency disorders. It is considered to be the extreme of stuttering. It is a disorder of timing and rhythm of speech where the person speaks too fast that his speech can't be comprehended. The thing is, a clutterer isn't aware that he is cluttering, while a stutterer is very much aware that he stutters. Speech And Language Problems Presented By Crouzon Syndrome Crouzon Syndrome is a condition that would require speech therapy. This is mainly because of the major features of the syndrome, which affect main physical components used for speech production, such as articulators. Crouzon Syndrome It is a result of premature closure of some cranial sutures and is also known as branchial arch syndrome as it specifically affects the first branchial arch where the maxilla and the mandible are developed. It is transmitted from generation to generation in an autosomal dominant manner. How Often Does Crouzon Syndrome Occur? As of year 2000, the demographics of Crouzon syndrome is that approximately one per twenty-five thousand live births have this condition. Crouzon syndrome also equally affects all kinds of ethnic groups. Language Characteristics of Individuals with Crouzon Syndrome The individual's mental capacity dictates his/her ability to comprehend language. Unlike what some people think, not all individuals with Crouzon Syndrome have cognitive deficits. Usually, their mental capacity is in the normal range, which tells us that they are capable of acquiring language and using it as a means for communication. These individuals have language skillswhich are at par with the skills of others of the same age. However, some still manifest significant mental developmental delay secondary to excessive intracranial pressure. In other cases, the presence of hearing problems contributes to the language acquisition difficulty. Still in other cases, inappropriate breathing patterns make speaking difficult which in turn makes communication a tiring and an unpleasant experience. Articulation Problems In some cases, an individual with Crouzon Syndrome may exhibit oral distortions of fricatives and affricatives especially sibilants and inconsistent distortions in productions of /r/ and /l/. Most of these errors are attributed to abnormal tongue placement as caused by the defective maxillomandibular relationship. However, some individuals may display speech problems that are in no way related to their oral structures. Other speech manifestations are also characterized by denasalization of /m/, /n/. Problems in articulating bilabials and round vowels may also be present due to reduced skills in lip closure and lip rounding. Voice Problems Hypernasal speech is a common characteristic of individuals with Crouzon Syndrome. This is usually due to velopharyngeal insufficiency. Hyponasal speech may also present itself albeit less common. It is often due to nasal obstruction, which is surgically correctable. These unusual resonance and speech patterns may either be a result of a small nose, high arched palate or the mandibular malocclusion. In terms of vocal quality, hoarseness may be present due to the development of vocal cord nodules in compensatory laryngeal activity. Psychosocial-Emotional Problems One psychosocial problem that individuals with Crouzon Syndrome face is the attractiveness vs. unattractiveness issue. Because of the prominent cranio-facial deformity these individual are often victims of bullying, teasing and social isolation. The visual and hearing impairments often hinder the comfortable flow of communicative exchanges. They feel restricted and limited in their socializations, with a marked difficulty in socializing with the opposite sex. Some may even be treated as if they were less capable than their peers. Most individuals with Crouzon Syndrome feel angry at society for demanding physical attractiveness. Although some of these issues may be generic, the people's response varies. Some may become painfully shy and lose confidence. And yet others may develop a rather strong character and work on proving to their community that they have worth and are just as good as everybody else. Roles Of Speech Therapist In Laryngectomy Management There are three phases of management for laryngectomy: pre-operative, operative, and post-operative management. Each phase has its advantage and goals. A speech therapist plays vital roles in the first and last phase. Consulting a speech therapist during the first phase is equally important with seeing a therapist during the last phase, which is when voice rehabilitation really begins. A speech therapist also has different roles in each phase, that's why it is vital for a therapist to know the two phases he plays a role in. Pre-operative Management Pre-operative management includes informing the patient of the anatomical changes, and expectations regarding swallowing, voice, and the family as a part of the team. The therapist also informs the patient on the different speech options he has after the operation. During this phase, the speech therapist should initiate ordering of the hardware or alternative means of communication. The therapist should also be open to questions that the patient may come up with. This is also the time for him to establish rapport with the patient. The therapist can also offer re-assuring consultation with appropriate laryngectomee volunteers. This is also the time where he assesses the pre-laryngectomy speech and cognition of the patient. The laryngectomee is also informed with his prognosis, where the potential for recovery and long-term rehabilitation is discussed. The advantages of this phase would be the evaluation of preoperative speaking skills such as speaking rate, articulation errors, accent patterns, oral opening degree when speaking, and vocal parameters. Cognition and hearing is also evaluated, along with oral-peripheral-mouth strength and sensation. The family can also get emotional support in this phase. Assessment is done by the use of modified barium swallowing or Fiberoptic Endoscopic Evaluation of Swallowing. The patient's communication needs are also assessed where living situation, occupation, social requirements and hobbies are looked at. Postoperative Management During this phase, the therapist is given an opportunity to help lessen the patient's fears, and depression. He should also help the patient to accept the loss of voice and swallowing difficulties. The motivation of the patient should be increased, so that he can easily learn how to use alternative speech. Social implications are also addressed. Arrangements for voice rehabilitation are also done during the early parts of this phase. Firs off, the therapist should confirm if the patient is already medically cleared for therapy. Then he should review the treatment procedure, re-evaluate the patient's swallowing function then give diet recommendations, and create a treatment plan. Problems Encountered During Postoperative Management After the operation some problems may still occur. With regards to Tracheostomy, the patient and therapist should always be watchful of stoma hygiene, cannula hygiene, stoma covers, excessive mucus in the trachea, mucus encrustations in the stoma, and stoma safety and first aid. There could also be problems related to taste, swallowing, smell and digestion. The patient may find it difficult to trap air within the lungs. This can lead to difficulties in creating internal subglottic pressure, elimination of body waste and childbirth. Problems of social adjustment may also be present. The patient may find it hard or embarrassing to use alaryngeal speech in public. The altered physical appearance of the patient may also be an issue. Sometimes, the laryngectomee also has unrealistic expectations regarding acquisition of alaryngeal speech. Play Levels Of Social Interaction In Speech And Language Therapy There are different levels of play used in the assessment of children's speech and language. These levels are used to measure children's play skills. However, there are also play levels of social interaction that can give a general overview of the child's play skills. In general, there are six play levels of social interaction that children go through respectively. Each level becomes more complex than the previous one, and requires more communication and language skills than the other. Unoccupied Play The first level of play is unoccupied play. In this kind of play, the child may seem like he is simply sitting quietly in one corner but actually is finding simple things that he sees around him to be rather amusing. A typical adult may not notice that what the child is doing is already considered to be play, unless they observe meticulously. The child may just be standing and fidgeting at times, but this could already be unoccupied play at work. Onlooker Play The second level is onlooker play. In this level, the child watches other children play but doesn't engage in play himself. This is when children learn to observe others. Such play level can show a child's attention and awareness skills. Solitary Play The third level is solitary play where the child plays by himself and doesn't intend to play with anyone else. This level shows an outright manifestation that the child do have play skills, only that it is still at a level that no interaction is required. A child can be at this level when he is already able to play functionally with an object, can play by himself up to fifteen minutes, and is able to follow simple play routines. Parallel Play The fourth one is parallel play. This level characterizes children who play side by side but don't communicate with each other. Neither do they share toys. It is said to serve as a transition from solitary play to group play and is at its peak around the age of four years. A child is said to be in this stage when he is able to play alone, but the activity he is doing is similar with the play activity that other children beside him are engaging in. The child also doesn't try to modify or influence the play of other children around him. Here, the child is playing 'beside' rather than 'with' the other kids in the area. Associative Play Next is the associative play. This is where the children still don't play with each other but are already sharing the toys that they are playing with. This level shows the child's awareness of other children, although there is no direct communication between them, other than the sharing of toys and the occasional asking of questions. Their play session doesn't involve role taking and has no organizational structure yet. The child still carries on the way he wants to play, regardless of what the other children around him are doing. Cooperative Play The last level is cooperative play. This is the final stage wherein the children are already playing together, sharing toys and communicating with each other. This level usually happens at about the age of five or six, where children engage into group games and other highly structured play activities. These levels can be utilized by the therapist as a guide when it comes to the interactions that he wishes to have with the child through play activities. Importance Of Play In Speech Therapy Play has a very important role in speech therapy. It is actually one way that speech therapy can be conveyed, especially if the one undergoing therapy is a child. What's Play Got To Do With It? Play isn't just used during the therapy proper. In fact, play is already used during the initial phases of assessment. Kids can be very choosy with people that they interact with, so seeing a therapist for the first time doesn't promise an instant click. Rapport has to be established first, and this is usually done through play. Benefits Of Play Other than using it as a tool to establish rapport, play also gives a lot of benefits. First off, it gives an over view of the child's skills, whether it be their abilities or limitations. Then, therapy wise, play can be used to make a child cooperate with whatever exercises a therapist has lined up for him/her. Since play doesn't put much pressure on a child, he/she would likely cooperate to do the exercises and not know that what he/she is doing is already called therapy. When the child is more relaxed, he can be at a more natural state. If a child is at his more natural state, then his skills could show more naturally. Thus, this would be a benefit on the therapist's part, since the therapist could get a more comprehensive assessment of the child's skills. Play could also make therapy more fun and less scary. Since play is an activity to be enjoyed, the child would not get bored with monotonous therapy activities that seem like chores, rather than activities. Play As A Skill In fact, play is considered to be a skill itself, because it is a natural activity that children do. If a child doesn't play, then there must be something wrong with him, most probably with his Inner Language skills. This is because; play is a representation of a child's inner language. This is just one of the many reasons why play is important. It actually has a domino effect, if you look at the bigger picture. Play is needed to have Inner language, which is in turn needed to have Receptive language that is a prerequisite of Expressive language. Thus, if a child has no play abilities, then his whole language system may be affected. Play And Cognition Play is also a basis of a child's cognition skills. The more developed a child's play skills are, the higher the probability that his cognition skills would be at a fair state. However, play and condition are not the same. Play is more likely a prerequisite or a co-requisite of cognition. What Parents Have To Say Unfortunately, most parents may have a negative impression when they see the therapist playing with their child. Initially, parents get surprised and shocked that they paid a very valuable amount for therapy, only to find out that their child would only be playing. That's why it is very important for therapists to explain the procedures that they are going to do with the child to the parents. To make the session more interesting, the therapist could also include the parent/s in the play session with the child. In this way, the child would definitely think that it is a play session. Additionally, the parent can also do the play activity at home with the child. Doing this, could serve to be practice of the targeted skill of the play activity. Early Learning To Listen Sounds And Speech Therapy Babies must first hear the sounds frequently and memorize them before learning to speak or learn their meaning. For children with hearing impairment, among the many activities that can facilitate listening to sounds are sound-object association activities also known as "learning to listen sounds". This type of activity involves associating a sound to a referent, an item such as transportation vehicle or animal with a routine meaningful action. Linking a sound to a referent is considered an important activity for auditory-based intervention because it encourages the child to attend to sounds, facilitate the recognition that sounds are different and help the child understand that different sounds have different meaning. This activity also develops stored perceptual representation for specific sounds or language-based phonemes. It also develops auditory familiarity with the spoken language. Considerations There are some important things to consider when facilitating this kind of activity. One thing is to incorporate toys or personal action for very young child. This allows children to actively participate in the learning and listening process as this activity is meaningful and enjoyable for them. Another thing is the variation of the supra-segmentals of these sounds. This restructures the auditory schema of a child for a particular sound each time he hears it in a different context. Also, toys used for learning to listen sounds should be simple representational items that are easily recognizable by young children. Adults should also remember that "hearing comes first" for an effective auditory-verbal strategy. This means that the adult should first vocalize the sound before showing to the child the toy. Magical Transportation Sounds An example of learning to listen sound associated with transportation vehicle is aaaah(airplane) which is a good basic vowel and even the deafest kid typically comprehend and use it quickly. The clinician can vary the suprasegmentals of this sound as he shows to the child how he moves the airplane up and down. Another sound is buhbuhbuh. It is one of the first consonants that the babies learn and besides from that, it is also an easy sound for the babies to imitate and produce on their own. The toy bus can be move around as the clinician vocalizes the sound. Ooooo is one sound that is good for stimulation of pitch variation with the same vowel. The clinician can use a fire truck as he produces the sound with alternating high-low configuration. Other learning to listen sounds associated with transportation vehicles include brrrrrr(car), p-p-p-p-p(boat), and ch-ch-ch-ch(train). These sounds concentrate on stimulating the lip articulator and develop listening for some high frequency sounds. Familiar Animal Sounds Learning to listen sounds is also associated with animal sounds. A common sound that is use by clinicians is mooo(cow) which is a good vowel combined with the initial consonant /m/. This sound is produce with low voice and this change in voice is interesting for children. The repeated tongue clicking for the hoarse is also a good sound because it is another prespeech skill. Most children are fascinated with the tongue clicking, thus, it is good for stimulation. This sound also exercises the movement of tongue. Meow has some nice vowel transition and clinician may use this to also produce inflectional variations within a two-syllable combination. Other learning to listen sounds for animals include arfarfarf(dog), ssss(snake), quakquakquak(duck),hop-hop-hop(rabbit), oinkoink(pig), ba-a-a-a(sheep), and squeak(mouse). There are also learning to listen sounds that can be associated with eating, sleeping, and clock. These sounds are mmmm, shhhhhhh, and t-t-t-t-t correspondingly. Delineating Speech And Language Therapy The field of speech and language therapy is somewhat a vague body of knowledge that only a few people understand. What most people don't know is that there is a difference between speech therapy as a whole and language therapy. Although the term 'speech and language' therapy is widely used, since speech and language problems coexist most of the time. Differentiating Speech And Language Therapy The truth of the matter is, that speech therapy and language therapy differ in some key areas. First off, they differ on the problems that they are targeting. The techniques and activities used during therapy are also different. Although there are times that these activities are done simultaneously, to target two problems at a time. Speech Therapy Speech therapy is done to treat speech problems. Such speech problems deal with how or the manner a person speaks. These speech problems are categorized into three general kinds. First, is voice or resonation disorders. Second, is articulation disorders. And, lastly, fluency disorders. Voice disorders mainly deals on problems with the voice box or the larynx itself. These may be due to physiological malfunction, anatomical differences, fatigue, or neurological problems. Some voice disorders present problems in pitch, volume, and tone. The presence of breathy, raspy, nasal and weak voice is viable too. Articulation disorders, on the other hand, deal with the manner a person speaks. The problem is rooted from the articulators themselves. Articulators are composed of the tongue, teeth, hard palate, soft palate, jaw, and cheeks. Articulation disorders may be due to weakness or physiological malfunction in any of the articulators, which results to distorted or incomprehensible speech. Fluency disorders would deal on problems regarding the fluency of the person. It may be the case that he talks too fast or too slow. Stuttering and Cluttering are two of the major fluency problems that speech therapists deal with. Speech therapy activities would likely include different exercises to practice speaking. Since most of the time, weak muscles are present; the therapy proper would usually include activities that can help strengthen these muscles. Different compensatory strategies are also taught, so that the patient can compensate for lost speaking skills. Language Therapy Language therapy mainly deals with problems regarding your inner language, receptive language and expressive language. Cognition skills can be the main cause of language problems. Unlike speech disorders, that manifest physical differences, most language disorders are due to problems the brain's language processing. Receptive language problems mainly deals on difficulties understanding received language, like what other people are telling you and comprehending written data. Expressive language problems on the other hand are difficulties on expressing oneself. You may have a hard time knowing which words to use verbally or even through writing. Language based problems are usually treated through mental exercises. Workbooks are often used to practice and develop language skills. For very young children, play therapy is used to develop inner language, so that the therapist could later on target improving receptive and expressive language, respectively. In some cases, speech and language problems are both present. This is especially true for individuals that had traumatic brain injuries or accidents that had an effect on the brain. They may manifest physiological problems due to damaged nerves that result to articulation or voice problems. The can also have language problems like aphasia, especially if their brain was hit on its language areas. Conditions For Speech Therapy: Laryngectomy A speech therapist has a vital role in the pre- and post op management of laryngeal cancer, because Laryngectomy patients have to undergo speech management. So here are some of the things to know about laryngectomy. A Team Approach Firs off, the management of laryngeal cancer requires a team approach. The patient gets to see a surgeon, radiologist, audiologist, speech-language pathologist, oncologist, physical therapist, maxillofacial prosthodontist, and a psychiatrist. All of these health care professionals work together to work on the management of the patient. What Is Laryngectomy? Laryngectomy is the total removal of the larynx. It is also the partition of the airway from the nose, mouth, and esophagus. A person that undergoes this kind of operation would have to breathe via an opening on the neck, called stoma. Laryngectomy is done when a person has laryngeal cancer. It may be considered to be a traditional way of managing laryngeal cancer, since a lot of laryngeal cancer cases nowadays are treated with the use of chemotherapy, radiation, or other laser procedures. In severe cases that these don't work, that is the only time laryngectomy is opted for. Other than the larynx, other structures are also removed. These other structures includes Sternocleidomastoid, Omohyoid muscle, Internal Jugular vein, Spinal Accessory vein (CNXI), Submaxillary salivary gland. In most severe cases, the external carotid artery, strap muscles of the neck, Vagus nerve (CN X), Hypoglossal nerve (CN XII) and the lingual branch of the Trigeminal nerve (CN V) are also removed. How Common Is Laryngectomy? It is estimated by the American Cancer Society, in 2003, that around nine thousand five hundred people in the US were diagnosed of laryngeal cancer. This condition occurs about 4.4 times more predominantly with men than with women. Though, similar with lung cancer, laryngeal cancer is becoming increasingly frequent with women. Tobacco smoking is so far the supreme risk factor in having laryngeal cancer. Other factors include radiation exposure, asbestos exposure, alcohol abuse, and genetic factors. In United Kingdom, laryngeal cancer is rather rare, since it only affects less than 3,000 people per year. Possible Problems After total Laryngectomy, possible problems may occur. These include having a scar tissue at the tongue base, narrowing of the esophagus, partial tongue base resection, dysphagia, Xerostomia, mouth sores and changes in smell, taste, appetite and weight. Effects And Impacts Of Laryngectomy Laryngectomy has two mechanistic effects. One, it separates respiration from speech. Two, it keeps the pharyngoesophageal region intact. There are also impacts that Laryngectomy brings about. The main impact would be the loss of voice for communication. You may also lose the ability to express emotions such as laughing. You also get physical problems with regard to tasting and feeding. Laryngectomy is frequently successful in treating early-staged cancers. Still, undergoing through the procedure would require major lifestyle change. There is also a risk of having severe psychological stress due to unsuccessful adaptations. After The Procedure: Voice Replacement And Care After the patient's larynx is removed, voice prosthetics is used. This serves as a replacement for the lost larynx, so that the person will still be able to communicate and speak. In this case, Laryngectomees would have to learn new methods of speaking. They should also be constantly concerned in taking care and cleaning their stoma. Severe problems can arise if foreign materials and water enter their lungs via their unprotected stoma. Conditions For Speech Therapy: Autism Autism is one condition that requires speech therapy treatment. However, autism is often misunderstood and thought of to be something that can be left untreated. However, that should not be how things work. Autism presents a lot of problems, but the intensity of these problems could be decreased if given the correct treatment. In Relation To Autism: Vocabulary A lot of terms are commonly heard in relation to autism, such as: classic autism, infantile autism, Pervasive Developmental Disorder (PDD), Atypical PDD, Autistic like, PDD-NOS, Asperger's Syndrome and high functioning Autistic. What Is It Exactly? Basically, Autism is a neurological disorder. It is classified to be a Pervasive Developmental Disorder. The main characteristic of Autism is that it affects three major areas in relation to speech and language. This triad is the impairment of the child's: social interaction, communication and imaginative play. Pervasive Developmental Disorder is actually an umbrella term for Autistic Spectrum Disorders. With the use of the term 'pervasive', it is emphasized that the disability's range of deficits is beyond psychological development. On the other hand, the term 'developmental' puts emphasis that the occurrence of the condition is during the child's development rather than later in life. Autism is actually only one condition under this umbrella. Other conditions include Rett's Disorder, which is a neurodevelopmental disorder that begins to show its symptoms during early childhood or infancy. Another is Childhood Disintegrative Disorder; it somewhat resembles Autism but the difference is the first two to four years of the child's life is rather normal, then the symptoms start to show. Asperger's syndrome is also in this umbrella. It is sometimes called high functioning autism. Lastly, PDD-NOS or Pervasive Developmental Disordere -- Not Otherwise Specified is also related to Autism. These are children that present symptoms similar to but don't quite match the other conditions. What Causes Autism? Even though a lot of research has been done, there is no identified single factor that causes Autism. Several factors are said to play a part in the occurrence of Autism. One of these is brain disorder. Recent studies show that there is a difference in the brains of people with Autism. Their cerebellum seems to be smaller than normal, and their limbic system is impaired. Chemical imbalances are also said to play a part here. It was found that in some cases, symptoms came from food allergies, chemical deficiencies, hormonal imbalances or elevated brain chemical levels. Heredity is also an important factor. A lot of genetic disorders have Autism as a symptom. An example would be the fragile-X syndrome. Other factors include pre-, peri-, post-natal trauma, brain damage complications and MMR immunization. Whatever the cause may be, the child with Autism should be given the same structured training in able to stimulate his learning, language and social skills. Diagnosis For a child to be diagnosed of having Autism, he should first qualify for the Diagnostic Criteria for Autistic Disorders according to the DSM-IV. Treatment: Therapy And Others Due to the triad of Autism effects on the child, speech therapy becomes a vital part of Autism management. However, other members of the team are also needed such as pediatrician, pediatric neurologist, child psychiatrist, psychologist, occupational therapist, behavior therapist, and educators like schoolteachers or Special Education teachers. Role Of Speech Therapist In Autism Rehabilitation The Speech Therapist assesses hearing. He also evaluates whether the speech and language difficulties of the child is really due to Autism or another disorder. This can be taken from analyzing the child's expressive language, receptive language, oral-motor functions, voice quality, articulation and fluency, auditory processing and pragmatic skills. Aphasia's Speech And Language Problems Targeted For Speech Therapy Aphasia can bring about a lot of speech and language problems that are to be treated for speech therapy. The kind of speech and language problems brought by Aphasia would highly depend on the kind of Aphasia that you may have. Broca's Aphasia Broca's Aphasia is also known as motor aphasia. You can obtain this, if you damage your brain's frontal lobe, particularly at the frontal part of the lobe at your language-dominant side. If Broca's Aphasia is your case, then you may have complete mutism or inability to speak. In some cases you may be able to utter single-word statements or a full sentence, but constructing such would entail you great effort. You may also omit small words, like conjunctions (but, and, or) and articles (a, an, the). Due to these omissions, you may produce a "telegraph" quality of speech. Usually, your hearing comprehension is not affected, so you are able to comprehend conversation, other's speech and follow commands. Difficulty in writing is also evident, since you may experience weakness on your body's right side. You also get an impaired reading ability along with difficulty in finding the right words when speaking. People with this type of aphasia may be depressed and frustrated, because of their awareness of their difficulties. Wernicke's Aphasia When your brain's language-dominant area's temporal lobe is damaged, you get Wernicke's aphasia. If you have this kind of aphasia, you may speak in uninterrupted, long, sentences; the catch is, the words you use are usually unnecessary or at times made-up. You can also have difficulty understanding other's speech, to the extent of having the inability to comprehend spoken language in any way. You also have a diminished reading ability. Your writing ability may be retained, but what you write may seem to be abnormal. In contrast with Broca's Aphasia, Wernicke's Aphasia doesn't manifest physical symptoms like right-sided weakness. Also, with this kind of Aphasia, you are not aware of your language errors. Global Aphasia This kind of aphasia is obtained when you have widespread damage on language areas of your brain's left hemisphere. Consequently, all your fundamental language functions are affected. However, some areas can be severely affected than other areas of your brain. It may be the case that you have difficulty speaking but you are able to write well. You may also experience weakness and numbness on the right side of your body. Conduction Aphasia This kind is also known as Associative Aphasia. It is a somewhat uncommon kind, in which you have the inability to repeat sentences, phrases and words. Your speech fluency is reasonably unbroken. There are times that you may correct yourself and skip or repeat some words. Even though you are capable of understanding spoken language, you can still have difficulty finding the right words to use to describe an object or a person. This condition's effect on your reading and writing skills can also vary. Just like other types of aphasia, you can have sensory loss or right-sided weakness. Nominal Or Anomic Aphasia This kind of aphasia would primarily influence your ability to obtain the right name for an object or person. Consequently, rather than naming an object, you may resort to describing it. Your reading skills, writing ability, hearing comprehension, and repetition are not damaged, except by this inability to get the right name. Your may have fluent speech, except for the moments that you pause to recall the correct name. Physical symptoms like sensory loss and one-sided body weakness, may or may not be present. Transcortical Aphasia This kind is caused by the damage of language areas on your left hemisphere just outside your primary language areas. There are three types of this aphasia: transcortical sensory, transcortical motor, and mixed transcortical. All of these types are differentiated from others by your ability to repeat phrases, words, or sentences.
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