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Speech Therapy

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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

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

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

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

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

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

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

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.


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

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

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

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

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

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 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.


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

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

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

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

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

For children that have adequate speech, the communication impairment is
manifested by not being able to initiate or sustain a conversation with other

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

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.


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.


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.


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

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

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).


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.


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.


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'.


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

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 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


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

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

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

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

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

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.


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

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

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

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

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

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

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

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


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

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

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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