Introduction to Communication Disorders A Lifespan Evidence-Based Perspective, 6th edition by Robert by Ace Test Banks

Instructor’s Manual and Test Bank For

Introduction to Communication Disorders: A Lifespan Evidence-Based Perspective 6th Edition Dr. Robert Owens, College of St. Rose Dr. Kimberly Farinella, Northern Arizona University

Prepared by Dr. Sarah Dachtyl, Northern Arizona University

Table of Contents

Chapter One:

The Field, the Professionals, and the Clients

Chapter Two:

Typical and Disordered Communication

Chapter Three:

Overview of the Anatomy and Physiology of the Speech Production Mechanism

Chapter Four:

Childhood Language Impairments

Chapter Five:

Speech Sound Disorders

Chapter Six:

Developmental Literacy Impairments

Chapter Seven:

Adult Language Impairments

Chapter Eight:

Fluency Disorders

Chapter Nine:

Voice and Resonance Disorders

Chapter Ten:

Motor Speech Disorders

Chapter Eleven:

Disorders of Swallowing

Chapter Twelve:

Audiology and Hearing Loss

Chapter Thirteen:

Augmentative and Alternative Communication

Test Bank with Answer Key

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CHAPTER 1 THE FIELD, THE PROFESSIONALS, AND THE CLIENTS Learning Outcomes When you have finished this chapter, you should be able to: 1. Describe communication disorders 2. Discuss the roles of audiologists, speech-language pathologists, and speech, language, and hearing scientists 3. Explain how intervention services change through the lifespan 4. Describe how evidence-based practice (EBP) influences clinical decisions 5. Outline the history of changing attitudes toward individuals with communication disabilities over the centuries and legislation over the past several decades

Introduction Communication is part of what makes us human. Even minor or temporary problems with communication are often frustrating. What if these problems were more lasting? In the first chapter of this text, we introduce the professionals who work with individuals who have communication and feeding and swallowing challenges. In addition, evidence-based practice and a historical perspective of laws that mandate appropriate care of those in need will be discussed. A holistic approach to diagnosis and treatment of people with communicative impairments will be used throughout the text. The professionals who work with those who have communication disorders, SLPs and audiologists, often choose these careers because they want to be useful to society, to contribute to the general good.

Content Outline COMMUNICATION DISORDERS ❖ A communication disorder impairs the ability to both receive and send, and also process and comprehend concepts or verbal, nonverbal, and graphic information. ❖ It may affect hearing, language, and/or speech. ❖ It may range from mild to profound severity, be developmental or acquired, and may be present in combination with other disorders or disabilities. ❖ SLPs work primarily with individuals who have communication disorders, but are also involved in feeding and swallowing disorders and nonverbal forms of communication. ❖ Speech disorder: Atypical production of speech sounds, interruption in the flow of speaking, or abnormal production and/or absences of voice quality (pitch, loudness, resonance, and/or duration). ❖ Language disorder: Impairment in comprehension and/or use of spoken, written, and/or other symbol systems. ❖ Hearing disorder: A result of impaired sensitivity of the auditory or hearing system. ❖ Central auditory processing disorders: Deficits in the processing of information from audible signals. ❖ Communication disorders are NOT differences, such as dialectal differences or speaking another language. ❖ Augmentative/alternative communication systems: Attempts often taught by SLPs to compensate and facilitate for impaired communication using, for example, signing or digital methods. ❖ Intervention for feeding and swallowing disorders varies from preterm infants with a weak sucking response to adult patients recovering from stroke and slowly regaining the motor control needed to chew and swallow properly.

THE PROFESSIONALS AND THEIR ROLES ❖ Professionals who serve individuals with communication disorders are employed in early intervention programs, preschools, schools, colleges and universities, hospitals, independent clinics, nursing care facilities, research laboratories, home-based programs, and private practice. ❖ Telepractice: Provision of language assessment and intervention via the Internet. ❖ Audiologists: Measure hearing ability and identify, assess, manage, and prevent disorders of hearing (including auditory processing disorders) and balance. They may dispense hearing aids.  Credentials for Audiologists ➢ Educational requirements are 3-5 years of professional education beyond the bachelor’s degree.

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➢ This culminates in a doctoral degree, either an AuD, PhD, or EdD in audiology. ➢ ASHA CCC-A: Requires doctorate, professional experience, national exam. ➢ State license is often needed and is frequently identical to ASHA CCC. ❖ Speech-Language Pathologists: Identify, assess, treat, and prevent expressive and receptive communication disorders in all modalities. They provide services for swallowing disorders and may be involved in modifying dialects.  Credentials for SLPs ➢ Public schools require at least a bachelor’s degree, but most states require a master's degree. Requirements vary from state to state. ➢ ASHA CCC-SLP: Requires master's degree or doctorate, professional experience, professional development, national exam. ➢ State license often needed and is frequently identical to ASHA CCC. There may also be additional requirements for the state’s department of education school certification. ❖ Speech, Language, and Hearing Scientists: Extend knowledge of human communication processes and disorders. They usually have doctorate degrees and are employed by universities, government agencies, industry, and research centers. Some may also work clinically. ♦ What Speech, Language, and Hearing Scientists Do ➢ Speech scientists may be involved in basic research exploring anatomy, physiology, and physics of speech-sound production. ➢ Use technology to learn more about typical and pathological communication. ➢ Development of computer-generated speech. ➢ Language scientists may investigate the ways children learn language. ➢ Conduct cross-cultural studies of language and communication. ➢ Study how languages are changing. ➢ Examine language disabilities and the nature of language disorders in children and adults. ➢ Hearing scientists investigate the nature of sound, noise, and hearing. ➢ They may help develop equipment for hearing assessment. ➢ Develop techniques for testing infants or those with physical or psychological impairments. ➢ Develop and improve assistive listening devices. ➢ Concerned with conservation of hearing and limiting environmental noise. ❖ Related Professions: A Team Approach: Teams can include family members, regular and special education teachers, psychologists, social workers, physicians and other medical personnel, and occupational, physical, and music therapists. They may collaborate with physicists and engineers.

SERVICE THROUGH THE LIFESPAN ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖

Individuals with communication disorders may be of any age. 1 in 5 people has a disability, and the likelihood increases as we age. Approximately 2% of all children born in the U.S. have some existing disabling condition. Infants are screened for hearing loss and other disabilities as soon as they are born. Babies and toddlers may exhibit developmental delay. An interdisciplinary approach is necessary in the assessment and treatment of young children, and an IFSP is developed for each child, which is directed to the entire family. Early intervention is highly valuable and may prevent later difficulties. Preschoolers may attend a special school where professionals can address the child’s needs. Almost half of all SLPs are employed in school systems. School-age children with communication difficulties often experience academic and social difficulties. 1.5 to 2 million Americans sustain a traumatic brain injury each year and may have subsequent cognitive and/or motor problems that interfere with their ability to communicate and/or eat. In those over age 65, stroke, neurological disorders, and cognitive impairments may interfere with communication and swallowing. Hearing loss may affect at least one quarter of older adults.

EVIDENCE-BASED PRACTICE ❖ SLPs and audiologists must provide the most effective intervention based on available evidence. ❖ Clinical decision-making: Combination of scientific evidence, clinical experience, and client needs. ♦ Assumptions of EBP: ➢ Clinical skill grows from experience and current available data. ➢ The SLP or audiologist seeks new therapeutic information to improve efficacy. ❖ Professional, peer-reviewed journals are the best source of clinical evidence.

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❖ Efficacy: The probability of benefit from an intervention under ideal conditions. There are three key elements: ♦ It refers to an identified population, not specific individuals. ♦ The treatment should be focused and the population should be clearly identified. ♦ The research should be conducted under optimal intervention conditions, although actual clinical conditions may be less than ideal. ❖ Effectiveness: The probability of benefit from an intervention method under average conditions. It is what works in real-world application of intervention. ❖ Efficiency: The quickest and least effortful method resulting in the greatest positive benefit. ❖ Additional factors affecting clinical decision making include the clinician’s expertise, experience, attitude, and motivation, client/family values and characteristics, and service delivery variables. ❖ Providing the best intervention possible is of foremost concern. Intervention options and supporting evidence should be discussed with clients and/or family members.

COMMUNICATION DISORDERS IN HISTORICAL PERSPECTIVE ❖ Disorders are not new but attitudes toward them have changed throughout the centuries. ❖ By the late 1700s, special residences were designed for individuals with specific disorders. ❖ The first U.S. “speech correctionists” were educators and others who took an interest in speech problems. ❖ The first professional journal related to communication, The Voice, was established in 1879. ❖ Early interest groups included teachers within the National Education Association and the National Association of Teachers of Speech. ❖ The American Academy of Speech Correction was formed in 1925, a precursor to ASHA. ❖ Audiology became a profession in the 1920s and experienced a boom in the 1940s due to World War II veterans who were experiencing noise-induced hearing loss. ❖ The American Coalition of Citizens with Disabilities was created in 1974. ❖ Select federal mandates affecting people with communication disabilities:  1975: Education for All Handicapped Children Act (EAHCA) (Public Law 94-142) ➢ Mandated that a free and appropriate public education (FAPE) must be provided for all handicapped children between ages 5 and 21.  1986: Education of the Handicapped Amendments (Public Law 99-457) ➢ Extended age of those served to cover children between the ages of birth and 5 years.  1990: Individuals with Disabilities Education Act (IDEA) ➢ Addressed the multicultural nature of the U.S.  2004: Reauthorization of IDEA ➢ Established birth-to-6 programs as well as new early intervention services.

Summary SLPs, audiologists, and other specialists work to assist individuals with communication impairments. They work in a variety of settings and with people throughout the lifespan. Clinicians have a master’s or doctoral degree and supervised clinical experience, and generally have the ASHA CCCs. ASHA is the largest organization of professionals working with communication disorders. ASHA’s missions include the scientific study of human communication, provision of clinical service in speech-language pathology and audiology, maintenance of ethical standards, and advocacy for individuals with communication disabilities. Federal legislation currently mandates services for people with disabilities.

Video Examples Video Example 1.1: Becoming an audiologist or speech-language pathologist Activity suggestion: This video is over 13 minutes long. You may assign this video to be viewed before class. Have students pair up at the beginning of the class period and talk about why they may or may not be considering a profession in speech-language pathology or audiology and what information in the video was reinforcing one way or another. Video Example 1.2: Audiology services for children Activity suggestion: In the video, it is stated that “It’s not only hearing development, it’s brain development.” Have students discuss what this statement means. Briefly introduce which areas of the brain are most involved in the perception of sound and the processing of the meaning of sound.

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Video Example 1.3: Exploring the SLP’s scope of practice Activity suggestion: This video is over 12 minutes long. Ask students to take notes on what parts of the scope of practice were surprising to them (whether viewed as an assignment outside of class or viewed in class), and then discuss as a group.

Thought Questions 1.1: Were you surprised by the scope of possible interventions for SLPs and audiologists? Did you begin reading thinking only of speech and hearing? What surprised you the most, and why? 1.2: As you think about intervention across the lifespan and working as a member of a team, think about variations in this arrangement. Are there ages of clients or severities of disorders in which you as an SLP might consult with other specialists, and still other times when you might serve as a member of a team?

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CHAPTER 2 TYPICAL AND DISORDERED COMMUNICATION Learning Outcomes When you have finished this chapter, you should be able to: 1. Explain the role of culture and environment in human communication. 2. Describe in the different aspects of human communication. 3. Demonstrate how communication disorders may be classified, including the names and frequency of occurrence of different types of communication disorders. 4. Describe in general the assessment and intervention process.

Content Outline ROLE OF CULTURE AND THE ENVIRONMENT ❖ Humans are social beings. ❖ Variables that affect communication and its success or failure include cultural identity, setting, and participants. ❖ Sociolinguistics: The study of such influences on communication. ❖ Cultural Identity ♦ Refers to our language and cultural communities (nationality, age, gender, ethnicity, etc.). ♦ The location and participants also influence the nature of communication. ❖ The Environment ♦ The communication environment includes the location in which communication occurs, as well as the people involved and the event in which they are involved.

ASPECTS OF COMMUNICATION ❖ The primary vehicle of human communication is language, and speech is the primary means of language expression for most individuals. ❖ Language ♦ A socially shared code that is used to represent concepts. It uses arbitrary symbols that are combined in rule-governed ways. It is also generative and dynamic. ♦ Grammar refers to the rules of a language. ♦ Generative means that you can create new utterances. ♦ Dynamic means that languages change over time. ♦ All languages have three primary components: form, content, and use. ♦ Form ➢ Consists of phonology, morphology, and syntax. ➢ Phonology is the sound system of a language. English consists of about 43 phonemes (unique speech sounds). ➢ Phonotactic rules specify how sounds may be arranged in words. ➢ Morphology involves the structure of words. ➢ Morphemes are the smallest grammatical units in a language. ➢ Free morphemes may stand alone as a word. ➢ Bound morphemes change the meaning of the original words and must be attached to free morphemes. ➢ Syntax is how words are arranged in a sentence and the ways in which one word may affect another. ♦ Content ➢ Consists of semantics, which refers to the meaning of language. ➢ Semantic features are pieces of meaning that come together to define a word. ➢ Each word has multiple meanings; other aspects of language such as form and use determine which of the definitions is appropriate in context. ♦ Use ➢ Consists of pragmatics, which is the purpose of language. Pragmatic rules vary with culture. ❖ Speech ♦ The process of producing the acoustic representations of language. ♦ Articulation

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➢ The way speech sounds are formed. ➢ Prosody: The component of speech that includes rate and rhythm. ➢ Prosodic features are known as suprasegmentals and include stress and intonation. ♦ Fluency ➢ The smooth, forward flow of communication, influenced by rhythm and rate of speech. ➢ Rate is the speed at which we talk. ♦ Voice ➢ Can reveal things about the speaker and the message. ➢ Both the overall level of loudness and the loudness pattern within sentences and words are important. ➢ By stressing different words within a sentence, you convey different meanings. ➢ Placing stress on different syllables within certain words also changes the meaning. ➢ Pitch is a listener’s perception of how high or low a sound is (frequency) ➢ Habitual pitch is the basic tone that an individual uses most of the time. ➢ Intonation is the pitch movement within an utterance. ❖ Nonverbal Communication ♦ About 2/3 of human meaning exchange is nonverbal. Nonverbal encompasses both the suprasegmental aspects of speech and the nonvocal (without voice) and nonlinguistic aspects of communication. ♦ Artifacts ➢ The way you look, your clothes, your possessions, and general appearance. ♦ Kinesics ➢ The way we move our body, or body language. ➢ This includes gestures and facial expression. ➢ Some gestures have explicit meanings and may contribute to the larger speech system. ➢ In contrast, signing may be a primary means of communication. ♦ Space and Time ➢ Proxemics is the study of physical distance between people as it affects communication. ➢ Tactiles are touching behaviors. ➢ Chronemics is the effect of time on communication. ➢ Age, sex, education, and cultural background influence every aspect of communication. ❖ Communication Through the Lifespan ♦ Infants must first learn the rudiments of communication and begin to master speech. ♦ The early establishment of communication between children and caregivers fosters the development of speech and language, which influences the quality of communication. ♦ This is fostered by physical, cognitive, and social development. ♦ The key to becoming a communicator is being treated as one. ♦ The process of learning speech and language is a social one that occurs through interactions of children and the people in their environment. ♦ In different cultures, the type of child-caregiver interaction, the model of language presented to the child, and the expectations for the child differ, but each is sufficient for learning the language of the culture. ♦ Every person’s speech and language continues to change until the end of life. ♦ A competent communicator continues to adapt to changes in the language and in the communication process.

COMMUNICATION AND SWALLOWING IMPAIRMENTS ❖ Communication disorders consist of disorders of speech (articulation, voice, resonance, fluency), oral neuromotor patterns of control and movement, language and/or literacy impairment, feeding and swallowing disorders, cognitive and social communication deficits, and hearing and processing difficulties. ❖ May be categorized on the basis of whether reception, processing, and/or expression are affected. ❖ Etiology is the cause/origin of a problem, and may be used to classify a communication problem. ♦ Faulty learning, neurological impairments, anatomical or physiological abnormalities, cognitive deficits, hearing impairment, or damage to any part of the speech system. ❖ Congenital: Present at birth. ❖ Acquired: The result of illness, accident, or environmental circumstances anytime later in life. ❖ Variations in communication and swallowing are not impairments. ❖ Dialects: Differences that reflect a particular regional, social, cultural, or ethnic identity. ❖ Language Disorders

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Disorders of Form ➢ Errors in sound use constitute a disorder of phonology. ➢ Incorrect use of past tense or plural markers is an example of a disorder of morphology. ➢ Syntactical errors include incorrect word order and run-on sentences. ➢ May be due to sensory limitations, perceptual difficulties, limited exposure to correct models, or neurological disorders. The cause may also not be apparent.  Disorders of Content ➢ Limited vocabulary, misuse of words, or word-finding difficulties. ➢ Difficulty understanding and using abstract language. ➢ A persistent pattern of avoiding naming objects and referring instead to “the thing” is another indication of a disorder of content. ➢ May be due to limited experience, concrete learning style, stroke, head trauma, or certain illnesses.  Disorders of Use ➢ Pragmatic language problems be related to limited or unacceptable conversational, social, and narrative skills; deficits in spoken vocabulary; and/or immature or disordered phonology, morphology, and syntax. ➢ Might include difficulty staying on topic, providing inappropriate or incongruent responses to questions, or continually interrupting the conversational partner. ❖ Speech Disorders ♦ May involve articulation, fluency, or voice.  Disorders of Articulation ➢ Articulation: The actual production of speech sounds. ➢ It is not always easy to determine whether an individual’s speech-sound errors indicate an impairment of phonology (a language problem) or articulation. ➢ The causes of phonological disorders are often not known but may result from faulty learning due to illness, such as ear infections, hearing or perceptual impairments, or other problems in the early years. ➢ The causes of articulation disorders include neuromotor problems such as cerebral palsy, physical anomalies such as cleft palate, and faulty learning. ➢ Dysarthria is a speech disorder caused by paralysis, weakness, or poor coordination of the speech musculature. ➢ Apraxia of speech is a speech disorder that is due to neuromotor programming difficulties.  Disorders of Fluency ➢ The smooth, uninterrupted flow of speech is affected. ➢ Developmental disfluency: Speech patterns common to young children (~age 3) such as repeating words, making false starts, and revising utterances. ➢ Fillers: Examples include “er,” “um,” and “ya know.” ➢ Hesitations: Unexpected pauses. ➢ Repetitions: Sounds or words are repeated, as in “g-go-go.” ➢ Prolongations: Excessively long duration, as in “wwwwwwwell.” ➢ Stuttering: When these speech behaviors exceed or are qualitatively different from the norm or are accompanied by excessive tension, struggle, and fear. ➢ Fluency disorders are generally first noticed before age 6. ➢ Adult onset of disfluency can also occur. ➢ The causes of nonfluent speech are typically unclear.  Disorders of Voice ➢ Congenital physiological conditions can affect voice, but are relatively rare. ➢ Vocal abuse: Excessive yelling, screaming, or loud singing. Can result in hoarseness or another voice disorder. ➢ Habits such as physical tension, coughing, throat clearing, smoking, and drinking alcohol can disrupt normal voice production. ➢ Can result in pathology such as polyps, nodules, or ulcers on the vocal folds. ➢ Other causes: Disease, trauma, allergies, and neuromuscular or endocrine disorders. ❖ Hearing Disorders  Results from impaired sensitivity in the auditory system.  May affect the ability to detect sound, to recognize voices or other auditory stimuli, to discriminate between different sounds, and to understand speech.  Deafness

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When a person’s ability to perceive sound is limited to such an extent that the auditory channel is not the primary sensory input for communication. It may be congenital or acquired. ➢ Universal neonatal hearing screening is mandated by law in many states, allowing congenital deafness to be identified and addressed very early. ➢ Total communication is considered the most effective intervention for deafness. ➢ Assistive listening devices, cochlear implants, and auditory training may be helpful.  Hard of Hearing ➢ People who are hard of hearing depend primarily on audition for communication. ➢ Hearing loss may be temporary or permanent, caused by disease, injury, or advancing age. ➢ Hearing loss is categorized in terms of severity, laterality, and type. ➢ Severity may range from mild to severe. ➢ The loss can be bilateral (involving both hears) or unilateral (involving one ear). ➢ The type of loss can be conductive, sensorineural, or mixed. ➢ Conductive: Caused by damage to the outer or middle ear. ➢ Sensorineural: Problems with the inner ear and/or auditory nerve. ➢ Mixed: Both conductive and sensorineural losses. ❖ Auditory Processing Disorders  Individuals with APD may have normal hearing but difficulty understanding speech. ♦ Difficulties include keeping up with conversation, understanding speech in noise, discriminating and identifying speech sounds, and integrating speech with nonverbals. ♦ Etiology is often unknown, but can be due to tumor, disease, or brain injury. ♦ May coexist with other disorders. ❖ Swallowing Disorders ♦ Difficulty swallowing is called dysphagia. ♦ Dysphagia is more common in older adults. ♦ Causes vary, and treatment depends on the cause. ❖ How Common Are Communication Disorders? ♦ What is "Normal"? ➢ Variability is the norm. ➢ Typical is a better term than “normal” when we mean “like most others of the same group.” ♦ Communication and Swallowing Disorders as Secondary to Other Disabilities ➢ Most communication disorders are secondary to other disabilities. ➢ Children with cleft palate also have physical health problems. ➢ People with cerebral palsy have more global motor deficits. ➢ Children with learning disabilities may also have academic and social difficulties. ♦ Estimates of Prevalence ➢ Prevalence: The number/percentage of people within a specified population who have a particular disorder or condition at a given point in time. ➢ Incidence refers to the number of new cases of a disease or disorder in a particular time period. ➢ About 17% of the U.S. population has a communication disorder. ➢ About 11% have a hearing loss. ➢ About 6% have a speech, voice, or language disorder. ➢ The percentage of people with hearing loss increases with age. ➢ Impairments of speech-sounds and fluency are more common in children than adults and more common in males that females. ➢ Speech disorders due to neurological disorders or brain and spinal cord injury occur more often among adults. ➢ 3-10% of Americans have voice disorders. ➢ Language disorders occur in 8-12% of the preschool population and decreases through the school years. ➢ 5-10% of older adults experience language disabilities related to stroke or cognitive impairment. ➢ 6 to 10 million Americans have dysphagia.

ASSESSMENT AND INTERVENTION ❖ The Role of the SLP in Prevention ♦ The goal of ASHA is that SLPs can help eliminate the causes and onset of communication disorders and foster optimal communication.

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Secondary to prevention is early identification and intervention to forestall more serious conditions. ♦ A key lifespan concept is wellness or the optimal level of communication competence at all stages of life. ❖ Assessment of Communication and Swallowing Disorders ♦ The purpose of screening is to determine whether a problem exists. ♦ Formal assessment occurs only after someone recognizes the possibility of a problem. ♦ Defining the Problem ➢ Assessment of communication disorders is the systematic process of obtaining information from many sources, through various means, and in different settings to verify and specify communication strengths and weakness, identify possible causes of problems, and make plans to address them. ➢ Diagnosis: Distinguishes an individual’s difficulties from the broad range of possible problems. ♦ Assessment Goals ➢ The primary goal of diagnosis is determining the nature of the disorder. ➢ Diagnostic therapy: Working with the client for a time to obtain a clearer picture of communication abilities and limitations. ➢ If a problem exists, the SLP should determine severity. ➢ Etiology (cause) should be determined. ➢ Predisposing causes may include genetic factors. ➢ Precipitating factors trigger a disorder ➢ Maintaining or perpetuating causes continue or add to the problem. ➢ Recommendations are often the most-read portion of an assessment report. ➢ The SLP makes a prognosis (informed prediction of an outcome) regarding whether the problem will persist if no intervention occurs and what the likely outcome is if a course of therapy or other treatment plan is followed. ♦ Assessment Procedures ➢ Authentic data: Actual real-life information ➢ A clinician should use a variety of procedures. ➢ Methods may include case histories, questionnaires, interviews, observations, testing, examination of the peripheral speech mechanism, dynamic assessment, and communication sampling and analysis. ➢ Norm referenced tests: Yield scores that are used to compare a client with a sample of similar individuals. ➢ Criterion-referenced tests: Evaluate a client’s strengths and weaknesses with regard to particular skills. ➢ Dynamic assessment includes probing to explore a client’s ability to modify behavior, as in a test-teach-retest paradigm. ➢ Speech or language sampling techniques may also be used. ♦ Evidence-Based Practice ➢ Most ASHA assessment guidelines are described in the following chapters. ❖ Intervention with Communication and Swallowing Disorders ♦ Failing to recognize and include consideration of an individual’s social identity can negatively impact intervention. ♦ Intervention is influenced by the nature and severity of the disorder, the age and status of the client, environmental considerations, and personal/cultural characteristics of client and clinician. ♦ Providing culturally responsive intervention is extremely important for children from culturally linguistically diverse backgrounds. ♦ ASHA has established the National Center for Treatment Effectiveness in Communicative Disorders and is currently coordinating a National Institutes of Health-funded effort to promote clinical research that will support EBP. ♦ Objectives of Intervention ➢ The client should show improvement and this should generalize. ➢ What has been learned should be largely automatic. ➢ The client must be able to self-monitor. ➢ The client should make optimum progress in the minimum amount of time. ➢ Intervention should be sensitive to the personal and cultural characteristics of the client. ♦ Target Selection

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The client’s personal needs and the potential for intervention to generalize are most relevant in making meaningful choices. ➢ Likelihood of success and typical behaviors of others at the client’s age and gender are also relevant. Baseline Data ➢ The client’s response accuracy for the target behavior multiple times and under multiple conditions before beginning intervention. ➢ Baselines are essential in determining a client’s progress and the success of a treatment program. Behavioral Objectives ➢ A statement that specifies the target behavior in an observable and measurable way. ➢ A: Actor: Who is expected to do the behavior? ➢ B: Behavior: What is the observable and measurable behavior? ➢ C: Condition: What is the context or condition of the behavior? ➢ D: Degree: What is the targeted degree of success? Clinical Elements ➢ Treatment Plan • SLPs select what they believe and evidence has shown to be the best intervention approach, types of materials, and logical steps to follow. ➢ Direct Teaching • Behavior modification: A systematic method of changing behavior. • The SLP provides a stimulus and reinforces the response if it is correct or provides corrective feedback if it is not. ➢ Incidental Teaching • The SLP follows the client’s lead but teaches along the way. ➢ Counseling • SLP can provide a supportive environment for the client and other key people in the client’s life. ➢ Family and Environmental Involvement • Family members may be asked to help the client with specific activities at home to foster carryover. • Support groups can provide an avenue to practice what has been learned in therapy, share feelings about the disability, and maintain communication skills once formal treatment has been terminated. Measuring Effectiveness ➢ Post-therapy tests can be used to determine whether clients have met their objectives. ➢ If therapy has been effective, the client is successful in generalizing the learned skills, can self-correct, self-monitor, and experiences automaticity. Follow-up and Maintenance ➢ Upon dismissal, the client or family should be encouraged to return if there is a need. ➢ A regular follow-up schedule can be established. ➢ Booster treatment may be provided if needed.

Summary Communication is an exchange of ideas, involving message transmission and response. It is strongly influenced by culture and environment. The primary vehicle of human communication is language. It may be spoken, written, or signed. The three major components are form (phonology, morphology, syntax), content (semantics), and use (pragmatics). Communication also happens nonverbally. Any aspect of communication can be impaired. About 17% of Americans currently experience some limitation of hearing, speech, and/or language. Assessment of communication and swallowing disorders requires an understanding of both in context. Referrals and screenings are the primary ways in which individuals are selected for assessment. Assessment and treatment function in a cyclical fashion, with one influencing the other. Successful intervention often uses a team approach that involves family members as well as professionals.

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Video Examples Video Example 2.1: How the Internet is changing the English language Activity suggestion: 1) Before watching the video, ask students to predict in what ways the English language has changed since widespread use of the Internet; 2) Dr. Crystal makes the assertion that “…language has become expressively richer as a result of the Internet.” Do students agree with this assertion? Ask students to defend the opposite assertion that the Internet has caused a degradation of the English language. A debate format could be used. Video Example 2.2: Overview of pragmatics Activity suggestion: Ask students to give an example of when they misinterpreted someone else’s intention or when someone misinterpreted their intention. Video Example 2.3: Stuttering Treatment Activity suggestion: Discussion questions for the class – What characteristics of this type of communication disorder did you observe and hear the children describe? How might some characteristics be shared with other communication disorders?

Thought Questions 2.1: As the U.S. population diversifies, it’s good to think about the impact of culture on communication and on disorders. Can you think of any communication differences that might be culturally based but might seem to the unaware person to be a disorder? Most of these, but not all, will affect pragmatics or language use. 2.2: You probably envisioned SLPs and audiologists working with individual clients or small groups of clients, helping them change communication and swallowing behaviors. Did you imagine yourself being a counselor or working with parents or spouses? When might you wish to do either or both?

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CHAPTER 3 OVERVIEW OF THE ANATOMY AND PHYSIOLOGY OF THE SPEECH PRODUCTION MECHANISM Learning Outcomes When you have finished this chapter, you should be able to: 1. Describe the structures, muscles, and physiology of the respiratory system. 2. Describe the structures, muscles, and functions of the laryngeal system. 3. Describe the structures and function of the articulatory/resonating system. 4. Explain the speech production process.

Introduction Speech production is complex. For those who have abnormalities in the anatomical structures and physiological systems that support speech, the production of speech can be quite difficult. Knowledge of speech anatomy and physiology is fundamental to understanding these communication disorders. Anatomy is the study of the structures of the body and the relationship of these structures to one another. Physiology is a branch of biology that is concerned with the functions of organisms and bodily structures. Three physiological subsystems are involved in speech production: 1) the respiratory system provides the driving force for speech by generating positive air pressure beneath the vocal folds; 2) the vocal folds, structures in the laryngeal system or larynx, vibrate at high speeds, setting air molecules in the vocal tract into multiple frequencies of vibration; and 3) the articulatory/resonating system acts as an acoustic filter, allowing certain frequencies to pass while blocking other frequencies.

Content Outline THE RESPIRATORY SYSTEM ❖ Primary biological functions: Supply oxygen to the blood and remove excess carbon dioxide. ❖ Also serves as the generating source for speech production. ❖ Structures of the Respiratory System ♦ Pulmonary apparatus ➢ Lungs: Pair of air-filled elastic sacs that change in size and shape and allow us to breathe. ➢ Trachea: Air moves into the lungs via the trachea and branches into bronchi. ➢ Pulmonary airways ➢ Chest wall (thorax) • Rib cage • Abdominal wall • Abdominal content • Diaphragm ❖ Muscles of the Respiratory System ♦ Inspiratory muscles are generally above the diaphragm. ♦ Expiratory muscles are generally below the diaphragm. ➢ Muscles of Inspiration • Diaphragm: Principal muscle of inspiration. Dome-shaped structure composed of a thin, flat, nonelastic central tendon and a broad rim of muscle fibers that radiate up to the edges of the central tendon. The central tendon is in direct contact with each lung. Contracts during inspiration, pulling down and forward, increasing lung volume. Numerous thoracic and neck muscles contribute to inspiration. ➢ Muscles of Expiration • The most important muscles of expiration are located in the front and on the sides of the abdomen. • These muscles assist the diaphragm’s movement back to its relaxed, dome-shaped configuration. • Other muscles may be used depending upon body position, pathological states, and environmental conditions. ❖ The Physiology of Tidal Breathing and Speech Breathing ♦ Resting tidal breathing: Breathing to sustain life.

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Inspiration: Diaphragm contracts, rib cage and lungs expand, lung volume increases and alveolar pressure drops, causing air to rush in and equalize with atmospheric pressure. ♦ Expiration: Decrease in the size of the rib cage wall, compression of the lungs, increase in pressure in the lungs, air rushes out to achieve equilibrium with atmospheric pressure. Does not require active muscle contraction. ♦ A respiratory cycle is one inhalation and one exhalation. ♦ During resting tidal breathing, the duration of inspiration and expiration is relatively equal. ♦ Speech breathing ➢ Contraction of diaphragm leads to rapid, forceful inspirations. ➢ Inspirations are much shorter than expirations. ➢ The amount of air inspired is greater than during resting tidal breathing. ➢ Inspiratory and expiratory muscles are both activated during speech. ❖ Lifespan Issues of the Respiratory System ♦ Resting tidal breathing rate decreases from birth to adulthood, related to more alveoli. ♦ Maximum lung capacity is reached in early adulthood; remains constant until middle age. ♦ Respiratory function is affected by exercise, health, and smoking.

THE LARYNGEAL SYSTEM ❖ The primary biological function of the larynx is to prevent foreign objects from entering the trachea and lungs. ❖ The larynx can impound air for forceful expulsion of foreign objects that threaten the lower airways. ❖ Structures of the Laryngeal System ♦ Larynx: An air valve composed of cartilages, muscles, and other tissue. It is the main sound generator for speech production. ♦ The larynx sits on top of the trachea and opens up into the pharynx. ♦ The larynx appears to be suspended from the hyoid bone, which is the point of attachment for laryngeal and tongue muscles. ♦ The larynx consists of the thyroid, arytenoid, and cricoid cartilages, which are attached via ligaments and membranes. ♦ Thyroid cartilage: The largest laryngeal cartilage; it forms the front and sides of the laryngeal skeleton and protects the inner components of the larynx. ♦ Thyroid prominence: A protrusion referred to as the “Adam’s apple,” which is located just below the thyroid notch. ♦ The larynx houses the vocal folds, which are attached at the front near the midline of the thyroid cartilage and at the back to the arytenoid cartilages via the vocal ligament. ♦ The vocal folds abduct during respiration and adduct during phonation. ♦ Glottis: The space between the vocal folds. ❖ Muscles of the Larynx  Thyroarytenoid muscle: The bulk of each vocal fold. Contraction shortens and thickens the vocal folds.  Cricoarytenoid muscle: Stiffens and lengthens the vocal folds. Increases vocal pitch (fundamental frequency).  Lateral cricoarytenoid and arytenoid muscles: Contraction results in vocal fold adduction.  Posterior cricoarytenoid muscle: Primary muscle of vocal fold abduction. ❖ Lifespan Issues of the Laryngeal System ♦ The larynx is small and high in the neck in newborns. It reaches its final position between 10 and 20 years of age. ♦ The laryngeal cartilages increase in size and become less pliable with age. ♦ The vocal folds increase in length differentially for males and females, reaching a final average length of 21 mm in females and 29 mm in males. ♦ Female laryngeal cartilage never completely ossifies. ♦ The vocal folds atrophy and lose elasticity with advancing age. ♦ Men notice an increase in pitch with advanced age, and women experience decreased pitch with the contribution of hormone-related changes in menopause.

THE ARTICULATORY/RESONATING SYSTEM ❖ Composed of the oral cavity, nasal cavity, and pharyngeal cavity. ❖ The vocal tract is a resonant acoustic tube that shapes the sound energy produced by the respiratory and laryngeal systems into speech sounds. ❖ Structures of the Articulatory/Resonating System

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Twenty-two bones comprise the facial skeleton and cranium. The mandible articulates with the temporal bone by the temporomandibular joint. Teeth ➢ Adults have 32 teeth within alveolar processes of the mandible and maxilla. ➢ The hard palate is composed of the horizontal bones of the maxilla. ♦ Tongue ➢ The tongue is a muscular hydrostat; it has no bone or cartilage. ➢ It provides its own structural support through contraction of its muscles and has a soft skeleton of connective tissue that surrounds and separates its components. ♦ Velum ➢ The velum is also called the soft palate and is located in the pharynx. ➢ Uvula: The termination of the velum. ➢ Velopharyngeal closure: Contact of the velum with the lateral and posterior pharyngeal walls. ➢ Velar elevation is necessary to prevent air (or food) escaping through the nose and to build up air pressure for production of pressure sounds. ➢ Any air that escapes through the nose during speech can result in a nasal quality. ❖ Lifespan Issues of the Articulatory/Resonating System ♦ The bones of the skull reach adult size by about 8 years of age. ♦ Newborns have 45 separate skull bones that fuse into 22 at adulthood. ♦ Lower facial bones reach adult size at about 18 years. ♦ Dentition emerges at about 6 months of age and is complete at around 3 years. ♦ Secondary dentition is complete at around 18 years. ♦ A newborn’s tongue occupies most of the oral cavity. ♦ The tongue reaches adult size at about 16 years of age. ♦ By 2 months of age, infants are able to close the velopharynx for syllable productions, but not consistently. Consistency is achieved between 6 months and 3 years. ♦ Aging has minimal impact on velopharyngeal function for speech. ♦ The length and volume of the oral cavity increases, which influences the overall resonant characteristics by lowering the frequencies at which the vocal tract naturally resonates.

THE SPEECH PRODUCTION PROCESS ❖ Speech production begins with phonation. ❖ The air pressure that builds up beneath adducted vocal folds is alveolar pressure. ❖ The air pressure from below displaces the lower edges of each vocal fold laterally, followed by the lateral displacement of the upper edges of each vocal fold. ❖ The elastic properties result in the vocal folds colliding, closing off the airway. ❖ Fundamental frequency: The number of cycles of vocal fold vibration per second. ❖ Harmonics: Whole-number multiples of the fundamental frequency. ❖ Sound that results from vocal fold vibration is complex. ❖ Movement of the tongue, lips, and larynx change the shape of the vocal tract and modify sound.

Summary This chapter is a general overview of the anatomy and physiology of the speech and voice mechanism. Although anatomy is static, these structures are capable of dynamic movement that can result in the unique human processes of speech. Knowledge and understanding of this information is important for evaluation and treatment of communication disorders that are a result of breakdown in these systems.

Thought Questions 3.1: How might breathing patterns differ while singing? 3.2: You are drinking water from a bottle. After you have taken a few sips, you blow air across the opening on the top of the opening. Was the sound different the second time you blew across the top of the bottle? The bottle is a resonator. What characteristics of the resonator changed, and how did those changes influence the sound that was produced?

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CHAPTER 4 CHILDHOOD LANGUAGE IMPAIRMENTS Learning Outcomes When you have finished this chapter, you should be able to: 1. Describe language development through the lifespan. 2. Characterize language impairment and associated disorders. 3. Explain the process of assessment in language impairment. 4. Describe the overall design of language intervention.

Introduction Language impairments are a heterogeneous group of developmental and/or acquired disorders and/or delays that principally affect the use of spoken or written language for comprehension and/or production and may involve the form, content, and/or function of language. Language differences are not disorders and so do not require clinical intervention; however, elective intervention is possible at a client’s request.

Content Outline LANGUAGE DEVELOPMENT THROUGH THE LIFESPAN ❖ Pre-Language  Much of the first year of life is spent learning to communicate.  Shortly after birth, infants become actively involved in a reciprocal process with family.  To maintain attention, caregivers exaggerate facial expressions and voice and vocalize more often.  During the first 3 months, caregivers' responses teach children the "signal" value of specific behaviors and infants learn a stimulus-response sequence.  By 3 to 4 months, rituals and game playing emerge.  At about 8 to 9 months, infants develop intentionality in interactions, primarily through gesture.  Intention to communicate is signaled in gestures accompanied by eye contact with a partner, consistent sound/intonation patterns for specific intentions, and persistent attempts to communicate.  The first meaningful word used to express an intention occurs around 12 months.  Better speech perception at 6 months is related to better word/phrase understanding and production later.  Perceptual ability is usually restricted to native language’s speech sounds by 8-10 months.  Learning to represent and symbolize is strongly related to cognitive abilities. ♦ Representation: The process of having one thing stand for another. ♦ Symbolization: Using an arbitrary symbol to stand for something. ❖ Toddler Language  By 18 months, children produce about 50 single words and begin to combine words predictably.  Within a few months, three- and four-word combinations appear.  Use ➢ Children may use a single word for a variety of purposes.  Content and Form ➢ Vocabulary growth increases rapidly. ➢ The ability to comprehend words develops gradually and is highly context-specific at first. ➢ By age 2, children have an expressive vocabulary of about 150 to 300 words. ➢ Children with larger vocabularies use a greater range of grammatical structures. ➢ Lexicon: Each child has a personal dictionary that reflects his or her environment. ➢ Early word combinations follow predictable word-order patterns. ❖ Preschool Language  Children can recount the past and remember short stories because of increased memory.  Preschool-aged children may use substitution, where their utterances differ only slightly from utterances produced previously (“doggies are yucky,” “kitties are yucky,” etc.).  Children form hypotheses about the rules of language and use this to produce more complex language.

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Caregivers provide feedback and models such as repeating the child’s utterance in mature form, or reformulating it.  Use ➢ With caregivers, children introduce topics and maintain them for 2-3 turns. ➢ Preschool children begin to consider the needs of the listener. ➢ Four-year-old children can tell simple sequential stories, usually about past events.  Content ➢ Expressive vocabularies grow to approximately 300 words by age 2, then to 900 and 1,500 at ages 3 and 4, respectively. ➢ They may comprehend two or three times that many in context. ➢ Fast mapping: Inferring meaning from context and using the word in a similar manner. ➢ Acquire locational terms, temporals, quantitatives, qualitative terms, familial terms, and conjunctions. ➢ Semantic development partly reflects cognitive development of skills such as categorization.  Form ➢ Changes in language form are dramatic during the preschool years. ➢ About 90% of adult syntax is acquired by age 5. ➢ Language becomes more complex as it becomes longer; can be calculated in mean length of utterance (MLU) in morphemes. ➢ By age 3, most utterances contain a subject and a verb. ➢ Articles, adjectives, auxiliary verbs, prepositions, pronouns, and adverbs are added. ➢ Adult-like negative, interrogative, and imperative sentences evolve. ➢ What and where develop, followed by who, which, and whose, and finally when, why, and how, and a more mature form in which the verb and subject or the auxiliary verb and subject are reversed. ➢ By the end of preschool, children form compound and complex sentences. ➢ Bound morphemes are added: Present progressive -ing, plural -s, possessive –‘s or –s’, past tense -ed. ❖ School-Age and Adolescent Language  Most communication now occurs in conversations outside the home.  The status of adolescents within their social groups is partly determined by communication skills.  The means of communication changes in school as children learn to read and write.  Metalinguistic skills: Enable the child to consider language in the abstract, make judgments about its correctness, and create verbal contexts.  Language development slows and begins to stabilize.  Many complex forms and subtle linguistic uses are learned in the adolescent period.  Semantic and pragmatic development blossoms.  Use ➢ Conversational skills continue to develop and narratives expand into mature storytelling. ➢ Learn effective ways to introduce new topics, to continue, and to end conversations. ➢ They can make relevant comments and adapt roles and moods to fit situations ➢ Teens demonstrate more affect and discuss topics infrequently mentioned at home. ➢ The number of turns on topic increases greatly. ➢ Interrupting increases but is in the form of asking questions or otherwise moving a topic along. ➢ Narratives, both in conversation and in writing, gain the elements needed.  Content ➢ First graders have an expressive vocabulary of approximately 2,600 words but may understand as many as 8,000 roots and possibly 14,000 when derivations are included. ➢ Receptive vocabulary grows to 30,000 by 6 th grade and to 60,000 words by high school. ➢ Definitions become more dictionary-like, related to the acquisition of metalinguistics. ➢ Multiple word meanings are acquired. ➢ Figurative language: Sayings that do not always mean what they seem to mean, as in idioms. Correlates with adolescent literacy skills.  Form ➢ By age 5, children use most verb tenses, possessive pronouns, and conjunctions. ➢ Five-year-old children also have limited use of the comparative -er and superlative -est, relative pronouns used in complex sentences, gerunds, and infinitives.

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Children gradually add passive sentences, reflexive pronouns, conjunctions such as although and however, and variations of compound and complex sentences. Morphological development focuses on derivational suffixes (as in paint/painter). Development of prefixes such as un-, ir-, and dis- will continue into adulthood.

LANGUAGE IMPAIRMENTS AND ASSOCIATED DISORDERS ❖ Categories are helpful for discussion of shared characteristics. ❖ Children with expressive vocabulary delays at 24 months of age are at increased risk for later speech/language problems and need for SLP services. ❖ The risk of being a late talker at 24 months is strongly associated with being a boy, low SES, not being a single child, older maternal age at birth, moderately low birth weight, low quality parenting, receipt of no day care or for less than 10 hr/week, and hearing or attention problems. ❖ Researchers are identifying important genetic factors that account for variance in children’s conversational language skills. ❖ Research indicates sustained attention deficits in children with LI. ❖ Children who are identified as late talkers at 24-31 months still have a weakness in language-related skills in late adolescence. ❖ When compared to typically-developing (TD) peers, children with LI had poorer outcomes in literacy, mental health, and employment, even at 34 years of age. ❖ Specific Language Impairment  Children with specific language impairment (SLI), increasingly called primary language impairment (PLI), have a disorder primarily characterized by issues with language.  Approximately 10-15% of middle-class U.S. children have delayed language development and about half outgrow it.  There is no obvious cause of SLI.  Children with SLI exhibit language performance significantly lower than their intellectual performance on non-verbal tasks.  SLI affects more males than females and there is an increased prevalence of SLI in families with a history of speech/language problems.  Brain imaging of children with SLI indicates brain symmetry in the left and right hemispheres, unlike the usual asymmetry of left-side predominance in language processing regions.  MRI results suggest different patterns of activation that result in less efficient patterns of functioning in areas critical for communication processing.  Many show marked deficits in working memory: An active process that allows limited information to be held in a temporary accessible state while cognitive processing occurs.  Many children with SLI show several significant limitations in WM mechanisms and in processing speed.  Executive function: The organizing and directing function of the brain.  Preschool children with SLI demonstrate executive function deficits in both visual and linguistic tasks and in less ability to shift tasks and inhibit behaviors.  Other examples of deficits in executive function include problems with both inhibition control and cognitive flexibility and controlling auditory attention.  Lifespan Issues ➢ SLI affects between 4% and 7% of preschool children. ➢ Preschool children with SLI are perceived negatively by their peers and have poor social skills. ➢ Many are later identified as having LD. ➢ Studies have indicated later academic difficulties, especially with language-based activities. ➢ Many adolescents with SLI perceive themselves negatively and are less independent. ➢ Deficits in the vocabulary system of young adults with SLI persist even among those who attend college.  Language Characteristics ➢ Children with SLI have difficulty: • Extracting regularities from language • Constructing word-referent associations for lexical growth • Registering different contexts for language ➢ Pragmatic problems seem to result from an inability to use language forms effectively. ➢ Children with SLI have deficits in the ability to recognize the impact of and to express emotions.

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Difficulty with grammatical morphemes suggests language processing deficits in phonological working memory where words are held while processed. ➢ Expressively, children with SLI may speak more slowly with frequent speech disruptions. ➢ The processing of semantic information in sentences is much slower in preschool children with SLI. ➢ Children with SLI are less efficient in using syntax to aid in vocabulary acquisition, have smaller receptive vocabularies, and difficulties with shorter words such as prepositions, articles, auxiliary verbs, and pronouns. ➢ Children with SLI exhibit persistent problems with morpheme use. ➢ Problems with morphology and less efficient use of syntax to aid vocabulary knowledge. ➢ Word retrieval problems reflect limited semantic knowledge and difficulty inhibiting activation of nontarget competing words. ➢ In addition to language problems, there are often problems in selective attention, working memory, and motor skills. ❖ Social Communication Disorder  Social communication is the ability to communicate with a variety of partners in various situations not only through language but through nonlinguistic means.  These behaviors vary by culture, situations, and partners.  Social communication disorder (SCD) is persistent difficulty in the social use of verbal and nonverbal communication and may include problems in all those areas.  In ASD, social communication problems are one of the defining features of the disorder. In SCD, we do not find the repetitive movements or fixated interests found in ASD.  The presence of SCD can limit effective communication and social participation, negatively affect relationships, and lead to academic and vocational problems.  It is estimated that 4% of all children exhibit characteristics of SCD. ♦ Lifespan Issues ➢ As infants, these children may prefer aloneness and not respond to or imitate others. ➢ Children with SCD may not form strong attachment bonds with their parents and family. ➢ A child with SCD may be slow to develop language and may fall behind in emotional understanding and expression. ➢ Diagnosis of SCD is rare before age 4, and children with mild SCD may not be diagnosed until adolescence. ➢ As teenagers, children with SCD may be bullied by others because of their lack of social skills. ♦ Language Characteristics ➢ The characteristics of SCD include problems with communication for social purposes, including deficits in interactional skills, social cognition, pragmatics, and language. ➢ Social cognition includes understanding and regulating our emotions as they affect others, and involves Theory of Mind (ToM). ➢ ToM is an evolving notion in children that others have a mind and emotions that differ from their own and that these must be considered in communication. ➢ Children with SCD may be very literal in their interpretations of indirect language. ➢ Conversations may be incoherent, with frequent abrupt topic shifts. ➢ Words and meanings may be misunderstood unless explicitly stated, and syntax may not reflect a child’s intended meaning; this may result in frequent communication breakdowns. ❖ Intellectual Disability  Intellectual disability (ID) consists of the following: ➢ Substantial limitations in intellectual functioning ➢ Significant limitations in adaptive behavior ➢ Originates before age 18  ID accounts for approximately 2.5% of the population.  Severity is usually based on the level of IQ and ranges from mild to profound.  Newer severity ratings are based on the amount of assistance an individual needs to get through his or her daily life.  Causes of ID can be biological or socioenvironmental.  Some individuals with ID do not rely on organizational strategies that link words and concepts to one another, nor do they spontaneously rehearse information for easy retrieval.  Memory or retrieval of information is poor and slow.

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Individuals with ID have more difficulty with auditory input (especially linguistic) than with visual input.  Lifespan Issues ➢ Some infants with ID will be identified early because of physical anomalies, at-risk indicators, or delayed development. ➢ It is best for the child if intervention begins as soon as possible. ➢ Some children with ID are not identified until age 2 or 3. ➢ Depending on severity, the child may either attend a regular education class and receive special services, or receive education in a self-contained, special classroom. ➢ Only children with the most profound ID accompanied by other disabilities reside in developmental centers. ➢ Generally, children who cannot reside at home live in community residences with 8 or 10 other children their age and with houseparents. ➢ In adulthood, living and working arrangements vary widely from living in the community and working competitively to being enrolled in day treatment programs.  Language Characteristics ➢ Children with Down syndrome and Fragile X have moderate to severe language delays. ➢ Boys with FXS make phonological errors similar to those of younger typically-developing youth, whereas those with DS have more significant phonological differences. ➢ Boys with FXS produce longer, more complex utterances than do boys with DS. ➢ Language comprehension and/or production can be below the level of cognition. ➢ Children with ID/MR produce shorter, more immature forms. ➢ In later development, the paths begin to differ more from typical development. ❖ Learning Disabilities  A heterogeneous group of disorders that are manifested by significant difficulties in the development and use of listening, speaking, reading, writing, reasoning, or mathematical abilities.  Approximately 15% of children with LD have major difficulty with motor learning and coordination.  More than 75% have difficulty learning and using symbols.  Approximately 3% of all individuals have LD, but severity varies widely.  Learning disabilities affect males four times as frequently as they do females.  Six categories of characteristics: motor, attention, perception, symbol, memory, and emotion.  Attentional difficulties include a short attention span, inattentiveness, and distractibility.  Some children become fixed on a single task or behavior and repeat it compulsively, called perseveration.  Children with perceptual disabilities often confuse similar sounds, similar-sounding words, and similar-looking printed letters and words.  As high as 80% of children with LD have some form of reading problem.  Some children exhibit word-finding problems that result in blocks and the use of fillers or circumlocutions.  Emotional problems are usually a factor that accompanies LD as a reaction to the frustration that these children feel.  Attention Deficit Hyperactivity Disorder (ADHD): An underlying neurological impairment in executive function that regulates behavior, causing impulsiveness.  There are possible biological causal factors, as well as neurological factors.  Socioenvironmental factors may account for (but not cause) at least some of the behaviors.  Children with LD exhibit poor ability to attend selectively, concentrating on inappropriate or unimportant stimuli.  Information that is poorly attended to and poorly discriminated will be poorly organized.  Lifespan Issues ➢ As preschoolers, children with LD may exhibit little interest in language or books. ➢ Linguistic demands of the classroom are often well above oral language abilities. ➢ Many require the services of special educators, SLPs, and reading specialists. ➢ Children with LD can be successful in the regular classroom if some adaptation is made. ➢ Some seem to outgrow aspects of their disability, although some require lifelong adaptations. ➢ Other adults continue to have difficulty.  Language Characteristics ➢ All aspects of language, spoken and written, can be affected in children with LD. ➢ Deducing language rules is particularly difficult.

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➢ Oral language development may be slow, and frequent communication breakdown is possible. ❖ Autism Spectrum Disorder  Children or individuals diagnosed with autism spectrum disorder (ASD) must have all of the following: ➢ Persistent problems in social communication and interaction across different contexts ➢ Problems with social-emotional reciprocity, nonverbal communicative and social interaction behaviors, developing and maintaining relationships appropriate for maturity level ➢ Restricted, repetitive patterns of behavior, interests, or activities characterized by two or more of the following: stereotypes or repetitive motor movements, use of objects, or speech; excessive reliance on routines, ritualized patterns of behavior, or resistance to change; highly fixated and restricted, abnormally intense interests or focus; hyper- or hypo-sensitivity and reactivity to environmental input or unusual interest in sensory information  Motor patterns of behavior may include rocking and fascination with lights or spinning objects.  A child may insist on certain routines or be preoccupied with specific objects, foods, or clothing.  May have an adverse reaction to other sounds or textures.  Incidence of ASD among children is 1 in 88.  Boys are five times more likely to display ASD characteristics.  Most children with ASD have IQs above 70 (above the cutoff for ID).  Approximately 25% of children with ASD exhibit ID.  The primary causal factors in autism are biological.  At least 15% of children with ASD have a genetic mutation not inherited from their parents.  Incidence of ASD is higher among males and among those with a family history of autism.  Eye and face detection processing of children with ASD may be delayed, explaining, in part, the early failure to bond with caregivers.  Overall processing by children with ASD has been characterized as a gestalt in which unanalyzed wholes are stored and later reproduced in identical fashion.  Lifespan Issues ➢ Children with ASD are identified by the time they are 2 or 3 years old. ➢ School-aged children may be included in regular education classes or be in special classes, depending on the severity of the disorder. ➢ People who are mildly involved may live on their own and hold competitive employment. ➢ Many have adult life patterns similar to those of adults with ID, requiring supervision and care.  Language Characteristics ➢ Communication problems are one of the first indicators of possible ASD. ➢ Between 25%-60% of individuals with ASD remain nonspeaking throughout their lives. ➢ Some autistic children who use speech and language demonstrate some immediate or delayed echolalia, which is a whole or partial repetition of previous utterances, often with the same intonation. ➢ Prosodic features such as stress, intonation, loudness, pitch, and rate, are often affected, giving the impression of a mechanical quality. ➢ Pragmatics and semantics are affected more than language form. ➢ Some use entire verbal routines, called formuli. ➢ Those who have good language might still misinterpret the subtleties of conversation. ❖ Brain Injury  Can result from traumatic brain injury (TBI), stroke, congenital malformation, convulsive disorders, or encephalopathy.  Among children, the most common form of injury is TBI.  Traumatic brain injury: May be localized or diffuse brain damage as the result of external force.  Approximately 1 million children and adolescents in the U.S. have experienced a TBI.  Variables include the site and extent of lesion, the age at onset, and the age of the injury.  Some recover fully, others remain in a vegetative state.  People with TBI exhibit a range of cognitive, physical, behavioral, academic, and linguistic deficits.  Psychological maladjustment or acting-out behaviors called social disinhibition may occur.  Lifespan Issues ➢ After an accident, the child may be unconscious. ➢ After regaining consciousness, disorientation and memory loss can occur. ➢ May be accompanied by physical disability and personality changes.

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Neural recovery is often unpredictable and irregular. Young children often recover quickly but experience difficulties learning new information and may exhibit severe, long-lasting problems. ➢ Older children have more to recover from memory but less new information to learn.  Language Characteristics ➢ Language problems may be evident even after mild injuries. ➢ Some deficits, especially in pragmatics, will remain long after the injury. ➢ Language comprehension and higher functions such as figurative language and dual meanings are also often impaired, although language form is relatively unaffected. ➢ Utterances are often lengthy, inappropriate, and off topic, and fluency is disturbed. ➢ Word retrieval, naming, and object description difficulties may be present. ➢ Narration (maintaining story structure and providing enough information) may be difficult. ❖ Other Language Impairments  Include nonspecific language impairment (NLI), late talkers, childhood schizophrenia, selective mutism (SM), otitis media, children who have received cochlear implants, and those who have been exposed to alcohol and drugs during pregnancy, along with those who have experienced abuse and neglect.  Children with NLI have a general delay in language development, a nonverbal IQ of 86 or lower, and no obvious sensory or perceptual deficits.  Child health is an important factor among late talkers, but most early language delay is due to environmental factors, such as poverty and/or homelessness.  Childhood schizophrenia is uncommon; about half have language delay (pragmatics).  In selective mutism, children do not speak in specific situations although they speak in others.  The effect of chronic otitis media can be delayed language development.  Children who receive cochlear implants have relatively typical language development. Those implanted later have an initial advantage of maturity that enhances language growth, but those implanted earlier begin to develop spoken language at an ever-increasing rate that eclipses those implanted later.  Fetal alcohol spectrum disorder (FASD) accounts for 1 in every 500-600 live births. These children demonstrate hyperactivity, motor problems, attention deficits, and cognitive disabilities. Language problems include delayed language development, echolalia or inappropriate repetition, and comprehension problems.  Children with prenatal cocaine exposure (PCE) have mild but persistent deficits in syntax and phonological processing, which adversely affects reading ability.  Each year in the U.S. approximately 900,000 children are maltreated sufficiently for the neglect and/or abuse to be reported to the authorities. Maltreated children demonstrate consistently poorer language skills with respect to receptive vocabulary, expressive language, and receptive language. Pragmatics is the most affected area of language ❖ Aspects of Language Affected ♦ Language impairments can also be characterized by the language features affected. ♦ In evaluations, SLPs assess many language features to determine where to begin intervention.

ASSESSMENT ❖ An SLP’s task is to distinguish between children who have a disorder and those who do not. ❖ Assessment should be sufficiently broad and deep so that all areas of possible concern are identified and described as accurately as possible. ❖ Bilingual Children, English Language Learners, and Dialectal Speakers  21% of the U.S. school-age population speaks a language other than English at home.  Many children speak dialects that differ from the majority American English dialects that teachers use for instruction.  Any assessment of children with culturally and linguistically diverse backgrounds must recognize the possible risk for LI.  Children from low-SES backgrounds with poorer maternal education have an increased incidence of LI.  ELLs and children with dialectal differences are more likely to be identified as needing special education services.  Diagnostic methods for children from culturally and linguistically diverse backgrounds vary widely, and no single measure is adequate.

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Diagnosis includes published tests, language samples, and dynamic assessments that are more open-ended and include descriptions of a child’s use of both English and the first language. Referral and Screening  Referral may occur at any point in the lifespan.  Parents can be effective referral sources for children with more severe language problems.  Screening tests are used to determine the presence or absence of a language problem.  Surveys and parental questionnaires are effective diagnostic tools.  Referral and subsequent evaluation may occur within an interdisciplinary team. Case History and Interview  Questions relate to language development, the language environment of the home, and possible causes for language impairment. Observation  It is helpful to observe a child using language in as many contexts as possible.  Note the child’s interests, topics, style, and methods of communicating.  Also note parental sensitivity to a child’s communication attempts and parental responding to these attempts.  Hypotheses about a child’s LI are formed during observation and are either confirmed or negated during the remainder of the assessment. Testing  Standardized tests are appropriate for determining if a problem exists.  More descriptive test results allow an SLP to explore child’s strengths and weaknesses.  It is best to use a series of testing tasks to ensure that many features of language are assessed.  A combination of tasks using children’s books, such as shared story retelling in which a familiar story element is altered and comprehension questions, may be effective in identifying around 96% of children with LI  Test methodology varies widely.  Unfamiliar tasks may unintentionally prejudice the results against the child.  Dynamic assessment: Probe performance to identify possible intervention procedures.  Test scores should be interpreted cautiously and should not be the only determinant in diagnosing language disorders. Sampling  Engage the child in challenging conversations to reveal difficulties.  A variety of discourse types should be included in the sample.  Narratives or stories are especially helpful for exhibiting deficits in school-age children because of the demands on a speaker.  Posing peer-conflict resolution problems is effective for eliciting grammatically complex utterances with adolescents.  Whenever possible, it is best to collect at least two samples of the child interacting with different partners, locations, and activities or topics.  Typical performance may also be enhanced if parents or teachers interact with a child in familiar settings.  The language transcript can be analyzed in several quantitative and qualitative ways, including mean length of utterance (MLU), average number of clauses per sentence, and the number of different words used within a given period of time.  Descriptive measures might be the variety of intentions expressed by the child, the number of conversational styles used, and the types of repair the child uses when the conversation breaks down.  Code switching: The movement between two languages.  For school-age children experiencing literacy difficulties, an SLP may also want to collect samples of written language.

INTERVENTION ❖ The complexity of language necessitates multiple intervention methods. ❖ Intervention goals should focus on stimulating language acquisition beyond the immediate target. ❖ The most effective intervention approach for older school-age children and adolescents with deficits in syntax is an integrated one in which naturalistic stimulation approaches are supplemented with deductive teaching procedures, in which the child is presented with a rule along with models. ❖ SLPs can include other individuals who work with the child in training.

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❖ Various techniques such as a Teach-Model-Coach-Review instructional approach have been shown to be effective. ❖ Target Selection and Sequence of Training  The goal is the effective use of language to accomplish communication goals within everyday interactions.  The child’s abilities are an important determiner of the method selected.  Training should be within meaningful communication contexts when possible. ❖ Evidence-Based Intervention Principles  Targets should not focus exclusively on one deficit area. ❖ Intervention Procedures ❖ SLPs teach by anticipating the types of support that a child is likely to need and the types of errors the child is likely to make.  Basic tenets of good teaching behavior include: ➢ Model the desired behavior ➢ Cue the child to respond • Cues may be verbal or nonverbal. • Each type of cue or prompt should be rated from least to most intrusive and supportive. ➢ Respond to the child in the form of reinforcement and/or corrective feedback • Natural reinforcers flow from the training target. • Corrective feedback may range from a gentle reminder to an instruction. • As a language feature is produced more correctly, the SLP relies less on direct forms of reinforcement/correction. ➢ Plan for generalization of the learned feature to the everyday environment  Success occurs when the language feature generalizes to a child’s everyday environment. ❖ Intervention through the Lifespan  Early intervention, especially for children with ID and ASD, can be very beneficial.  Initial training might target presymbolic communication skills and cognitive abilities.  Parents might be trained to treat their child’s behaviors as having some communicative value or to interpret consistent behaviors as attempts to communicate.  An SLP may attempt to establish an initial communication system by using an AAC system.  Early symbolic training may focus on vocabulary, semantic categories, word combinations, and early intentions.  Preschool children usually work on language form in both conversations and narratives.  Intervention with school-age children may focus on pragmatics and semantics.  Academic skills might also be targeted.  SLPs may use computerized programs to supplement more face-to-face intervention.  Adolescents may continue to exhibit language impairments and be in need of services.  Adults with severe ASD or ID will most likely require continued intervention for language and communication deficits.  Individuals with LD may require additional support in postsecondary education.

Summary Several disorders associated with language impairment (LI) were discussed in this chapter. LIs are very complex. It is important to remember that each child is unique. As a result of the assessment process and through repeated assessment during intervention, the SLP attempts to find the most efficient and effective method for teaching new skills.

Video Examples Video Example 4.1: Introduction to and overview of learning disabilities and how they affect language Activity suggestion: Before watching the video, ask students to share what they know about learning disabilities and what professional or personal experiences they have had with individuals with LD. Video Example 4.2: An autism meltdown Activity suggestion: Ask students if they are aware of any strategies that might be helpful in a situation such as this. In addition, ask them to consider how having a child with autism and behaviors seen in this video might impact a family.

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Video Example 4.3: The good side of autism Activity suggestion: Discuss the things Ian’s family reported as his strengths and the things he likes. How are they similar to or different from the children or adults with autism with whom your students are familiar (or media representations)? Video Example 4.4: Sentence recasts Activity suggestion: After watching this video, provide students with a list of utterances that a young child might say. Ask students to pair up. One student will say the child-like utterance, and the other student will practice sentence recasts. Halfway through the list of utterances, have students switch roles.

Thought Questions 4.1: At what ages would you say children are able to participate in communication, comprehend language, or hold up their end in a simple conversation? On what would you base these decisions? 4.2: If you understand the underlying cause for a type of language disorder, you can often predict the aspects of language that will be difficult. Let’s take two different disorders with similar outcomes. Children with SLI and those with LD both tend to omit morphological endings but for different reasons. With limited capacity, children with SLI tend to not remember endings. Those with LD often misperceive morphological endings or do not notice them at all. 4.3: Why is pragmatics or language use so frequently the aspect of LI seen in several disorders? Is it related to the nature of pragmatics and how it differs from other aspects of language? 4.4: Did you think initially that testing alone would be sufficient for assessing LI? Can you think of some reasons why testing may not give a total picture of a child’s communication?

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CHAPTER 5 SPEECH SOUND DISORDERS Learning Outcomes When you have finished this chapter, you should be able to: 1. Explain how speech sounds (vowels and consonant) are classified. 2. Outline the sequence of normal speech sound acquisition across the lifespan. 3. Discuss types of children’s speech sound disorders, associated disorders, and related causes. 4. Describe the goals and procedures in speech sound assessment. 5. Describe approaches and techniques for treatment of articulatory and phonological disorders, including supporting evidence.

Introduction Speech sound disorders in children refer to difficulties related to how speech sounds are used in the language (i.e., phonology), and how sound of the language are produced (i.e., articulation). Causes of speech sound disorders include impairments in the phonological representation of speech sounds, including knowledge of the rules that govern sound combinations; an inability or difficulty perceiving speech sounds; structural abnormalities that affect the integrity of the speech production mechanism; and/or motor speech disorders such as dysarthria and childhood apraxia of speech. Speech sound disorders can be mild in severity, as in when the impairment affects a single sound, to more severe, as in when the child deletes all sounds in the final position of words.

Content Outline UNDERSTANDING SPEECH SOUNDS ❖ ❖ ❖ ❖ ❖ ❖

Spoken English has about 43 different speech sounds or phonemes. Phonemes and letters are not the same. Phonotactic rules exist that specify acceptable sequences and locations. Allophones are variations of phonemes. Aspiration is a little puff of air that can follow a sound such as /p/ or /t/. Classification of Speech Sounds  Phonemes are often categorized as either vowel or consonant.  Consonant phonemes may be classified by place of articulation, manner of production, and voicing.  Vowels are normally described according to tongue and lip position and relative degree of tension in the articulators. ❖ Classification of Consonants by Place, Manner, and Voicing  The point of contact or constriction is used to classify consonants by place.  Consonants can be: ➢ Bilabial, labiodental, interdental, linguadental, alveolar, palatal, velar, glottal.  Consonants are characterized by the degree of constriction or closure somewhere along the vocal tract, referred to as the manner of consonant production.  Complete closure of the vocal tract in which airflow is completely blocked results in stop consonants.  Fricatives are produced with a narrow passageway for the air to pass through.  Affricates begin as stops and are released as fricatives.  Nasals are the only sounds produced with an open velopharyngeal port so that the sound energy comes through the nose opposed to the mouth.  Glides occur when the articulatory posture changes gradually from consonant to vowel.  Liquids include /r/ and /l/ and are produced with an open vocal tract, and are thus considered vowel-like consonants.  Voicing refers to what the vocal folds are doing during consonant sound production; consonants can be either voiced or voiceless.  Consonants that have the same place and manner but differ with regard to voicing are called cognate pairs. ❖ Classification of Vowels by Tongue and Lip Position and Tension

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Vowels are produced when the sound energy produced by the vibrating vocal folds is modified and resonated by the opened vocal tract. The sound made is dependent upon which part of the tongue is elevated (front, center, back), its height (high, mid, low), and the amount of tension (tense, lax). Whether lips are rounded or retracted influences the sound. When two vowels are said in close proximity, they produce a diphthong.

NORMAL SPEECH SOUND ACQUISITION THROUGH THE LIFESPAN ❖ Most children can produce English speech sounds by early elementary school. ❖ Speech Sound Emergence  Disappearance of the newborn’s reflexive sounds is partially due to increased brain growth and myelination (development of the protective myelin sheath around the cranial nerves).  Infants initially cry on both inspiration and expiration.  Crying helps children get used to air flow across the vocal folds and to modifying breathing.  Noncrying sounds usually accompany feeding or caregiver interactions.  By 2 months, infants develop nondistress sounds called either “gooing” or “cooing.”  By 3 months, infants vocalize in response to the speech of others.  Between 4 and 6 months, infants are able to imitate tone and pitch and begin babbling (random vocal play).  At 6-7 months, infants’ babbling changes to reduplicated babbling (strings of consonant-vowel syllable repetitions or self-imitations).  Between 8 and 12 months, children begin to imitate sounds that they have produced spontaneously on their own.  Gradually, infants begin to use variegated babbling (adjacent and successive syllables in the string are purposely nonidentical).  In the second half of the first year, children begin to recognize recurring patterns of sounds within specific situations and may produce them in those situations.  Infants may experiment with jargon, long strings of syllables with adult-like intonation.  Speech sounds develop sound-meaning relationships called phonetically-consistent forms, which function as protowords or “words” for the infant.  Children adopt a problem-solving or trial-and-error approach to word production. ❖ Toddler Speech  The first recognizable word is produced around 12 months.  When faced with a difficult word, children adopt similar strategies, or phonological patterns (or processes).  Toddlers often omit final consonants.  Multisyllable words may be reduced to one or two syllables, or the syllables may be repeated.  Consonant blends might be shortened to single consonants.  One type of sound might be substituted for another. ❖ Preschool Speech  Most of the phonological patterns described for toddlers disappear by age 4.  Consonant blends may continue to develop into early elementary school.  Children who experience phonological difficulties continue to use immature phonological patterns.  Children continue to master new speech sounds throughout the preschool period.  A sound may be produced correctly in single words but not in connected speech.  Phoneme acquisition is gradual and depends on the sound, its location, frequency, and proximity to other sounds.  Vowels are easier to master than consonants.  Many sounds are first acquired in the initial position in words.  Consonant clusters are not mastered until age 7 or 8.  Some sounds are easier than others to produce and are acquired early. Stops, nasals, and glides are usually first.  Sounds that are more difficult to produce are acquired later, including fricatives, affricates, and liquids.  Much individual difference exists.  Most children can produce all of the English speech sounds correctly by the age of 8.  Children with neurological disorders, sensory deficits, genetic syndromes, perceptual problems, or poor learning skills have difficulty acquiring all sounds of the language.

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❖ School-Age Speech  By early elementary school, the phonological system resembles that of adults.  Morphophonemic contrasts (changes in pronunciation as a result of morphological changes) take several years to master, extending into adulthood.  Five-year-olds still have difficulty with a few consonant sounds and with consonant blends.  Six-year-olds have acquired most English speech sounds.  By age 8, children have acquired consonant clusters. ❖ Phonology and Articulation  The correct use of speech sounds within a language requires knowledge of the sounds of the language and the rules that govern their production and combination (phonology).  Speech requires neuromotor coordination to say sounds, words, and sentences (articulation).  Phonological impairments are disorders of conceptualization of language rules.  Open syllable: Ends in a vowel.  Closed syllable: Ends in a consonant.  Articulation impairments are disorders of production and are therefore motor based. ➢ Substitutions ➢ Omissions ➢ Distortions ➢ Additions  Distinguishing speech sound disorders as impairments in phonology or articulation can be difficult, especially in young children.  Some individuals have disorders of both phonology and articulation.

ASSOCIATED DISORDERS AND RELATED CAUSES ❖ When a child is not acquiring speech sounds at the expected rate based on normative data, or when a young child produces errors on later-developing sounds, he or she is said to be delayed. ❖ Some researchers argue that these children are actually disordered in their speech sound development, since a delay can lead to some aspect of speech or language eventually becoming disordered. ❖ For most children with speech sound disorders, there is no obvious cause or the cause is difficult to determine. ❖ Speech Sound Disorders of Unknown Origin  Three subtypes of speech sound impairments of unknown etiology include a family history of speech or language problems, a history of early and frequent ear infections that involve fluid buildup behind the middle ear, or a personality that makes it more difficult for the child to master speech sound production skills.  Three subtypes of speech sound impairments of unknown origin are believed to result from motor speech impairments.  The last two subgroups represent children who exhibit distortion errors of later developing sounds.  Trying to determine a specific cause or causes for the child’s speech sound impairment is important in ultimately choosing the most effective treatment approach for the child.  Lifespan Issues ➢ Approximately 75% of preschool children will normalize their speech sound errors by age 6 with or without treatment, and the majority will normalize by age 8. ➢ Errors that persist may have a negative impact on an individual’s academic or professional accomplishments, as well as on personal relationships. ➢ Speech production patterns become habituated and increasingly difficult to change as we get older. ❖ Correlates of Speech Sound Disorders  Correlates (related factors) are important to consider because the causes of speech sound disorders are not readily identifiable.  Correlation means that two or more things occur together but one does not necessarily cause the other.  Examples of relevant correlates of speech sound disorders include hearing loss, impaired oralmotor skills, feeding difficulties, cognitive impairments, low maternal education, etc. ❖ Cognitive Impairments  There is a poor relationship between intelligence and speech sound production skill.  This indicates that other factors (e.g., anatomical differences, impaired motor control processes, poorer short-term memory skills) contribute to the speech sound disorder.

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Lifespan Issues ➢ Speech production abilities of cognitively impaired children are noticeably different from typically developing children by about age three. ➢ Children with cognitive impairment show significant variability in the emergence of speech sounds. ➢ Persistent use of error patterns that are more typical of very young children is also common. ➢ Children and adults with Down syndrome exhibit vowel errors, inconsistent errors, and prosodic abnormalities, which are consistent with childhood apraxia of speech. Language Impairments  Children who have language impairments may also be impaired in speech sound production.  There are more complications than with a speech sound impairment alone.  Lifespan Issues ➢ Speech sound disorders are likely to affect the acquisition of reading and writing skills. ➢ May have poor phonological awareness skills. Male Sex  Speech sound delay tends to be more common in preschool-aged boys.  One possible reason is the slower rate of maturation of certain cognitive processes such as attention and planning.  Also, brain areas that control the ability to perform certain fine motor and tactile tasks are different in males and females.  Lifespan Issues ➢ Many tests of articulation and phonology have separate normative data for males and females to account for differences in speech sound acquisition rate in early childhood. ➢ The differences between boys and girls ultimately disappear as children get older. Hearing Loss  Phonology, voice quality, pitch, rate, and rhythm will be similarly affected.  Although an exact relationship between type and degree of hearing loss and speech cannot be made, certain patterns are frequently observed.  Lifespan Issues ➢ Individuals who are born deaf or with severe hearing impairment typically have poorer speech than those who lose hearing later in life. ➢ Speech deteriorates over time for those who lose their hearing after learning to talk. ➢ Accuracy of speech sound production can be enhanced by hearing aids and training. Structural Functional Abnormalities  Usually only gross abnormalities of oral structures negatively impact speech intelligibility.  Individuals are remarkably adept at compensating for most structural abnormalities.  Severe deformity of the hard and soft palates as a result of clefting is far more detrimental.  Lifespan Issues ➢ Many children born with craniofacial anomalies (congenital malformations of the head and face) struggle with speech sound acquisition, feeding, and breathing. ➢ Clefts of the lip are typically surgically closed at 3 months of age. ➢ Clefts of the hard and soft palates are closed between 9 and 12 months of age. ➢ Additional surgeries are usually necessary later to treat continued difficulties with velopharyngeal closure. ➢ High pressure consonants, fricatives, and affricates are often problematic for individuals with cleft palate. ➢ Normal articulation can be expected in about 25% of preschoolers with repaired cleft palate who receive care early on from a qualified team of professionals. Dysarthria  The dysarthrias are a group of motor speech disorders caused by neuromuscular deficits that result in weakness or paralysis and/or poor coordination of the speech musculature.  About 90% of children with cerebral palsy (a neuromotor disorder caused by brain damage that occurred sometime before, during, or soon after birth) exhibit some form of motor speech impairment.  Location and severity of brain damage predict dysarthria type and degree of impairment.  Articulatory difficulties and reduced speech intelligibility are common problems for children with CP.  Lifespan Issues ➢ In CP, the general motor and speech signs are present from early childhood onward.

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➢ Approximately 1/3 of individuals with CP have normal intelligence. ➢ Accompanying deficits are epilepsy, visual processing deficits, and hearing impairment. ➢ General motor functioning may deteriorate over time. ➢ The symptoms of dysarthria may become more severe with increasing age. ❖ Childhood Apraxia of Speech (CAS)  Neurological speech sound disorder that affects the ability to plan and/or program the movement sequences necessary for accurate speech production.  Speech is often unintelligible, segmented/choppy, disfluent, or lacking in prosodic variation.  Children may be aware that speech is difficult and are often unwilling to try to talk.  Speech characteristics that may assist in diagnosing CAS include inconsistent errors on consonants and vowels in repeated productions of syllables or words; lengthened and disrupted transitions between sounds and syllables; and inappropriate prosody, especially in the realization of word or phrasal stress. May have limited consonant and vowel repertoires, exhibit groping or trial and error behaviors, omit or inappropriately add sounds, and have difficulty with running speech.  Often have concomitant expressive language and phonological impairments.  Lifespan Issues ➢ Children can be diagnosed as early as 3 or 4 years of age. ➢ Standardized assessments are available, but no one test has been shown to be completely reliable or valid with regard to diagnosing CAS. ➢ Strand’s 10-point checklist provides the 10 speech and prosodic features that are frequently associated with CAS. ➢ Children with severe CAS may be nonverbal early on. ➢ Normal or near-normal cognition and receptive language are good prognostic indicators for verbal communication. ➢ Likely have difficulties with phonological awareness, reading, writing, and spelling. ➢ The most readily apparent difficulties are prosodic abnormalities for those who persist with motor planning/programming difficulties. ➢ CAS is a speech diagnosis that changes with maturation and treatment. ❖ Language and Dialectal Variation  Must differentiate between disordered phonology and language or dialectal differences using a variety of techniques and assessments.  If dialect differences are targeted, the SLP must assess the client’s attitude toward his or her dialect and the individual’s motivation for accent reduction. ❖ Characteristics of Articulation and Phonology in Dialectal Variation  Many variations in articulation and phonology reflect non-English or dialectal influences.  The first language may interfere with languages learned later.  Some first language interference is neutral or positive.  Lifespan Issues ➢ Some adults for whom English is a second (or third or fourth) language choose to modify their foreign accent. ➢ For adolescents and beyond the articulatory patterns of a first language are often firmly established and are difficult to entirely eliminate. ➢ The goal is not to make a non-native speaker sound like a native, but to improve intelligibility and thereby the person’s communicative effectiveness.

SPEECH SOUND ASSESSMENT ❖ The goals of speech sound assessment are to:  Describe the speech sound system and determine if it deviates from normal to the extent that treatment is necessary  Identify phonological patterns if they are present  Determine the impact of speech sound errors or error patterns on communication  Identify factors that relate to etiology or maintenance of the speech sound impairment  Determine the intervention approach or approaches to be used, and the behaviors to be targeted during therapy  Make a prognosis about the likelihood of change with and without treatment  Monitor change over time ❖ The case history, interview, hearing screening, and oral peripheral examination provide insight into the etiology of the disorder and contribute to prognosis. ❖ Collection of baseline data is an integral part of the assessment.

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❖ Description of Phonological and Articulatory Status  Speech Sound Inventory ➢ Appropriate for young children and for those whose speech is markedly unintelligible.  Syllable and Word Structure ➢ List most common word and syllable shapes as well as reductions or simplifications.  Sound Error Inventory ➢ The SLP identifies phonemes that the client misarticulates. ➢ Standardized assessments are available. ➢ Sound errors: Substitutions, omissions, distortions, and additions. ➢ Errors can be compared with norms for the child’s age.  Phonological Pattern Analysis ➢ Targeting a pattern encourages generalization to similar phonemes and contexts. ➢ Standardized assessments and computerized programs can be used to analyze phonological patterns.  Intelligibility ➢ Speech intelligibility refers to how easy it is to understand the individual. ➢ Depends on factors such as number, type, and consistency of speech sound errors. ➢ Voice, fluency, rate, rhythm, language, and use of gesture also contribute. ➢ Other factors include the listener’s hearing acuity, familiarity with the speaker, and experience listening to disordered speech, plus noise, message complexity, and cues. ➢ A measure of intelligibility is percentage of intelligible words or percentage of intelligible syllables/consonants. ❖ Prognostic Indicators  Include the client’s age, severity of the disorder, other medical and concomitant problems, and availability of family support.  For adults, etiology largely impacts prognosis.  For children, error consistency, stimulability, and the ability to discriminate errors may help.  Consistency ➢ Lack of consistency is a positive prognostic indicator. ➢ An individual with consistent errors may be easier to understand. ➢ Inconsistent errors, though, can be indicative of motor planning/programming deficits, which are more difficult to remediate than speech sound errors associated with phonological impairments. ➢ Evaluate speech during more than one task and in more than one context.  Stimulability ➢ The ability to produce the target phoneme when given focused auditory and visual cues. ➢ Children who are stimulable may respond more quickly to correction of the target phoneme and may also be more likely to self-correct without therapy. ➢ Sounds for which a child is not stimulable are highly unlikely to change without treatment. ➢ Among children in therapy, those with low stimulability scores often make more progress, especially with untreated sounds, than do those who are more stimulable.  Speech Sound Discrimination ➢ External or interpersonal error sound discrimination refers to the ability to perceive differences in another person’s speech. ➢ Internal or intrapersonal error sound discrimination is the ability to judge one’s own ongoing speech. ➢ Children who are better at internal discrimination have been reported to have more correct articulations. ➢ Error sound discrimination ability signals a more favorable prognosis.

TREATMENT FOR SPEECH SOUND DISORDERS ❖ Target Selection  Goal is to make the client easier to understand and improve communicative effectiveness.  Factors in target selection are phoneme frequency and likelihood of success.  Greater generalization to nontarget phonemes may occur when targets are more difficult. ❖ Treatment Approaches  Most SLPs adjust their approach to suit each client and combine procedures to provide individually-tailored therapy.  Bottom-Up Drill Approaches

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Progression from the simplest to the most complex movements. Each error sound is targeted one at a time. Speech assignments promote generalization after mastery in therapy. Instruction on self-monitoring of correct speech sound production and/or monitoring by others may be introduced. ➢ Traditional motor approach: Begins with auditory discrimination training, establishment of the new sound, production in isolation, nonsense syllables, words, phrases, sentences, and conversation, and generalization maintenance and practice. ➢ Sensory-motor approach: There is no auditory discrimination training; it begins with production at the syllable level.  Language-Based Approaches ➢ Instruction is implicit, or within the context of learning language. ➢ Not appropriate for children who have severe speech delays and require more direct, structured speech practice. ➢ Have proven effective for generalization to spontaneous speech following drill.  Phonological-Based Approaches ➢ Children who have multiple speech sound errors and are highly unintelligible may benefit. ➢ Cycles approach: Starts with the most stimulable phonological process and progresses through multiple cycles until all phonological processes have been addressed. Each session involves a review, auditory-perceptual training, and production of selected targets using drill play. ➢ In minimal pair contrasts, the child is presented with two pictured words that differ by one phoneme, one of which is the child’s error sound/pattern, and the other is the correct form. The child is to produce both words in sentences and determine whether the sentences make sense. ➢ Multiple Oppositions Approach: Uses maximal contrasts, and is effective for children who substitute one sound for multiple sounds. ➢ Metaphon Approach: Aims to increase metaphonological skills. ▪ Phase 1: Focus on expanding knowledge of the sound system. ▪ Phase 2: Focus on transferring knowledge to communication situations and teaches selfmonitoring and self-correction.  Complexity Approach ➢ Training more difficult sounds leads to generalization of untreated, less complex sounds. ➢ Considered more efficient. ➢ It may take longer initially to train production of more complex targets. ➢ Success depends on severity, frustration level, and overall goal of therapy. ❖ Treatment of Motor Speech Disorders  Dynamic Temporal and Tactile Cueing ➢ An intensive, motor-based, drill-type treatment for children with severe CAS. ➢ Treatment targets include a small number of functional words and phrases. ➢ Target words are practiced slowly and produced simultaneously with the clinician. ➢ Moves to direct imitation, delayed imitation, and spontaneous productions. ➢ The clinician may use tactile cues. ➢ The goal is to produce the word correctly spontaneously, both in and out of the clinic. ➢ 5-10 minutes of home practice daily with family members is recommended.  Lee Silverman Voice Treatment ➢ An intensive treatment provided 4 days a week, 60 minutes per session, for 4 weeks. ➢ Originally designed to increase loudness levels of patients with Parkinson disease. ➢ It has been successfully used with children with CP with slight modifications. ➢ Must obtain proper training and certification prior to using this approach with clients.  Computer Applications ➢ Computer programs and games can be used in conjunction with direct treatment. ➢ Provide an opportunity for daily practice, which is essential when learning new skills. ❖ Generalization and Maintenance  Many SLPs introduce self-monitoring exercises at the beginning of therapy.  Once a client is ready for dismissal, follow-up sessions may be scheduled.  If progress is maintained over time, remediation has been successful.

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Summary Producing the sounds of a language during speech is a complex process. As children develop spoken language, they typically use phonological patterns that simplify adult forms. If these persist beyond the expected ages, they may present difficulties. Assessment of articulation and phonology includes a detailed description of the individual’s speech sound system, as well as investigation of etiology and determination of prognosis. The general goal of intervention is to improve intelligibility in spontaneous speech.

Thought Questions 5.1: How does speech differ for someone who has congenital deafness versus someone who became deaf later in life? Why? 5.2: If you had your own clinic or private practice, which standardized articulation or phonological tests (if any) would you purchase, and why? 5.3: Do you think iPad apps that target speech production are a good way for kids with speech sound disorders to practice at home? Why or why not?

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CHAPTER 6 DEVELOPMENTAL LITERACY IMPAIRMENTS Learning Outcomes When you have finished this chapter, you should be able to: 1. Explain important aspects of reading and their development. 2. Characterize reading problems through the lifespan. 3. Detail assessment and intervention for reading impairment. 4. Explain important aspects of writing and their development. 5. Characterize writing problems through the lifespan. 6. Detail assessment and intervention for writing impairment.

Introduction Literacy is the use of visual modes of communication, specifically reading and writing. It encompasses language, academics, cognitive processes, and is related to other forms of communication. Reading and writing are not just speech in print. There seems to be an interaction between a child’s early reading abilities, conversational language abilities, and history of language difficulties. As many as 60% of children with language impairments (LI) experience difficulty with literacy. Because children with LI are at high risk for literacy disabilities, preliteracy, reading, and writing assessment should be a portion of a language evaluation when appropriate. Assessment and intervention for literacy are also vital parts of rehabilitation for adults with neurological impairments. Literacy and associated skills, disorders, assessment, and intervention will be discussed in this chapter.

Content Outline READING ❖ Several steps are involved in reading and reading comprehension. ❖ Decoding: Segmenting a word and blending the sounds together to form a word. ❖ Words take on more meaning based on grammar and context. ❖ We interpret what we read based on what we know, which is called comprehension. ❖ An active reader uses self-monitoring, semantic organization, summarization, interpretation, mental imagery, connection with prior knowledge, and metacognition. ❖ Phonological Awareness (PA)  Knowledge of sounds/syllables and the sound structure of words.  It includes phonemic awareness, which is the ability to manipulate sounds, such as blending sounds to create new words or segmenting words into sounds.  PA is related to reading skills.  The ability to determine a word when a phoneme or syllable is deleted, to blend, or create a word from individual sound and syllables, and to compare initial phonemes for likeness and difference are areas of PA that are important for reading development. ❖ Morphological Awareness  By 10 years of age or earlier, awareness of and knowledge about the morphological structure of words is a better predictor of decoding ability.  Morphological complexity of words increases as children progress into middle school. ❖ Comprehension  There are several levels of text comprehension.  At the basic level, the reader is primarily concerned with decoding.  Meaning is actively constructed from words and sentences and from personal meanings and experiences.  Critical literacy: Active analysis and synthesis of information; ability to explain content.  Dynamic literacy: Relate content to other knowledge through reasoning; comparing/contrasting, integrating, and using ideas for raising problems and solving them.  Comprehension occurs as a reader combines text, text grammar, and world knowledge and experience.  Metacognition: Knowing what to do and how to do it. Two aspects are important for reading: ➢ Self-appraisal: Knowledge of one’s own cognitive processes.

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Executive function: Self-regulation that includes the ability to attend; set reasonable goals; to plan and organize to achieve goals; to initiate, monitor, and evaluate performance in relation to goals; and to revise plans and strategies based on feedback. ❖ Reading Development Through the Lifespan  Emerging Literacy ➢ Reading development begins around age 1 when books are shared with toddlers. ➢ Dialogic reading: An interactive method of reading picture books. ➢ Print awareness: Early on, it consists of knowledge of the meaning and function of print, basic concepts concerning the direction print proceeds across a page and through a book, and recognition of some letters. Begins to develop around age 3. Later, it includes recognizing words as discrete units, being able to identify letters, and using terminology such as letter, word, and sentence. ➢ Children with good language seem to enjoy reading and pretend to read at an early age. ➢ By age 4, children notice phonological similarities and syllable structure and may find rhyming funny. ➢ Many preschool teachers have limited training in emergent literacy, but they can learn to facilitate development of emerging literary skills. ➢ The best predictors of kindergarten reading status are oral language, alphabet knowledge, and print concept knowledge. ➢ By middle and high school, overall language predicts both decoding and reading comprehension. ➢ In children with speech sound disorders, vocabulary predicts both decoding and reading comprehension at early elementary school. ➢ By kindergarten, additional variables seem to predict reading success by second grade, including rapid automatized naming (RAN) and maternal education level. ➢ Children develop reading skills more rapidly at earlier ages. ➢ Phonics: Sound-letter correspondence. ➢ Reading becomes more automatic or fluent, aided by grapheme-phoneme patterns in memory and by analogy. ➢ By third grade, there is a shift from learning to read to reading to learn.  Mature Literacy ➢ Mature readers use very little cognitive energy determining word pronunciation. ➢ Language and experience are used to understand the text, which is monitored to ensure the information makes sense. ➢ Prediction of the next word or phrase aids quick processing. ➢ Reading is an active process in which ideas and concepts are formed and modified, details remembered and recalled, and information checked. ➢ Reading skill continues to be strong through adulthood, as long as we exercise our ability and do not experience any neuropathologies. ➢ Reading is one of the primary ways adults increase their vocabulary and knowledge.

READING PROBLEMS THROUGH THE LIFESPAN ❖ Risk of reading difficulties is greatest for children with a history of problems in both articulation and receptive and expressive language. ❖ Poor reading comprehenders have deficits in oral language comprehension, but normal phonological abilities. ❖ Children who are poor decoders have poor phonological abilities but little or no oral language comprehension difficulties. ❖ Children from low SES environments acquire language skills more slowly, have delayed letter recognition and phonological awareness, and are at risk for reading impairment. ❖ Children with a specific learning disorder in literacy (SLDL) have learning disorders primarily manifested in reading and writing (previously dyslexia). ❖ Children with SLDL have poor word recognition or decoding abilities, accompanied by problems with phonological processing. ❖ Three types of SLDL have been described, including a language-based disorder that may affect comprehension and/or speech sound discrimination, a speech/motor disorder that may affect speech sound blending and motor coordination, and a visuospatial disorder that may affect letter form discrimination. The language-based disorder is the most common.

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❖ Children with SLI may be similar, exhibiting grapheme-phoneme errors and syntactic, semantic, and pragmatic errors when reading; comprehension may also be impaired and may be related to poor vocabulary. ❖ Children with hyperlexia have poor comprehension but typical to above-average word recognition ability. This can occur in some children with ASD. ❖ Causal factors for literacy impairment may be extrinsic or intrinsic to an individual.  Extrinsic: These factors may include early exposure to books, reading experience, and the manner of instruction.  Intrinsic: These factors may include genetics, vision-based deficits, auditory processing problems, attention deficits, language impairment, and neurological problems. ➢ Many children with ASD have accompanying literacy impairments and uneven development of skills that are predictive of reading.  Severely delayed in vocabulary.  Oral narratives are challenging.  Often excluded from standard literacy curricula. ❖ Children with LD acquire reading skills more rapidly in the initial stages and then gradually slow; these children are substantially below typical readers by 5 th grade. ❖ Some children might memorize word shapes, letter names, or guess rather than decoding. ❖ Poor reading comprehension is associated with poor oral language. ❖ Poor readers lack strategies to guide and control their reading (poor executive functioning). ❖ Many children with language impairments are at risk for reading impairment. In general, they:  Begin with less language and have difficulty catching up.  Have poor comprehension skills because they lack language knowledge that would enable them to integrate what they read.  Have poor metalinguistic skills.  Possess linguistic processing difficulties. ❖ As adolescents, poor readers exhibit vocabulary, grammar, and verbal memory deficits. ❖ There is a significant negative correlation between children’s nonmainstream dialect use and reading achievement.

ASSESSMENT AND INTERVENTION FOR READING IMPAIRMENT ❖ Assessment of Developmental Reading  Early literacy questionnaires often ask about the frequency of book reading, responses to print, language awareness, interest in letters, and early writing.  Information can be gathered from interviews with teachers, parents, and the child and by observation within the classroom.  Reading assessment should include standardized measures, oral language samples, analysis of miscues, and written story retelling, as well as comprehension measures.  Phonological Awareness ➢ Assess reading, spelling, phonological awareness, verbal working memory, and RAN. ➢ Informal assessment can address rhyming, syllabication, segmentation, phoneme isolation, deletion, substitution, and blending.  Word Recognition ➢ Decoding is the basis for word recognition. ➢ Guidelines for assessment: • Materials should be age and developmentally appropriate. • Tasks should be of various types to assess different levels of processing. • Several measures should be used. • Cultural and linguistic background must be considered. • Unfamiliar tasks need to be demonstrated and trained. • Reading deficits are not limited to children with emergent literacy skills. • Observation and interpretation of test behaviors is important. ➢ Curriculum-based measures and dynamic assessment may be more appropriate for children with language impairments or cultural and linguistic differences. ➢ Word recognition testing should be done with and without clues. ➢ Note all errors, types of errors, and the way in which the child sounds out words so that potential strategies can be noted.  Morphological Awareness ➢ SLPs should examine adolescent students’ understanding of common morphemes.

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➢ Actual words can be chosen based on frequency of word use in text and curricular materials. Text Comprehension ➢ At the very least, asses a child’s: ▪ Oral language with attention on syntactic style used in literature ▪ Knowledge of narratives and text grammar ▪ Metacognition ➢ Norm-referenced tests should be supplemented by measures of a child’s ability to identify grammatical units, interpret and analyze text, make inferences, and construct meaning by combining text with personal knowledge and experience.  Executive Function ➢ Good readers read actively and with purpose, constructing mental models and organizing information as they go. ➢ Self-regulation in reading can be assessed by: ▪ Interview questions about different strategies used for different reading tasks ▪ Think-alouds or verbalizing thoughts accompanying reading ▪ Error or inconsistency detection while reading ❖ Intervention for Developmental Reading Impairment  The SLP supports the instruction of the other team members.  An embedded/explicit model of intervention may be used wherein children participate in both literacy-rich experiences in the daily curriculum and in explicit therapeutic teaching of reading.  Effective instruction for reading should include sound and letter processes used in word identification, grammatical processes, and the integration of those with meaning and context.  Print awareness can be improved with print-focused reading activities, emphasizing word concepts, and alphabetic knowledge.  Most integrated approaches to preliteracy and early literacy consider two semi-independent sets of preliteracy skills: meaning foundations (vocabulary and sentence-level skills) and form foundations (learning about the alphabet and becoming aware of phonological units within spoken words).  Later, intervention might target both linguistic and metalinguistic skills.  Phonological Awareness ➢ Children who receive phonological awareness training have higher phonemic awareness, word attack, and word identification skills at the end of kindergarten. ➢ Phonological awareness intervention should begin before children lag too far behind, most likely in preschool or kindergarten. ➢ Phonological awareness should be taught within meaningful text with older children. ➢ Programs that focus on one or two phonological awareness skills yield better results. ➢ Intervention can begin with syllable and sound recognition and identification. ➢ Next, the SLP can move to syllable segmentation and blending, and finally to phoneme segmentation and blending. ➢ Once blending and segmentation are established, an SLP can provide a link to classroom decoding and spelling instruction by providing practice that facilitates the application of phoneme awareness to spelling and decoding words. ➢ The concept of syllables can be introduced as naturally occurring “beats” in a word. ➢ Phoneme intervention might progress from recognition of a target sound in isolation, through identification when paired with other sounds, to sounds in syllables, then words.  Morphological Awareness ➢ Reading and spelling accuracy can be improved through instruction in morphological awareness together with other forms of linguistic awareness. ➢ Intervention might focus on increasing awareness of the morphological structure of words and the orthographic rules that apply when suffixes are added.  Word Recognition ➢ Goals for word recognition intervention are: • Teach decoding skills. • Develop a vocabulary of written words. • Improve reading comprehension. ➢ Context can be used to help children predict words in text.  Text Comprehension ➢ Children who lack story frameworks necessary for interpreting narratives might begin intervention with telling stories. 

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Intervention can progress to oral and written narrative interpretation. Storybook reading can be divided into before, during, and after reading activities. Postreading can include story organizers, retelling, and creating narrative variations. Comprehension may also be enhanced by teaching children the more explicit and precise language style found in written communication. ➢ Complex grammar may be taught through books with familiar stories or books in which the grammar becomes increasingly complex. ➢ During reading, SLPs can facilitate comprehension through instruction, questions, visual and verbal cues, explanations, and comments. ➢ Ideally, students internalize comprehension strategies and use them as they read. ➢ Comprehension training addresses the author’s goals and character motivation. ➢ Instruction in multi-strategy approaches to inferencing seems to have a positive effect on the comprehension of struggling middle school readers. Executive Function ➢ Working memory, self-directed speech, and problem solving can be targeted. ➢ Distancing from the text and toward independent thinking is important for more advanced readers.

WRITING ❖ ❖ ❖ ❖

Writing is using knowledge and new ideas combined with language knowledge to create text. It involves motor, cognitive, linguistic, affective, and executive processes. Writing is more abstract and decontextualized (outside of a conversational context) than conversation. There are several aspects to the writing process:  Spelling  Executive function  Text construction, or going from ideas to writing  Memory ❖ Spelling  Spelling of most words is self-taught using a trial-and-error approach.  Approximately 4,000 words are explicitly taught in elementary school.  Mature spellers rely on memory, spelling and reading experience, phonological/semantic/morphological knowledge, orthographic knowledge and mental grapheme representations, and analogy.  Spelling competes with other aspects of writing for limited cognitive energy. ❖ Writing Development Through the Lifespan  Emerging Literacy ➢ Initially, children treat writing and speaking as two separate systems. ➢ Spoken and written systems converge over time, although speech is more complex. ➢ Writing slowly overtakes speech as written sentences become longer and more complex. ➢ Children become more aware of the audience and alter syntax, vocabulary, textual themes, and attitude.  Mature Literacy ➢ For some writers, speaking and writing become consciously separate. ➢ The writing of adults contains longer, more complex sentences and uses more abstract nouns and more metalinguistic and metacognitive words.  Spelling ➢ Preliterate attempts consist mostly of scribbles and drawing with an occasional letter. ➢ Later, children use some phoneme-grapheme knowledge along with letter names. ➢ May use invented spelling, in which the names of letters may be used in spelling. ➢ As spelling becomes more sophisticated, children learn about spacing, sequencing, various ways to represent phonemes, and the morpheme-grapheme relationship. ➢ As children begin to recognize more regularities and consolidate the alphabetic system, they become more efficient spellers. ➢ Increased memory capacity for these regularities support spelling. ➢ Many vowel representations, phonological variations, and morphophonemic variations take several years to acquire. ➢ Most shift from a phonological strategy to a mixed one between second and fifth grade. ➢ Adults spell in several ways: letter-by-letter, by syllable, and by sub-syllable unit.

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Executive Function ➢ Writers develop the cognitive processes needed for mature writing in early adulthood. ➢ Young writers need guidance in planning and revising their writing. ➢ By junior high school, teens are capable of revising all aspects of writing. ➢ Improved long-term memory results in improved overall compositional quality. Text Generation ➢ Early compositions often lack cohesion and use structures repeatedly. ➢ Mature writers use more variety for dramatic effect. ➢ Written narratives or stories emerge first, followed by expository texts. ➢ In adolescence, expository writing increases in length, MLU, multi-clause production, and use of literate words that transition between thoughts, abstract nouns, and metalinguistic/metacognitive verbs.

WRITING PROBLEMS THROUGH THE LIFESPAN ❖ Children with LI often have writing deficits, evidenced in reduced written productivity, total number of words, total number of utterances, or total number of ideas. ❖ There are also deficits in writing complexity and writing accuracy. ❖ Children with LD may have difficulties with all aspects of the writing process. ❖ Deficits in Spelling  Poor phonological processing and knowledge/use of phoneme-grapheme information.  Poor spellers tend to rely on visual matching skills and phoneme position rules to compensate for limited knowledge of sound-letter correspondence. ❖ Deficits in Executive Function  Some children with LD write whatever comes to mind, with little planning.  They produce and elaborate little, revise ineffectively and with seeming indifference to the audience, detect errors poorly, and experience difficulty executing intended changes.  Planning is difficult because of language formulation difficulties. ❖ Deficits in Text Generation  Children with LI may lack mature internalized story models or may be unable to visualize the words even from their own spoken narratives.  Narratives of children with LD contain shorter, less complex sentences, are shorter and have fewer episodes, contain fewer details, and fail to consider the needs of the listener.  Children with LI often put little thought or organization into writing, and there is often little revision.  Children with LD have substantial difficulty using morphological endings in writing, even when they can use these morphemes correctly in speech.

ASSESSMENT AND INTERVENTION FOR WRITING IMPAIRMENT ❖ Assessment of Developmental Writing  One method of assessing writing is through the use of portfolios of children’s writing.  Narrative samples are best for young elementary school children.  Older elementary school children or adolescents can provide expository writing samples.  Executive function is best measured within writing tasks as part of the writing assessment.  Writing can be analyzed on several levels: Textual, linguistic, and orthographic (spelling).  Assessment of Spelling ➢ Assessed through dictation, connected writing, and standardized assessment. ➢ Descriptive analysis should focus on patterns evident in the child’s spelling.  Assessment of Text Generation ➢ Writing analysis can include total number of words and number of different words used. ➢ Other measures include word choice, clause and sentence length, and coherence. ❖ Intervention for Developmental Writing Impairment  Spelling ➢ Spelling intervention should be integrated into writing and reading in the classroom. ➢ Words selected for intervention should be individualized and reflect the curriculum, the child’s desires, words attempted but in error, and error patterns. ➢ The goal is to learn strategies of spelling and rules rather than specific words. ➢ Children with LD benefit from multisensory input such as pictures, objects, or action. ➢ Word analysis and sorting tasks can be used. ➢ Spell checkers help less for children with LD than for children developing typically.

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If children with literacy impairments are taught to spell phonetically when unsure of the correct spelling, spell checkers generate more correct suggestions. ➢ Proofing and editing on a hard copy also seems to increase the number of correctly spelled words. Executive Function ➢ Executive function can be targeted during writing using a goal-plan-do-review format. ➢ Allowing children to select their own topic can increase motivation. ➢ Ask the child questions to help them focus on their potential audience. ➢ Children with LD who receive training in executive function along with word processing make greater gains in the quality of their writing. ➢ Speech recognition software allows a child to compose by dictation, but this cannot overcome oral language difficulties. Narrative Text Generation ➢ Narrative writing intervention may need to begin at the oral narrative level. ➢ Story grammar: The common event sequences and elements of a narrative. ➢ Children with language and writing impairment may not realize that they know a narrative or how to get it started. ➢ Writing can be guided through brainstorming, story guides, prompts, and acronyms. ➢ Written narration may require explicit instruction in story grammar or structure. ➢ Story maps may be necessary initially. Expository Text Generation ➢ Em-POWER: Treats writing as a problem-solving task involving six steps: Evaluate, Make a Plan, Organize, Work, Evaluate, and Rework. ➢ Writing can be fostered through prompt cards containing key words for each section. ➢ The student can get feedback from peers with SLP mediation before revision.

Summary Children with speech and language difficulties often have difficulty moving from spoken to written forms of expression. Working within a team, the SLP helps children obtain language-based skills upon which literacy is based. This is a natural extension of the SLP’s concern for language in all modes of communication.

Video Examples Video Example 6.1; Hearing and recognizing sound differences Activity suggestion: Ask students to note how sound recognition and letter identification are linked. Video Example 6.2: What is dyslexia? Activity suggestion: Pause the video around the 20 second mark. Ask students to individually write down what they believe the message actually says. Ask them to reflect about the level of difficulty, and to predict how they might feel if this was the process they encountered each time they had to read. How likely would they be to read as much as they currently do? Video Example 6.3: What causes dyslexia? Activity suggestion: Ask students to discuss in small groups what information in the video either matched what they already knew about dyslexia or that was new to them. Video Example 6.4: My reading disability, stress, and anxiety Activity suggestion: This video is approximately 17 minutes long. You may choose to have students view it before class. For students to discuss: The woman in the video talks about hating school because of her difficulty with reading comprehension. How can we help students avoid this feeling or work through it?

Thought Questions 6.1: Many professionals recognize that literacy is not just speech in print form. If this is the case, why is oral language considered so important as a good literacy base? 6.2: Why might the child who has not been exposed to books or interactive reading be at a disadvantage?

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6.3: As we proceed, is the role of the SLP becoming obvious? What expertise does an SLP possess that a teacher or reading specialist may not have? 6.4: We have mentioned a few times that literacy is more than speech in print and that reading and writing are not opposite processes. How do the processes of reading and writing differ? 6.5: Have you gained a new impression of how you spell and learned to spell? If so, what has changed?

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CHAPTER 7 ADULT LANGUAGE IMPAIRMENTS Learning Outcomes When you have finished this chapter, you should be able to: 1. Outline language development beyond childhood. 2. Describe the main parts of the nervous system that are related to speech and language. 3. Discuss the different types of aphasia, concomitant or accompanying deficits, and assessment and intervention considerations. 4. Describe right hemisphere brain damage and assessment and intervention considerations. 5. Describe traumatic brain injury and assessment and intervention considerations. 6. Describe cognitive impairment and assessment and intervention considerations.

Introduction Many language impairments found in childhood continue into the adult years. Persistent deficits in adults may entitle them to academic support services or workplace accommodations. This chapter focuses on language disorders that occur or develop during adulthood. Specifically, we discuss aphasia, right hemisphere brain damage, traumatic brain injury, and degenerative neurological conditions.

Content Outline LANGUAGE DEVELOPMENT THROUGH THE LIFESPAN ❖ Unless debilitated in some way through accident, disease, or disorder, adults continue to refine their communication throughout their lives. ❖ Language development proceeds slowly throughout adulthood, even in adults with ID. ❖ Use  Adults are effective communicators and skilled conversationalists who use a variety of styles.  Competent communicators sense their role and adjust language and speech accordingly.  The number of communicative intentions increases gradually.  Changes in writing and reading abilities are not dramatic.  Narratives improve into middle age and senior years, decreasing after the late seventies. ❖ Content  Adults use between 30,000 and 60,000 words expressively.  Specialized vocabularies develop for various aspects of life.  Some words fade from the language and new words are added.  Multiple definitions and figurative meanings are expanded.  Seniors experience some deficits in accuracy and speed of word retrieval and naming. ❖ Form  Continue to acquire prefixes, morphophonemic contrasts, and some irregular verbs.  Conversations become more cohesive through more effective use of linguistic devices.  In general, written language is more complex than spoken language.  Complex sentence production declines with advanced age, related to word retrieval.  Decline in oral/written language comprehension, understanding complex syntax, and inferencing.

THE NERVOUS SYSTEM ❖ ❖ ❖ ❖

Consists of the brain, spinal cord, and all associated nerves and sense organs. The neuron is the basic unit of the nervous system and has three parts: cell body, axon, and dendrites. A nerve is a collection of neurons. Electrochemical impulses generally pass between the axon of one neuron to the dendrites of another across the synapse. ❖ Central Nervous System  Composed of the brain and spinal cord.  The CNS communicates with the rest of the body through nerves. ❖ The Brain  Consists of the cerebrum, cerebellum, and brainstem.

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The cerebrum is divided into right and left hemispheres. The sensory and motor functions of the cerebrum are mostly contralateral. Each hemisphere consists of white fibrous connective tracts running below the surface and covered by a gray cortex of cell bodies approximately .25 inch thick.  The cortex has a wrinkled appearance caused by little hills called gyri and valleys called fissures.  Each hemisphere has four lobes: frontal, temporal, parietal, and occipital.  There are generalized areas of the brain that are responsible for particular operations.  In 98% of individuals, the left hemisphere is dominant for most aspects of receptive and expressive language and motor speech production.  The cerebellum consists of right and left cerebellar hemispheres and a central vermis.  The cerebellum coordinates the control of fine, complex motor activities, maintains muscle tone, and participates in motor learning.  The cerebellum also has considerable influence on language processing and higher-level cognitive and affective functions. ❖ Language Processing  In most individuals, linguistic information is processed in the left hemisphere.  Nonlinguistic and paralinguistic information are primarily processed in the right.  Incoming auditory information is held in working memory in Broca’s area in the frontal lobe while it is processed.  Most incoming linguistic processing occurs in Wernicke’s area in the left temporal lobe, assisted by the angular gyrus for words and the supramarginal gyrus for grammar.  For outgoing information, concepts are formed, and the angular gyrus and supramarginal gyrus contribute to the overall message formation that occurs in Wernicke’s area while held in working memory in Broca’s area.  Broca’s area sends programming information to the motor cortex, which sends signals to the motor neurons for speech.

APHASIA ❖ Aphasia: Literally means “without language.” ❖ The population with aphasia is extremely diverse. ❖ It is estimated that over 1 million Americans have aphasia. Problems in auditory comprehension and word retrieval are common to all aphasias to some degree. ❖ Memory may also be impaired in some way. ❖ Aphasia may affect listening, speaking, reading, and/or writing, as well as specific language functions such as naming. ❖ May also affect functions such as math, gesturing, telling time, counting money, or interpreting environmental sounds. ❖ Expressive deficits may include reduced vocabulary, omission or addition of words, stereotypic utterances, delayed and reduced output of speech or hyperfluent (very rapid) speech, and word substitutions. ❖ Language comprehension deficits involve the impaired interpretation of linguistic information. ❖ Severity may range from individuals with a few intelligible words and little comprehension to those with very subtle linguistic deficits. ❖ Severity is related to the cause, location, extent, and age of brain injury, as well as age and general health of the individual. ❖ Several patterns of behavior exist that allow categorization into types or syndromes. ❖ Aphasia is not a result of a motor speech impairment, cognitive impairment or dementia, or deterioration of intelligence. ❖ Other neurogenic disorders such as apraxia or dysarthria often exist with aphasia. ❖ Depression is a common condition in neurological disorders. ❖ Most individuals with aphasia also have a variety of attention and other cognitive deficits. ❖ Concomitant or Accompanying Deficits  Hemiparesis: Weakness on one side of the body.  Hemiplegia: Paralysis on one side of the body.  Hemisensory impairment: A loss of the ability to perceive sensory information on one side of the body.  Hemianopsia: Blindness in the visual field of each eye contralateral to the site of a deep lesion.  Dysphagia: Difficulty chewing or swallowing.  Seizure disorder or epilepsy is seen in about 20% of individuals with aphasia.

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 Agnosia: Difficulty understanding incoming sensory information.  Agrammatism: Omission of grammatical elements.  Agraphia: Difficulty writing.  Alexia: Reading problems.  Anomia: Difficulty naming entities.  Jargon: Meaningless or irrelevant speech with typical intonational patterns.  Neologism: A novel word.  Paraphasia: Word substitutions found in clients who may talk fluently and grammatically.  Verbal stereotype: An expression repeated over and over. ❖ Types of Aphasia  Fluent Aphasias ➢ Characterized by word substitutions, neologisms, and often verbose verbal output. ➢ Lesions tend to be in the posterior portions of the left hemisphere. ➢ In Wernicke’s Aphasia, the individual speaks in rapid-fire strings of sentences with little pause for acknowledgement or turn taking. Individuals are often unaware of their difficulties. Content may seem to be a jumble, and may be incoherent or incomprehensible although fluent and well articulated. ➢ In anomic aphasia, most aspects of speech are normal, with the exception of word retrieval. ➢ In conduction aphasia, conversations are abundant and quick, filled with paraphasia. Paraphasia may be severe enough to make speech incomprehensible. ➢ In transcortical sensory aphasia, conversation and spontaneous speech are as fluent as in Wernicke’s aphasia, but filled with word errors.  Nonfluent Aphasias ➢ Characterized by slow, labored speech and struggle to retrieve words/form sentences. ➢ In general, the site of lesion is in or near the frontal lobe. ➢ The most common traits of Broca’s aphasia are short sentences with aggrammatism; slow, labored speech and writing; and articulation and phonological errors. ➢ Transcortical motor aphasia is characterized by difficulty initiating speech or writing. Severely impaired speech is a characteristic of damage to the motor cortex. ➢ Global, or mixed, aphasia is characterized by profound language impairment in all modalities, associated with a large, deep lesion in an area below the brain’s surface. ❖ Causes of Aphasia  The onset of aphasia is rapid.  The most common cause of aphasia is a stroke or cerebrovascular accident.  Strokes affect half a million Americans annually.  As a result of stroke, approximately 100,000 people become aphasic each year.  Strokes are of two basic types: Ischemic and hemorrhagic.  Ischemic stroke results from a complete or partial blockage of the arteries transporting blood to the brain. ➢ Cerebral arteriosclerosis: Thickening of the walls of cerebral arteries in which elasticity is lost or reduced, the walls become weakened, and blood flow is restricted. ➢ Embolism: Obstructed blood flow caused by blood clot, fatty materials, or air bubble. ➢ Thrombosis: Plaque buildup or blood clot formed on site and does not travel, causing blood flow to be restricted. ➢ Transient ischemic attack: Temporary condition with symptoms mirroring a stroke; blood flow to a portion of the brain is blocked or reduced, but then returns after a short interval.  A hemorrhagic stroke is one in which weakened arterial walls burst under pressure. ➢ Aneurysm: A saclike bulging in a weakened artery wall. ➢ Arteriovenous malformation: Poorly formed tangle of arteries and veins; malformed arterial walls may be weak and give way under pressure.  Patterns of recovery differ with the type of stroke.  Ischemic: Noticeable improvement with the first weeks, but slows after 3 months.  Hemorrhagic: Most rapid recovery is at the end of the first month and into the second.  Aphasia-like symptoms may be noted with head injury, neural infections, degenerative neurological disorders, and tumors, but because other cortical areas are also affected they are considered clinically different disorders.  Primary progressive aphasia: A degenerative disorder of language with preservation of other mental functions and of activities of daily living. It progresses to a near-total inability to speak over time.

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❖ Lifespan Issues  Most victims of stroke are in middle age and beyond.  Risk of stroke increase with history of smoking, alcohol use, poor diet, lack of exercise, high blood pressure, high cholesterol, diabetes, obesity, and previous strokes or TIAs.  First signs are loss of consciousness, headache, weak/immobile limbs, and slurred speech.  Approximately 1/3 of individuals will die from the stroke or shortly thereafter.  For those who survive, there may be a period of unconsciousness, followed by disorientation.  As chronic effects settle in, the individual begins to focus on the physical and language complications, which can lead to frustration and depression.  Families of individuals with aphasia are often frightened and confused.  Following acute care, the individual may require rehabilitative hospitalization, outpatient rehabilitation, or nursing home care.  Most individuals receive services for at least the first several months.  The individual with aphasia may exhibit perseveration, disinhibition, and emotional problems.  The course and extent of recovery is difficult to predict.  The most frequent linguistic gains are in auditory comprehension.  Spontaneous recovery: A natural restorative process.  Maximum spontaneous recovery for language occurs in the first 3 months.  Assessment and intervention begin as soon as the client’s individual condition permits.  The earlier the treatment, the better the rate of recovery.  Loss of language ability changes social roles and can lead to social isolation.  The individual with aphasia may become dependent on others for daily tasks, and there may be economic problems within the family. ❖ Assessment for Aphasia  The assessment process may continue in several stages as the client stabilizes and experiences spontaneous recovery.  Especially important are medical history, interview with the client and family, the oral peripheral examination, hearing testing, and direct speech and language testing.  Counseling will be ongoing.  Observing spontaneous language use can give an SLP important information about the nature and extent of the disorder.  A thorough examination of the peripheral speech mechanism is important because of the potential for either neuromuscular paralysis or weakness.  Formal testing is usually postponed until the patient is stable.  Formal testing should address overall communication skills as well as receptive and expressive language within all modalities and across all five aspects of language.  Several standardized tests are available for assessing specific language skills.  Interpretation of client behavior during testing is extremely important. ❖ Intervention  The overall goal of intervention is to aid in the recovery of language and to provide strategies to compensate for persistent language deficits.  Goals are determined by assessment results and the desires of the client and family.  Decide whether to work on underlying skills or specific skill deficits.  Cross-modality generalization: Skills trained in one modality generalize to another.  Using semantic associations increases naming accuracy in patients with anomic aphasia.  Conversational techniques can provide language therapy and therapeutic support.  Another method is to access the language in the left hemisphere by “bridging” from the right.  Using gestures and pantomime may have a positive effect on noun retrieval.  Many SLPs prefer more direct multimodality stimulation of the affected cognitive processes.  AAC may become the primary communication modality for severely impaired clients.  Intervention might also focus on cognitive abilities, such as memory and attention.  Neural plasticity holds promise for individuals with aphasia.  It may be beneficial to involve family members in the communication training program. ❖ Evidence-Based Practice  We cannot definitively say which intervention methods are best for various forms of aphasia.  Failure to participate in intervention has an adverse effect on recovery.

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❖ Conclusion  Aphasia is complex, varying in scope and extent across individuals.  Clients may have other impairments, such as paralysis.  The individual variation in symptoms and severity, the team approach to intervention, and the possibility of spontaneous recovery complicate efforts to measure intervention effectiveness.

RIGHT HEMISPHERE BRAIN DAMAGE ❖ Right hemisphere brain damage: Group of deficits resulting from injury to the right hemisphere of the brain. ❖ RHBD can result in visuospatial neglect and other attention deficits; difficulties with memory and components of executive function, such as problem solving, reasoning, organization, planning, and self-awareness; and a wide range of communication impairments. ❖ 50%-78% of individuals with RHBD exhibit one or more communication impairments, but many do not receive treatment. ❖ Communication disorders that clients with RHBD experience do not seem to be strictly language based. ❖ Nonlinguistic and paralinguistic information are processed in the right hemisphere; the right hemisphere plays a role in some aspects of pragmatics, including the perception and expression of emotion; understanding of jokes, irony, and figurative language; and production and comprehension of coherent discourse, as well as processing emotion. ❖ The right hemisphere is also involved in figuring out ambiguous meanings. ❖ Characteristics  Deficits in RHBD are not as obvious as those that result from left hemisphere damage.  Common characteristics are: ➢ Neglect of information from the left side ➢ Unrealistic denial of illness or limb involvement ➢ Impaired judgment and self-monitoring ➢ Lack of motivation ➢ Inattention  Disturbances can be grouped into attentional, visuospatial, and communication.  Attentional: Client’s lack of response to information coming from the left side of the body.  Visuospatial: Poor visual discrimination and poor scanning and tracking.  Communication: Can be further divided into linguistic and nonlinguistic or paralinguistic deficits.  Facial expression, body language, and prosody are all nonverbal means of conveying intent.  Individuals with RHBD may exhibit poor auditory and visual comprehension of complex information and limited word discrimination and visual word recognition.  The right hemisphere is important for activation of distant word and sentence meanings.  An individual with RHBD is slower in suppressing incorrect meanings of multiple meaning words, making them less efficient in interpreting conversations.  Topic maintenance, appreciation of the communication situation, and determination of listener needs are affected areas of pragmatics.  Expressive language is tangential and egocentric.  There is verbosity or paucity of speech.  Contextual cues may be missed or ignored.  Comprehension deficits include misinterpretation of intended meaning.  Clients with RHBD exhibit poor judgment in determining which incoming information is important and which is not.  Other problem areas include naming, repetition, and writing, especially letter substitutions and omissions.  Paralinguistic deficits include difficulty comprehending and producing emotional language.  Aprosodia: The reduced ability or inability to produce or comprehend affective aspects of language. ❖ Assessment  Assess visual scanning/tracking, auditory/visual comprehension of words and sentences, direction following, response to emotion, naming/describing pictures, and writing.  Sampling and observation are essential in assessing the client’s pragmatic abilities.  Portions of aphasia batteries, standardized tests for RHBD, and nonstandardized procedures may be used, such as interviewing, observation, and ratings of behavior.

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❖ Intervention  Intervention often begins with visual and auditory recognition.  Very little knowledge about effective treatments exists at this time.  For expressive aprosodia, clients may imitate a sentence in unison with the SLP, or use cognitivelinguistic treatment in which there are cues to modify prosody.  For interpretation of nonliteral or figurative language, a semantic intervention approach may be used where word meanings and connotations are mapped and diagrammed.  Intervention for activating meanings and for suppression of noncontextual ones can be accomplished through contextual pre-stimulation, where a client is given sentences to activate different meanings prior to being given a word.  Clients are helped to respond appropriately in common communication situations and to track increasingly complex information in conversations.  Sequencing and explaining actions help organize linguistic content improve relevance.  The SLP helps the client synthesize multiple skills within conversation.  Important nonlinguistic markers such as eye contact, body language, and gestures may be targeted, with topic maintenance and relevant conversational contributions stressed.

TRAUMATIC BRAIN INJURY ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖

❖ ❖ ❖ ❖

Disruption in normal functioning caused by a blow or jolt to the head or a penetrating head injury. Leading causes include falls, motor vehicle accidents, blows to the head (as from sports), and assaults. Annually, 1.5 million people sustain TBI in the U.S. Males are twice as likely to sustain a TBI. At least 5.3 million Americans currently have a long-term need for help to as a result of TBI. TBI can include diffuse injury to the brain. Closed head injuries that include swelling of the brain result in diffuse injury. Open head injury may accommodate swelling, resulting in less damage that is more focused. Brain damage may result from:  Bruising and laceration of the brain from coming into contact with the rough inner surface of the skull  Secondary edema, or swelling due to increased fluid, which can lead to increased pressure  Infection  Hypoxia (oxygen deprivation)  Intracranial pressure from tissue swelling  Infarction: Death of tissue deprived of oxygen supply  Hematoma: Focal bleeding Aphasia-like symptoms are rare, but linguistic impairments related to cognitive damage are not. May have sensory, motor, behavioral, and affective disabilities. Seizures, hemisensory impairment, and hemiparesis or hemiplegia may occur. Characteristics  Usually, the most devastating aspect is an inability to resume interests and daily living tasks to the level that existed before the injury.  Affects orientation, memory, attention, reasoning/problem solving, and executive function.  Language may be affected in three out of four individuals with TBI.  The two most commonly reported symptoms are anomia and impaired comprehension.  The most disturbed language area is pragmatics.  Pragmatic deficits include the inability to inhibit behavior, errors of judgment, rambling speech and incoherence, poor turn-taking skills, poor affective language abilities, and inappropriate laughter and swearing.  Deficits may include speech, voice, and swallowing difficulties.  Approximately 1/3 of all individuals with TBI exhibit dysarthria.  Psychosocial and personality changes may include disinhibition or impulsivity, poor organization and social judgment, and either withdrawal or aggressiveness.  Physical signs may include difficulty walking, poor coordination, and vision problems.  Severity seems to be related to initial levels of consciousness and post-traumatic amnesia.  Brain volume loss may be predictive of general cognitive functioning after TBI, but measures of atrophy in specific regions of the brain may be more informative about specific language functions.

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❖ Lifespan Issues  Most adults with TBI are young and have experienced an auto or motorcycle accident.  Several phases of recovery exist and clinical intervention varies with each.  Most individuals will not reach full recovery.  Initially, the individual may be nonresponsive and need total assistance in a hospital.  Gradually, the individual begins to respond to stimuli and recognize familiar individuals.  As the client becomes more alert, he or she may be confused or agitated.  The individual may have incoherent, inappropriate, or emotional language.  Later, the individual can remain alert for short periods of time and hold brief conversations with the use of external cues.  The individual becomes oriented to person and place, although time is still problematic.  They can be socially inappropriate, uncooperative, unrealistic in their expectations, and unaware of the needs and feelings of others.  Frustration may build with greater understanding of their condition and limitations.  In the later stages of recovery, the individual can initiate and carry out familiar tasks.  Finally, the individual may be able to consistently act in a socially appropriate manner, respond appropriately to others, and to plan, initiate, and complete familiar/unfamiliar tasks.  Periodic depression may occur and irritability may reappear at times.  Most will have some lingering deficits, especially in pragmatics. ❖ Assessment  The SLP assesses communication, cognitive-communication functioning, and swallowing.  Assessment must be ongoing and varies with each stage.  Few comprehensive tools exist for assessment of language skills in individuals with TBI.  Sampling is essential because pragmatic behavior varies across communication contexts. ❖ Intervention  Those with TBI recover in a plateau fashion.  Cognitive rehabilitation: Intervention for cognitive-communication deficits in individuals with TBI; increases functional abilities by improving processing capacity. ➢ Restorative approach: Rebuild neural circuitry and function through repetitive activities. ➢ Compensatory approach: Develops alternatives for functions that will not be recovered.  The SLP designs and implements treatment programs to decrease the effects of impairment.  Also identifies functional supports that aid in successful independent living.  Early stages: Intervention focuses on orientation, sensorimotor stimulation, and recognition of familiar people and common objects and events.  Early intervention results in shorter rehabilitation and higher levels of cognitive functioning.  Middle stages: Aim to reduce confusion and improve memory and goal-directed behavior.  Late stages: Targets include comprehension of complex information and directions and conversational and social skills.

COGNITIVE IMPAIRMENT ❖ Intellectual capacity is frequently unimpaired with advanced age. ❖ Fewer than 15% of the elderly experience dementia or cognitive impairment, and up to 20% respond to treatment. ❖ Cognitive impairment is an umbrella term for a group of both pathological conditions and syndromes that result in declining of memory and at least one other cognitive ability that is significant enough to interfere with daily life activities. It is acquired and is characterized by intellectual decline due to neurogenic causes. ❖ Irreversible cognitive impairment is most frequently caused by Alzheimer’s disease (AD), vascular cognitive impairment (VCI) or multi-infarct dementia, or a combination of both, referred to as mixed cognitive impairment. ❖ Can be divided into cortical and subcortical types. ❖ Cortical cognitive impairments include Alzheimer’s and Pick’s diseases and resemble those of focal impairments such as aphasia and RHBD, including visuospatial deficits, memory problems, judgment and abstract thinking disturbances, and language deficits in naming, reading, and writing, and auditory comprehension. ❖ Subcortical cognitive impairments may accompany MS, AIDS-related encephalopathy, and Parkinson’s and Huntington’s diseases. A slow, progressive deterioration of cognitive functioning occurs with deficits in memory, problem solving, language, and neuromuscular control.

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❖ Language functions most dependent on memory are primarily affected. ❖ Communication disorders associated with cognitive impairment progress over time and include anomia, discourse production and comprehension deficits, and, eventually, the inability to express oneself via speech and language. ❖ Alzheimer’s Disease (AD)  A cortical pathology that affects approximately 13% of individuals over age 65 and possibly as high as 50% of those over 85.  AD is the most expensive disease in the U.S., costing families and society around $200 billion annually.  AD is twice as common in women as in men, primarily because women tend to live longer.  The cause is unknown but may be a combination of genetic and environmental factors.  Characterized by the presence of twisted neurofilaments that deteriorate cell functioning; most pronounced in the temporal lobe and associational parts of the brain.  Nerve fibers degenerate, resulting in brain atrophy.  Extensive damage to the hippocampus and formation of senile plaques in the cortex that affect nerve cell interactive functioning also occur.  Mild cognitive impairment: Name recall difficulty, occasional disorientation, and memory loss.  Language is not affected in all individuals initially.  Early problems in language involve word finding, off-topic comments, and comprehension.  Later characteristics include paraphasia and delayed responding.  In more severe stages, expressive and receptive vocabulary and complex sentence production become reduced; pronoun confusion, topic digression, and inability to return to and to shift topic are more pronounced; and writing and reading errors occur.  In its most severe form, language is characterized by naming errors and the use of generic words, syntactic errors, minimal comprehension, jargon, echolalia, or mutism.  Writing problems reflect deficits in language, working memory, attention, and motor control.  Lifespan Issues ➢ Often the person who will be afflicted with AD is unaware and/or ignores early signs. ➢ At present, there are no cures, but some early drug therapies seem to lessen the effects. ➢ In the early stages, the individual experiences memory loss, especially of new information. ➢ As the disease progresses, memory loss increases and vocabulary decreases. Comprehension and language production are reduced. Irritability and restlessness may increase. ➢ In the most advanced stages, all intellectual functions including memory are severely impaired and almost all individuals reside in nursing homes. Language may be meaningless, or the individual may be mute or echolalic.  Assessment ➢ Definitive diagnosis is difficult in the early stages. ➢ Neuroimaging techniques may help in early identification, especially for specific protein buildup in the brain. ➢ Computer-based assessments are being developed and tested; they usually test attention, recognition, and recall of words and pictures. ➢ SLPs usually identify changes in language performance that may signal intellectual deterioration and aspects of behavior amenable to change. ➢ Genetic history and general and neurological health data are important. ➢ Observation in different communication environments is also important. ➢ Few language tests for this population exist. ➢ Decline in written language may precede other cognitive and spoken language deficits. ➢ Several scales exist for rating the severity of a client’s loss. ➢ Many assessments for individuals with aphasia can be used.  Intervention ➢ Intervention can help maintain the client at his or her highest level of performance and help others maximize the client’s participation in conversation. ➢ Emphasize the use of intact cognitive abilities to compensate for deficient ones. ➢ In cognitive rehabilitation, the client, health professionals, and families develop individualized goals and implement strategies based on those goals. ➢ Cognitive training can be used to improve specific cognitive functions, such as attention, memory, and executive functions.

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➢ ➢ ➢ ➢

Cognitive stimulation is less direct and is usually conducted in groups; it can be used to enhance cognitive and social functioning and might involve relaxation exercises or music therapy. Interventions include computer-assisted cognitive interventions, Montessori-based interventions, reminiscence therapy, errorless learning, simulated presence therapy, SpacedRetrieval, and vanishing cues, as well as indirect interventions. Family members can be trained to foster a good communication environment. Intervention that stimulates cognitive processes combined with pharmacological approaches that increase certain neural chemicals important for memory is best.

Summary Aphasia, right hemisphere brain damage, traumatic brain injury, and cognitive impairment result in very different types of language impairment. In these adult language impairments, the SLP functions as a member of a multidisciplinary team. The role of the SLP includes assessment of communication and the implication of other cognitive deficits, swallowing, and associated neurological disorders, as well as treatment planning and programming, direct intervention, consultation, and family training and counseling. Intervention usually focuses on retrieval of language skills and on compensatory strategies.

Video Examples Video Example 7.1: Wernicke’s aphasia Activity suggestion: Play this video after discussing features of Wernicke’s aphasia in class. After students watch the video, ask them to describe features of Byron’s language that are consistent with Wernicke’s aphasia. Ask students to describe how Wernicke’s aphasia might affect communication interactions with family members and unfamiliar people, both in person and on the phone. Video Example 7.2: Broca’s aphasia Activity suggestion: Play this video before discussing Broca’s aphasia in class. Ask students to describe what they hear in Grace’s speech and language. Provide relevant clinical terminology for what students describe. Video Example 7.3: Interview with a client with RHBD Activity suggestion: This is a simulation to demonstrate deficits that might be seen after RHBD. Remind students that this interview is not how one would be completed with an actual client. Discuss additional examples of prosopagnosia (The Man Who Mistook His Wife for a Hat – Oliver Sacks), anosognosia, and the safety implications of left neglect. Video Example 7.4: Experience 12 minutes in Alzheimer’s Dementia Activity suggestion: Use this video to discuss the impact of Alzheimer’s disease on a family unit, and the potential benefit of family education and counseling early on in the disease process.

Thought Questions 7.1: Where is the emphasis in adult language development? Does it differ from earlier child development? If so, how? 7.2: Pick one of the areas of the brain important for language processing. What would happen if that area was damaged in some way? 7.3: How is recovery influenced by the type of stroke? Why do you think the patterns of recovery differ? 7.4: Why might it be better to work on language processes in a communication framework rather than separately or individually? 7.5: Why are the symptoms of RHBD different from those for aphasia? 7.6: Try to visualize the four cognitive disorders discussed. Begin with causes. How do they differ? Which are progressive? Which are not? How is language affected?

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CHAPTER 8 FLUENCY DISORDERS Learning Outcomes When you have finished with this chapter, you should be able to: 1. Describe differences between fluent speech and stuttering. 2. Outline and describe the onset and development of stuttering through the lifespan. 3. Describe the major etiological theories and conceptual models of stuttering. 4. Describe the stuttering evaluation. 5. Describe efficacious treatment approaches for children and adults who stutter.

Introduction Fluent speech is the consistent ability to move the speech production apparatus in an effortless, smooth, and rapid manner resulting in a continuous, uninterrupted, forward flow of speech. The focus of this chapter is on developmental stuttering, or simply stuttering. Stuttering is characterized by involuntary repetitions of sounds and syllables, sound prolongations, and blocks. The cause of stuttering remains elusive, and our understanding of stuttering is incomplete despite its long and diverse history. The lifetime incidence of stuttering may be as high as 8%. Approximately 70% of children will recover from stuttering within the first 2 years after its onset, and 85% will recover within the next few years. It is not well understood why some children naturally recover from stuttering and others do not. However, females appear to recover more frequently and quickly than males, family history of stuttering increases the risk that stuttering will persist, and a child with a later onset of stuttering (after 3.5 years of age) or a child who continues to stutter more than a year post-onset is at greater risk for persistent stuttering. The incidence of stuttering is about 1% and affects more males than females. Genetic and environmental factors likely play a role.

Content Outline DIFFERENCES BETWEEN FLUENT SPEECH AND STUTTERING ❖ Children exhibit hesitations, revisions, and interruptions. ❖ There is an increase in disfluent speech beginning around age 2, improving after age 3. ❖ Normal Disfluencies  At age 2, whole-word repetitions, interjections, and syllable repetitions are common.  Revisions are the dominant disfluency type when the child reaches 3 years.  Normal disfluencies persist throughout the course of one’s life.  Fluent speakers may repeat whole multisyllabic words, interject a word or phrase, repeat phrases, or revise sentences. ❖ Stuttering  Stuttering or stuttered speech involves certain core behaviors, including repetitions of sounds, syllables, or one-syllable words, prolongations of sounds, or blocks, where an inappropriate stop in the flow of air or voice occurs during speech production.  Stuttering frequency by itself is not a definitive clinical measure for stuttering.  More than two repetitions of a sound or word is considered a stuttering moment.  One or two repetitions of an interjection is generally considered a normal dysfluency, but more than two repeats of an interjection is equated with stuttering.  “Clustered disfluencies” (more than one dysfluency in a word) are common in young children who stutter and may indicate incipient stuttering (just beginning).  Secondary behaviors or accessory characteristics may accompany speech disfluencies. ➢ Include eye blinking, facial grimacing or tension, and exaggerated movements of the head, shoulders, and arms. ➢ Interjected speech fragments (e.g., “…that is to say…”) are also considered secondary characteristics. ➢ Secondary behaviors are adopted in an effort to reduce instances of stuttering. ➢ Some behaviors are so habituated that they are permanently associated with stuttering.

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THE ONSET AND DEVELOPMENT OF STUTTERING THROUGH THE LIFESPAN ❖ Developmental stuttering: The most common form of stuttering; begins in the preschool years. ❖ Neurogenic stuttering: Typically associated with neurological disease or trauma and is acquired after childhood. ❖ Developmental stuttering usually occurs on content words, whereas they can occur on function words in neurogenic stuttering. ❖ People who have developmental stuttering frequently exhibit secondary behaviors and fear and anxiety about speaking, whereas individuals with neurogenic stuttering do not. ❖ Developmental stuttering occurs on the initial syllables of words, whereas neurogenic stuttering can be more widely dispersed throughout the utterance. ❖ Neurogenic stuttering does not improve with repeated readings or singing. ❖ Onset of developmental stuttering is between 2 and 5 years of age, and is gradual with severity increasing with age. ❖ The developmental framework has age groups:  Younger preschool years (about 2-3 years of age) ➢ Periods of stuttering are followed by periods of relative fluency. ➢ The child will stutter most when upset or excited, or under pressure. ➢ Sound and syllable repetitions are the dominant feature. ➢ Stuttering occurs at the beginning of sentences, clauses, and phrases on both content and function words. ➢ Most children are unaware or are not bothered by disfluencies and do not exhibit secondary behaviors.  Older preschool years (about 4-6 years of age) ➢ Stuttering may begin to sound rapid and irregular. ➢ Blocks may begin to appear, and increased tension of the speech mechanism may be observed. ➢ Stuttering is more widely dispersed throughout the child’s utterances. ➢ Secondary behaviors may appear; the child has conscious awareness of his/her stuttering, and may become frustrated.  School-age ➢ Fear and avoidance of stuttering begin to emerge. ➢ Stuttering seems to be in response to specific situations. ➢ Certain words are regarded as more difficult than others and such words may be avoided. ➢ Blocks are more common than repetitions and prolongations, and characterized by excessive muscular tension.  Older teens and adults ➢ Stuttering is in its most advanced form. ➢ The individual has developed a self-concept as a person who stutters. ➢ A primary characteristic is vivid and fearful anticipation of stuttering. ➢ Certain sounds, words, and speaking situations are feared and avoided. ➢ Longer, tense blocks are the most frequent core stuttering behavior; repetitions still occur but they are more rapid and irregular and may co-occur with blocks. ➢ Secondary behaviors and circumlocution continue. ➢ There is evidence of embarrassment, helplessness, fear, and shame. ❖ The onset of stuttering may be sudden and distinct for as many as 36% of children.

THEORIES AND CONCEPTUAL MODELS OF STUTTERING ❖ Etiological theories of stuttering can be classified into three categories.  Organic Theory ➢ Proposes an actual physical cause for stuttering. ➢ Many have been proposed, but all have failed to explain stuttering satisfactorily. ➢ There is renewed interest in the theory of cerebral dominance due to findings of structural and functional differences in the brains of adults with chronic developmental stuttering.  Behavioral Theory ➢ Asserts that stuttering is a learned response to conditions external to the individual. ➢ Diagnosogenic theory: Overly concerned parents react negatively to a child’s normal speech hesitations and repetitions, causing anxiety in the child and increased stuttering. • There is contrary evidence to this theory and no supporting evidence. • Natural recovery may actually be due in part to parents explicitly telling their child to slow down, stop and start again, or think before speaking.

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Psychological Theory ➢ Contends stuttering is a neurotic symptom, treated most appropriately by psychotherapy. ➢ Psychological theory has yet to provide a satisfactory explanation for the underlying cause of stuttering or its onset and development. Current Conceptual Models of Stuttering ➢ Covert repair hypothesis: Stuttering is a reaction to a flaw in the speech production plan. Poorly developed phonological encoding skills cause errors in the speech plan. Stuttering is a “normal” repair reaction to an abnormal phonetic plan. ➢ Demands and capacities model: Stuttering develops when the demands to produce fluent speech exceed the child’s physical and learned capacities. Fluency depends on motor skills, language production, maturity, and cognitive development. Children who stutter presumably lack one or more of these capacities. The DCM is a tool for understanding the forces that contribute to stuttering. ➢ The Packman and Attanasio 3-factor model: Suggests that there are three factors that cause moments of stuttering: a deficit in the neural processing of language and inherent instability of the speech production system; triggers, or certain features of spoken language that are associated with greater speech motor demands that negatively affect an already unstable speech production system; and modulating factors, such as physiological arousal in an individual that can alter the threshold at which a stuttering moment occurs. ➢ Computer simulation models have been programmed to simulate stuttering, providing evidence for a disrupted speech motor control system in individuals who stutter.

EVALUATION OF STUTTERING ❖ Two important components of the evaluation of a child suspected of stuttering are observations of the child speaking and a detailed parental interview. ❖ The primary component is a detailed analysis of the child’s speech behaviors. ❖ The SLP determines the average number of each type of dysfluency the child produces. ❖ More than 10 disfluencies per 100 words spoken may indicate that the child has a fluency problem. ❖ The SLP will also measure the number of units that occur in each repetition or interjection. ❖ Standardized tests may be used. ❖ Determining the child’s or adult’s feelings and attitudes about his/her stuttering is an essential component of the stuttering evaluation. ❖ The following behaviors are generally associated with natural recovery of stuttering without treatment:  Decrease in stuttering behaviors during the 12 months after initial onset  The child is female  No family history of stuttering or relatives who stuttered have fully recovered  Receptive and expressive language and phonological skills are typical for the child’s age  Cognitive abilities are within the typical range for the child’s age  The child has an outgoing, carefree personality and is therefore less sensitive to potential stressors in his/her environment.

TREATMENT FOR STUTTERING ❖ Indirect Treatment  Focus is on the child, the child’s parents, and the child’s environment.  The SLP shares information and teaches parents to provide a slow, relaxed speech model for the child.  Play-oriented activities that encourage slow and relaxed speech are a central component.  There is no explicit discussion about the child’s fluent or stuttering speaking behaviors.  The goal is to facilitate fluency through environmental manipulation and is often effective for younger preschool children over a period of 1-2 months.  If stuttering does not decrease within 6 weeks, direct treatment may be recommended. ❖ Direct Treatment  Involve explicit and direct attempts to modify the child’s speech and speech-related behaviors.  Children are taught to identify “hard” and “easy” speech produced by the SLP first, and then in their own speech.  Then the SLP teaches strategies to increase easy speech and change from hard to easy speech when required.

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❖ Treatment of Stuttering in Preschool-Age Children  The Lidcombe Program can reduce stuttering to zero or near-zero levels in children younger than age 6.  It involves parent-administered verbal contingencies for stutter-free speech (“that was nice and smooth”) and stuttering (“oops, that was bumpy”), as well as requests for self-correction.  Verbal contingencies are first administered daily during structured play, then during unstructured interactions.  Weekly visits with the SLP involve direct measurement of stuttering and ensure the program is implemented correctly by the parent.  Parents provide a weekly stuttering rating. ❖ Treatment of Stuttering in Older Children and Adults  Involving family members and significant others in the treatment process, and encouraging the individual who stutters to increase social connection with others may be more beneficial in the treatment of stuttering than just teaching the individual to modify his/her speech.  Teaching older children to be more open about their stuttering and acknowledging their stuttering in a casual manner can be effective.  Self-disclosure of stuttering can be used. ❖ Direct Therapeutic Techniques  Fluency Shaping Techniques ➢ Prolonged speech: Reducing speech rate; one of the most powerful ways to reduce or eliminate stuttering. • Delayed auditory feedback: A speaker hears their speech after an instrumental delay. • When a person speaks under DAF, his or her speech is slowed involuntarily. • The slowing of speech rate is accompanied by a substantial decrease in stuttering. • The individual should be taught to prolong the duration of each syllable rather than the duration of pauses between syllables. • DAF times are adjusted to create specific speaking rates, such as 30-60 syllables per minute at the beginning of treatment to 120-200 syllables per minute at the termination of treatment. ➢ Light articulatory contacts and gentle voicing onsets (GVOs): Reduces speech rate and physical tension before and during occurrences of stuttering, promoting smooth speech. Reduced tension is believed to prevent prolonged articulatory postures that interfere with smooth articulatory transitions. ➢ Gentle voicing onsets (GVOs) are tension-free onsets of voicing that gradually build in intensity. ➢ Pausing/phrasing: Lengthens naturally occurring pauses and adds pauses. ➢ Gradual Increase in Length and Complexity of Utterance program: Effective in reducing or eliminating stuttering, particularly in school-age children. ➢ Response-contingent stimulation (RCS): Originated from operant conditioning paradigms. ➢ Response-contingent time-out from speaking (RCTO): Requires pausing briefly after stuttering. • The pause serves as the consequence for stuttering. • Research shows reduced stuttering frequency to zero or near-zero levels. • Adolescents and adults who stutter have been taught to self-administer a time-out from speaking immediately after a self-identified instance of stuttering.  Stuttering Modification Techniques ➢ Teaches the person to react to stuttering calmly, without unnecessary effort or struggle. ➢ Cancellation phase • The individual completes the stuttered word and then pauses deliberately for a minimum of 3 seconds. • They then produce the stuttered word slowly. ➢ Pull-out phase • The individual modifies the stuttered word during the actual occurrence of stuttering. • Involves slowing down the sequential movements of the syllable or word. ➢ Preparatory sets • The individual prepares to use fluency producing strategies before attempting the word. • The goal is to initiate the word in a more fluent manner.

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❖ Selecting Intervention Techniques  Selection of a management technique depends on severity, the motivation and specific needs of the person who stutters and the SLP’s knowledge of the available techniques. ❖ Effectiveness of Stuttering Intervention through the Lifespan  Efficacy of Intervention with Preschool-Age Children ➢ Indirect and direct treatment approaches for preschool children have both been found to be effective, and might be more effective when combined. ➢ Those in a parent-conducted program maintained their fluent speech in long-term clinical follow-up studies.  Efficacy of Intervention with School-Age Children ➢ Various treatment approaches and techniques for this age group are effective in establishing fluent speech, but the child’s ability to use these techniques in various settings and maintain improvements is problematic. ➢ It is important to address the psychosocial aspects of stuttering.  Efficacy of Intervention with Adolescents and Adults ➢ Positive client-clinician relationship has been shown to contribute to successful treatment outcomes. ➢ Studies suggest a 60-80% improvement rate, regardless of therapeutic technique.  Stuttering intervention across all age groups results in an average improvement for about 70% of cases, with preschool-age children improving more quickly and easily. ❖ The Effects of Stuttering through the Lifespan  Current evidence suggests that stuttering affects the ability to communicate and participate in life situations from an early age.  Stuttering can also have a negative impact in the workplace, and is a vocationally disabling condition because employers view it as a disorder that decreases employability and opportunities for promotion.  Individuals who stutter are more prone to anxiety, depression, and negative affect.

Summary Stuttering is a disabling condition primarily characterized by sound and syllable repetitions and sound prolongations that interrupt the smooth forward flow of speech. In most cases, stuttering appears between the ages of 2 to 4 years, and as the disorder progresses, it increases in severity. It can adversely affect an individual’s school performance, employment, and social interactions. Treatment is most effective when it is initiated in early childhood, although treatment at any age can reduce stuttering. A number of theories attempt to account for the onset and development of stuttering, but its cause is unknown.

Thought Questions 8.1: What kinds of jobs require a great deal of speaking? Do you think people who stutter avoid such jobs? 8.2: If you were a person who stutters, would you feel comfortable using “self-disclosure” as a treatment strategy? Why or why not? 8.3: What might be the advantages and disadvantages of social media for school-age children who stutter?

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CHAPTER 9 VOICE AND RESONANCE DISORDERS Learning Outcomes When you have finished this chapter, you should be able to: 1. Explain the normal processes of phonation and resonance. 2. Briefly describe voice and resonance disorders. 3. Describe the primary components of a voice and resonance evaluation. 4. Describe the major goals of voice and resonance treatment, and effective voice and resonance treatment approaches and techniques.

Introduction Voice is our primary means of expression and is an essential feature of speech. The voice is an emotional outlet that mirrors moods, attitudes, and general feelings. It is a powerful tool that delivers a message and simultaneously adds to the meaning of that message. Resonance is the quality of the voice that is produced from sound vibrations in the pharyngeal, oral, and nasal cavities. Failure of the velopharyngeal mechanism to separate the oral and nasal cavities during speech production and swallowing is called velopharyngeal dysfunction (VPD). In This chapter, we extend some of the basic concepts related to normal voice and resonance, and discuss disorders of voice associated with structural pathologies, neurological disorders, and psychological and stress conditions. We will also discuss disorders of resonance related to craniofacial anomalies involving the head and face.

Content Outline NORMAL VOICE AND RESONANCE PRODUCTION ❖ Vocal Pitch  Perceptual correlate of F0 associated with rate of vocal fold vibration, measured in hertz (Hz) (the number of complete vibrations per second).  F0 for men is around 125 Hz, women are around 250 Hz, and children can be up to 500 Hz.  Although individuals have a habitual speaking frequency, the frequency of the voice constantly varies during speech production.  Monotone voice: Result of not varying habitual speaking frequency.  Varying the pitch of the voice has linguistic significance.  Modifications in the length and tension of the vocal folds are necessary to produce pitch change. ❖ Vocal Loudness  The perceptual correlate of intensity, measured in decibels (dB).  The loudness of conversational speech averages around 60 dB.  Changes in vocal intensity require the vocal folds to stay together longer, but alveolar pressure is the major determinant of vocal intensity. ❖ Voice Quality  The unique traits of an individual’s voice quality are derived from the anatomy of the larynx, the shape of the vocal tract and its resonant characteristics, and suprasegmental aspects of speech such as rate and rhythm, which can alter the way the vocal folds vibrate.  Lifespan Issues ➢ Beginning in the third decade for men and the fourth decade for women, some of the laryngeal cartilages and joints begin to ossify, while others calcify, causing the larynx to become stiff and brittle. ➢ Age-related changes to the larynx can lead to presbyphonia, a voice disorder characterized by perceptual changes in pitch, pitch range, loudness, and voice quality in the voice of older individuals. ➢ Menopause and hormone-related factors causing increased edema may be responsible for the change in women (lowered F0) ➢ For men, age-related changes to laryngeal muscle due to atrophy may be responsible for the increased F0 in older men.

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❖ Resonance  Normal resonance is largely determined by the velopharyngeal structures and the adequacy of their function.  Structures of the velopharyngeal mechanism include the velum, the lateral pharyngeal walls, and the posterior pharyngeal wall.  The velopharyngeal port remains open most of the time to allow for nasal breathing and for nasal consonants but must achieve complete or nearly complete closure for production of oral speech sounds.  Lifespan Issues ➢ Velopharyngeal closure patterns may vary among individuals and can change over time. ➢ For instance, young children with enlarged adenoids may achieve complete velopharyngeal closure via elevation of the velum against the adenoid mass. After adenoidectomy, the child may have hypernasal speech until the closure pattern is altered. ➢ From young adulthood through advanced age, velopharyngeal function during speech production remains intact and unchanged.

DISORDERS OF VOICE AND RESONANCE ❖ Deviations may be in voice quality, pitch, and/or loudness. ❖ Approximately 3-9% of adults in the U.S. have a voice disorder, with women more commonly affected than men. ❖ In children 3-10 years of age, the prevalence of voice disorders is estimated at about 6%, with boys affected more often than girls. ❖ Specific vocal behaviors such as loud talking, coughing, or throat clearing may predispose some individuals to voice disorders. ❖ Voice disorders in children are usually related to vocal misuse/abuse and are typically temporary, but adult voice disorders are quite varied. ❖ Perceptual signs and case history are initial benchmarks in differential diagnosis. ❖ When one or more perceptual aspects of voice such as pitch, loudness, or voice quality are outside the range of normal for an individual’s age, sex, cultural background, or geographic location, we say a voice disorder exists. ❖ Classification of Voice Disorders  Organic Voice Disorders ➢ Physical changes to the larynx can result from aging or structural abnormalities. ➢ Neurological disorders interfere with normal vocal fold vibration as the result of damage to central or peripheral nervous system substrates. ➢ Structural Abnormalities Resulting in Voice Disorders • Vocal Nodules: Localized growths resulting from frequent, hard vocal fold collisions. Generally bilateral, occurring at the juncture of the anterior one-third and posterior twothirds of the vocal folds. Nodules are soft and pliable at first, and can become hard and fibrous. Most common in adult women between 20 and 50 years old. Can also occur in children prone to excessive loud talking or screaming. The primary perceptual voice symptoms are hoarseness and breathiness. May complain of sore throat and an inability to use the upper third of the pitch range. Newly formed nodules are often treated with vocal rest. Consulting an SLP for voice therapy and education is usually recommended. Longstanding nodules may require surgical removal followed by voice therapy. • Vocal Polyps: Fluid filled lesions that develop when blood vessels rupture and swell. Tend to be unilateral, larger than nodules, vascular, and prone to hemorrhage. Can result from a single traumatic incident. Sessile polyps closely adhere to vocal folds and can cover two-thirds of the vocal fold. Pedunculated polyps appear to be attached by means of a stalk. Hoarseness, breathiness, and diplophonia are the primary vocal symptoms. There may be the sensation of something in the throat. Surgical removal and voice therapy is effective. • Contact Ulcers and Granulomas: Contact ulcers are small, reddened ulcerations on the posterior surface of the vocal folds in the region of the arytenoid cartilages. They are usually bilateral and painful. As contact ulcers heal, they are replaced by granulated tissue, referred to as a granuloma. GERD is a significant contributing factor to the development of contact ulcers. Contact ulcers and granulomas can develop as a result of trauma induced during surgical intubation of the larynx. The primary voice symptoms of contact ulcers are hoarseness and breathiness. Throat clearing and vocal fatigue are

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present. Treatment efficacy is questionable, and many contact ulcers reappear after surgical removal. Managing GERD is important. • Laryngitis: Inflammation of the vocal folds that can result from exposure to noxious agents, allergies, or vocal abuse. Acute laryngitis is a temporary swelling that can result in hoarseness. Chronic laryngitis is a result of vocal abuse during periods of acute laryngitis and can lead to serious deterioration of vocal fold tissue. The vocal folds become dry and sticky, resulting in a persistent cough, and the individual reports frequent throat aches. Voice symptoms range from mild hoarseness to near aphonia, lowered pitch, and complaints of vocal fatigue. Voice treatment and lifestyle changes are necessary to treat chronic laryngitis. • Papillomas: Laryngeal papillomas are small wart-like growths of the vocal folds and interior of the larynx. Caused by the human papillomavirus (HPV) and are the most common abnormal laryngeal pathology in children younger than 6 years. Noncancerous but can obstruct the airway. Children exhibit inspiratory stridor. Must be surgically removed but tend to reappear; repeated surgery can damage tissue. • Webs: Laryngeal webs are the result of connective tissue growing between the vocal folds; they can be congenital or acquired as the result of trauma or prolonged infection. Can interfere with breathing, causing stridor and shortness of breath. Must be removed surgically. May produce a high-pitched, hoarse quality or even absence of voice. • Cancer: Laryngeal cancer has been linked to cigarette smoking and excessive use of alcohol, although there are additional risk factors. One of the early signs is persistent hoarseness in the absence of colds or allergies. It is often necessary to remove the entire larynx; the trachea is repositioned to form a stoma on the anterior aspect of the throat for breathing. Some alaryngeal speakers use esophageal speech, where the esophagus is a vibratory source. An electrolarynx is a prosthetic device that has a vibrating diaphragm placed on the lateral aspect of the neck. Some alaryngeal speakers are candidates for tracheoesophageal puncture (TEP) or tracheoesophageal shunt in which air is directed from the trachea to the esophagus so the speaker can use the cricopharyngeous m. for voice production. Neurologic Voice Disorders • Damage to Cranial Nerve X (Vagus): Unilateral and bilateral vocal fold paralysis result from damage to the 10th cranial nerve. The recurrent laryngeal nerve supplies most of the laryngeal m. for voice. The voice symptoms of unilateral vocal fold paralysis include a hoarse and breathy vocal quality, reduced loudness, monoloudness, pitch breaks, and diplophonia. In bilateral vocal fold paralysis, the voice is very breathy, weak, or totally absent. The risk of aspiration during swallowing increases when the folds are in the abducted position. Surgical intervention may be needed. Voice treatment following surgery aims to increase vocal fold closure and loudness. • Parkinson Disease: Results from degeneration of dopaminergic neurons in the substantia nigra, interfering with the function of the basal ganglia. Muscle rigidity, reduced range of movement, tremor at rest, hypokinesia are characteristics of PD. Facial appearance is masklike, and voice symptoms include reduced loudness, monopitch, monoloudness, hoarseness, harshness, and breathiness. PD is treated with a variety of drugs and sometimes deep brain stimulation. Intensive voice treatment aimed at increasing vocal fold adduction has been successful in improving vocal loudness and speech intelligibility. • Amyotrophic Lateral Sclerosis (ALS): A motor neuron disease characterized by degeneration of both the upper and lower motor neurons causing flaccid and spastic weakness. Voice symptoms vary, and may include breathiness, harshness, and/or a strained/strangled quality, reduced loudness, monoloudness, inspiratory stridor, and abnormally high or low pitch. Given the degenerative nature of the disease, compensatory strategies are beneficial. An AAC device is eventually needed. • Spasmodic Dysphonia: Neurological voice disorder reflecting damage to the basal ganglia and cerebellar control circuits. The average age of onset is 45-50 years of age, with women affected more often than men. SD can be neurological, psychological, or idiopathic. Abductor SD can cause a strained, effortful, tight voice and intermittent voice stoppages. SD can be associated with voice tremors. Botox injection into specific laryngeal m. is the preferred method of treatment for neurological or idiopathic SD.

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Functional Voice Disorders ➢ Muscle Tension Dysphonia • Primary MTD is a voice disturbance caused by abnormal muscle activity in the absence of structural or neurological abnormalities. • Hoarseness is a common voice symptom, along with strained-harshness, strainedbreathiness, aphonia, and intermittent pitch breaks. • Voice treatments that address laryngeal hyperadduction are generally used to manage MTD, but evidence is limited. ➢ Conversion Aphonia • Strong emotions, when they are suppressed, can cause psychogenic voice disorders. • These are sometimes called conversion disorders because the person is converting emotional conflicts into physical symptoms. • Conversion aphonia: These individuals are capable of coughing and clearing the throat, but do not approximate the vocal folds for speech production. • It will likely persist until the person is willing to resolve the emotional conflict. ➢ Mutational Falsetto • Also known as puberphonia. • The continual use of a high-pitched voice by adolescent or adult males who have completed the maturational changes associated with puberty. • Psychological counseling is sometimes necessary, but most individuals benefit from behavioral voice treatment focused on lowering pitch. ❖ Resonance Disorders  Can accompany voice disorders or be caused by a number of structural abnormalities, including clefts of the palate.  A cleft is an abnormal opening in an anatomical structure caused by a failure of the structures to fuse or merge correctly early in embryonic development.  A resonance disorder may develop when there is a blockage in the nasopharynx that impedes sound energy from traveling through the nose for production of nasal sounds (hyponasality).  When there is a complete blockage, denasality occurs.  When the velopharyngeal mechanism fails to decouple the oral and nasal cavities, hypernasality secondary to velopharyngeal dysfunction occurs.  VPD can also result in audible nasal emission, which can result in a loud, turbulent sound called a nasal rustle or nasal turbulence.

EVALUATION OF VOICE AND RESONANCE DISORDERS ❖ At minimum, a voice evaluation requires an otolaryngologist and an SLP. ❖ For evaluation of resonance disorders, particularly of VPD secondary to cleft palate, a cleft palate or craniofacial team is necessary. ❖ The Voice Evaluation  The primary objectives are to determine the presence or absence of a voice disorder, determine the nature of the voice disorder, and determine the severity of the voice disorder.  The first step is an examination performed by an otolaryngologist.  A direct examination of the vocal folds and other laryngeal structures can be achieved using laryngeal mirrors or with an endoscope.  Biopsies of vocal fold tissue may be taken if laryngeal cancer is suspected.  The SLP’s role typically begins by obtaining a case history. ➢ Description of the voice problem, when it started, the duration, what the client believes might be causing it, how it affects daily life activities, the person’s social and vocational use of the voice, and his or her overall physical and psychological condition are important.  The SLP conducts an auditory-perceptual evaluation to describe pitch, loudness, and voice characteristics.  The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) is a tool developed to help SLPs standardize the way in which these parameters of voice are evaluated and judged.  The clinical voice evaluation may also involve detailed acoustic and physiological measurements regarding vocal function that can be compared to normative data.  Instruments are also available that measure airflow and air volume exchanges during phonation that can objectively assess breathiness.

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The Voice Handicap Index can help determine the psychosocial handicapping effects of a voice disorder. ❖ The Resonance Evaluation  Case history information is important.  Auditory-perceptual evaluation of resonance is still the “gold standard.”  There are standardized rating scales for assessing vocal resonance.  Ask the client to repeat sentences containing voice, oral sounds with few high pressure consonants for assessment of hypernasality.  Ask the client to repeat sentences that contain mostly nasal sounds for assessment of hyponasality.  The presence of audible nasal emission can best be determined by having the client repeat sentences loaded with high-pressure consonants.  Nasometer: Measures simultaneously the relative amplitude of acoustic energy being emitted through the nose and mouth during phonation. A nasalance score is computed to reflect the magnitude of hypernasality.  Multi-view videofluoroscopy: A motion picture X-ray recorded on DVD, which permits the imaging of velopharyngeal function from three different perspectives.  Videonasendoscopy: Also known as fiberoptic nasendoscopy. Consists of a lens, fiberoptic light cable, insertion tube, camera, and connection to a monitor for viewing velopharyngeal function.

MANAGEMENT OF VOICE AND RESONANCE DISORDERS ❖ Classification of Behavioral Treatment Approaches for Voice Disorders  Direct treatments modify vocal behavior in some way, and are either physiologic or symptomatic.  Indirect treatments modify the cognitive, behavioral, psychological, or physical environment in which voicing occurs.  Educating the client about vocal hygiene or counseling the client to identify psychosocial factors that negatively impact the voice are examples of indirect voice interventions.  A combination of direct and indirect treatments is necessary for effective treatment of most voice disorders. ❖ Treatment of Voice Disorders Associated with Benign Structural Abnormalities  Voice therapy is frequently the clinical method of choice for voice disorders associated with benign structural abnormalities that result from and are maintained by vocal misuse/abuse.  Clients are taught to modify vocally abusive behaviors and are educated about laryngeal pathology.  The goal of direct treatment approaches is to teach the client to eliminate the vocally abnormal or abusive behavior by producing a voice that balances respiratory, laryngeal, and articulatory/resonatory subsystems. ❖ Intervention for Voice Disorders Associated with Neurological Diseases  Treatment may focus on increasing overall speech intelligibility or identifying assistive or alternative means of communication.  For direct voice intervention, the goal is to assist the individual to produce the best voice possible to remain communicatively functional in vocational and social settings. ❖ Intervention for Voice Disorders Associated with Psychological or Stress Conditions  Treatment can be effective if the individual is convinced there is nothing physically wrong via specific voicing techniques.  The voice can return to normal in minutes or over several sessions.  Psychiatric referral is often not needed after successful treatment. ❖ Elective Voice Intervention for Transgender/Transsexual Clients  For females transitioning to males, hormone replacement often serves to lower pitch to an appropriate level.  Individuals transitioning from male to female often need assistance in raising vocal pitch to be perceived as female.  For biological males to be perceived as females, they must raise their F0 to 155-165 Hz or as high as 180 Hz.  SLPs can train individuals to place their tongue more anteriorly in their mouth when speaking, achieving a more “forward” resonance associated with the female voice. ❖ Treatment of Resonance Disorders  Medical Management

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Treatment of hypernasality secondary to VPI in individuals with cleft palate typically begins with surgical intervention. ➢ Children born with palatal clefts undergo surgical closure of the cleft between 9 and 18 months of age. ➢ Surgery to repair a cleft lip occurs before 3 months of age.  Prosthetic Management ➢ A palatal obturator is a prosthetic device similar to a retainer that can be used to cover a defect such as a fistula until further surgery is warranted. ➢ A speech bulb obturator can be used when the velum is too short to contact the posterior pharyngeal wall or when the velum is immobile. ➢ A palatal lift can be used to elevate the velum in cases where the velum is immobile.  Behavioral Management ➢ In individuals with VPI resulting in a mild degree of hypernasality following surgical repair of a cleft palate, behavioral management may be appropriate. ➢ Continuous positive airway pressure (CPAP) can be used to strengthen the muscles of the velum. ➢ CPAP is based on the exercise physiology principle of progressive resistance training.  Treatment of Articulation Disorders Secondary to VPD ➢ Direct intervention for speech-sound development should begin prior to the first palatal surgery, and as early as 5-6 months of age. ➢ Early intervention should focus on increasing the child’s consonant inventory, especially pressure consonants, and on increasing oral airflow. ➢ Teaching the difference between nasal and oral sounds, as well as how to direct air stream through the mouth (using a nose clip) may also be helpful. ➢ For children who substitute glottal stops for high-pressure consonants, direct treatment should begin as soon as possible. ➢ Electropalatography (EPG): A promising technique for speech sound production in which an artificial palate plate containing electrodes connected to a computer is used to determine when the tongue contacts the electrodes. ➢ Children can use EPG to learn correct placement of articulators. ❖ Efficacy of Voice and Resonance Treatment  For voice disorders, particularly those associated with vocal misuse and abuse, including those with structural tissue damage, and for some voice disorders associated with neurological conditions like Parkinson disease, and voice disorders associated with psychological or stress conditions, treatment has shown to be reasonably effective.  Individuals born with cleft palate who receive medical and behavioral intervention earlier in their life generally speak normally by the time they are adolescents.  Changing habituated behaviors that contribute to vocal misuse or abuse is hard work and takes time.

Summary The human voice reflects one’s personality, general state of health and age, and emotional condition. The human vocal tract acts as a filter, changing in size and shape to alter the sound generated by the larynx, thus contributing to the resonance, or quality, of the voice. Closure of the velopharyngeal mechanism is necessary to produce the majority of speech sounds in the English language, and inadequate closure due to structural abnormalities such as cleft palate results in the perception of hypernasality. Voice and resonance disorders range in etiology and severity. Effective and ethical management requires a team approach.

Thought Questions 9.1: Do you think there is such a thing as a “voiceprint” similar to a person’s fingerprint? 9.2: What impact might a cleft palate have on family-infant bonding? 9.3: If you were prescribed a specified period of vocal rest, how would your daily life activities be affected? Could you comply with this treatment approach?

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CHAPTER 10 MOTOR SPEECH DISORDERS Learning Outcomes When you have finished this chapter, you should be able to: 1. Describe the structures of the brain that are important for motor speech control. 2. Describe the types and etiologies of dysarthria and apraxia in adults and children. 3. Discuss assessment techniques for motor speech disorders. 4. Discuss evidence-based treatments for dysarthria and apraxia in adults and children.

Introduction Motor speech disorders are related to problems of movement as a result of neurological disorder or injury. They are a heterogeneous group of impairments that affect the planning, coordination, timing, and execution of speech movements in children and adults. As with language, there does not seem to be a specific area of the brain devoted to speech motor control. In this chapter, we discuss two types of motor speech disorders: dysarthria and apraxia of speech. We discuss five types of dysarthria and briefly how to differentiate each from one another, and from apraxia of speech.

Content Outline STRUCTURES OF THE BRAIN IMPORTANT FOR MOTOR SPEECH CONTROL ❖ A complex network of structures and pathways in the brain is responsible for speech motor control. ❖ The frontal lobes house the primary motor cortex. ❖ Descending pathways originate from primary motor cortex and are important for initiating voluntary motor movements. ❖ The direct activation pathway, or pyramidal tract, originates in the primary motor cortex and it is responsible for rapid, discrete, volitional movement of the limbs and articulators for speech; connects directly to the cortex. ❖ The indirect activation pathway, or extrapyramidal tract, is important for regulating reflexes and maintaining posture and muscle tone, providing the necessary framework to facilitate movement. ❖ The direct and indirect activation pathways form the upper motor neuron system. ❖ The basal ganglia are large subcortical nuclei that regulate motor functioning and maintain posture and muscle tone (part of the extrapyramidal system). ❖ The BG modulates the activity of the primary motor cortex and indirectly influence movement. ❖ Depending on which pathway is involved, damage to the BG will either result in reduced and/or slowed movement (Parkinson disease) or in abnormal, involuntary movements (Huntington’s chorea). ❖ The cerebellum and its connections coordinate the control of fine, complex motor activities, maintain muscle tone, and participate in motor learning. ❖ Motor Speech Production Process  First, the movement plan/program is retrieved from memory.  The plan is sent to the motor control areas.  It is then transmitted with precise timing along the nerves to muscles and structures of the speech mechanism, resulting in sequences of acoustic signals that are recognized as speech sounds.  Nerve impulses are modified to ensure precise, smooth muscle movement.  Typical movement patterns are purposeful and efficient and are under the control of the individual.  Motor responses are initiated, changed, and coordinated on the basis of both external and internal sensory information.  For speech production, auditory and proprioceptive feedback help ensure proper coordination of the speech mechanism. ❖ Cranial Nerves Important for Speech Production  The peripheral nervous system consists of 12 pairs of cranial nerves, most of which originate in the brain stem, and 31 pairs of spinal nerves that exit the vertebral column and travel to and from muscles.  The cranial nerves are especially important for speech production.  The majority of spinal nerves are important for breathing purposes of speech production.  Special control centers in the brain stem govern breathing for life.

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MOTOR SPEECH DISORDERS ❖ Dysarthria  Group of neuromuscular impairments resulting from disturbances in the CNS and PNS that control the muscles of speech production.  Dysarthria can affect the speed, range, direction, strength, and timing of motor movement as the result of weakness, spasticity, discoordination, or involuntary movements.  Respiration, phonation, resonation, and articulation may all be affected.  Motor movements that were previously established may have been lost or modified in some way, though the pattern for that movement still exists.  Flaccid Dysarthrias ➢ Hypotonia: A weak, soft, low muscle tone. ➢ Usually results from lesions in the cranial and spinal nerves (lower motor neurons) or in the muscle unit itself. ➢ May result in reduced respiratory drive for speech breathing, continuously breathy voice quality, reduced pitch and loudness levels, monopitch, hypernasality, and imprecise articulation. ➢ Bell’s Palsy • An idiopathic condition that results in unilateral damage to the facial nerve. • It occurs suddenly and resolves spontaneously in most cases. • Flaccid dysarthria usually results in mild articulatory imprecision. ➢ Progressive Bulbar Palsy • A neurological disease that causes degeneration of lower motor neurons resulting in flaccid paralysis and eventual muscle atrophy. • Fasciculations: Visible, isolated twitches in resting muscle due to spontaneous firing of nerve impulses in response to nerve degeneration. • Speech sounds weak, hypernasal, monopitched, and articulation is imprecise. ➢ Myasthenia Gravis • An autoimmune disease that affects the neuromuscular junction. • Characterized by rapid weakening of the muscles due to inadequate transmission of nerve impulses to the muscles. • With repeated use such as during speech production, muscles become progressively weak but regain their strength with a short period of rest. • Imprecise articulation and hypernasality that rapidly gets worse with prolonged speaking, but dramatically improves with 1-2 minutes’ rest.  Spastic Dysarthria ➢ Spastic paralysis reflects the combined effects of weakness and loss of inhibitory motor control. ➢ Reflexes become hyperactive, muscle tone is increased at rest, and individuals exhibit spasticity, or increased resistance to passive stretch. ➢ Movements of the articulators become slowed and reduced in force and range of motion. ➢ Spasticity at the level of the larynx results in a strain-strangled voice quality. ➢ Spastic dysarthria typically results from bilateral upper motor neuron lesions in the cerebral hemispheres or a single lesion in the brain stem.  Ataxic Dysarthria ➢ Damage to the cerebellum or cerebellar control circuitry results in incoordination and reduced muscle tone, called ataxia. ➢ Ataxic dysarthria reflects the effects of incoordination and the improper timing of movements, causing irregular breakdowns in articulation and abnormalities of prosody. ➢ Movements are inaccurate, jerky, and lacking smoothness.  Hypokinetic Dysarthrias ➢ Hypokinetic movements are slow and reduced in range of motion due to the effects of rigidity. ➢ Individuals with hypokinesia (reduced movement) feel stiff and find it difficult to get movements started. ➢ Once started, they struggle to stop. ➢ The most common cause of hypokinesia is Parkinson disease where a degeneration of dopaminergic neurons in the brain stem prevents proper functioning of the BG. ➢ Reduced range of motion is a hallmark of hypokinetic dysarthria. ➢ As a result, speech rate becomes very fast, and disfluencies are common.

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Loudness levels gradually diminish. Parkinson Disease • Common idiopathic degenerative neurological disease that affects 1-2% of individuals over age 50. • Genetic and environmental factors are believed to play a role. • Hypokinetic dysarthria is eventually present in 90% of cases of PD. • Speech difficulties result in reduced loudness, accelerated rate of speech, disfluencies, and imprecise articulation. • Voice quality may be breathy and harsh or hoarse, and pitch and loudness variability is significantly reduced, resulting in monopitch and monoloudness.  Hyperkinetic Dysarthrias ➢ Due to damage of the BG control circuitry; the indirect pathway and/or structures of the BG that help to inhibit unwanted movements are damaged. ➢ Hyperkinetic dysarthria is essentially the production of motorically normal speech that is interrupted in some fashion by abnormal involuntary movements. ➢ Tremor involves rhythmic movement of a body part. ➢ Tics are rapid, patterned movements that are not completely involuntary and can be suppressed for brief period with effort. ➢ Dystonia is a slow hyperkinesia that may involve the entire body or may be localized to just one body part. Hyperkinetic dysarthria in individuals with dystonia may include excessive pitch and loudness variations, irregular breakdowns in articulation, variable rate, and inappropriate silences. ➢ Chorea is characterized by rapid and unpredictable movements of the limbs, face, and tongue. Hyperkinetic dysarthria associated with chorea is characterized by variable speech rate, irregular articulatory breakdowns, and significant prosodic abnormalities. ➢ Huntington’s Chorea • Inherited progressive disease that results in degeneration of structures in the BG. • Initial symptoms include involuntary choreatic movements and changes in behavior. • Later, involuntary movements worsen and become more generalized. • Significant changes in mood and personality become evident with subsequent development of depression and dementia.  Mixed Dysarthrias ➢ When two or more types of dysarthria are present in an individual. ➢ Can occur in neurodegenerative diseases that cause damage to multiple areas of the CNS. ➢ In amyotrophic lateral sclerosis (ALS), both upper and lower motor neurons degenerate, causing both spastic and flaccid paralysis. ➢ The severity of mixed dysarthria in individuals with ALS becomes worse as the disease progresses, and 75% of those affected are unable to speak at the time of death. ➢ TBI also causes mixed dysarthria, usually mixed spastic-ataxic. ➢ Axonal shearing in TBI causes diffuse damage.  Lifespan Issues ➢ Most acquired dysarthrias occur in adulthood. ➢ For some individuals, even a slight speech abnormality can be cause for embarrassment or depression. ➢ In more severe cases of dysarthria, individuals may be frustrated as loved ones and acquaintances attempt to communicate for them by finishing their sentences or ordering for them in restaurants. ➢ This may cause them to socialize less. ➢ In the later stages of progressive degenerative diseases, an individual with dysarthria may be unable to live independently and may need daily living assistance or institutional care. ➢ The person may be unable to speak at all, and the SLP can work to provide AAC for communication. ❖ Apraxia of Speech  Neurological speech disorder that impairs the ability to plan or program the sensory and motor commands needed for speech production.  Results in disordered articulation of vowels and consonants, slowed rate, and prosodic disturbances.  It generally occurs following damage to the left cerebral hemisphere, particularly the motor and premotor areas.

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Speech is characterized by groping attempts to find correct articulatory position, great variability over repeated attempts, sound substitutions, omissions, additions, and difficulty sequencing sounds in multisyllabic words.  Speech production may appear stuttering-like.  Consonants and consonant clusters and blends are particularly challenging.  Complex, long, unfamiliar words are the most difficult to produce.  Monitoring of speech in anticipation of errors tends to be slowed, with equal stress and spacing.  Lifespan Issues ➢ Most individuals who acquire apraxia of speech do so following a stroke in the left hemisphere, specifically Broca’s area in the left frontal lobe. ➢ Depending on the severity of the stroke, individuals can make a full recovery and speech may return to normal. ➢ In other cases, speech may recover to some extent, but mild prosodic abnormalities such as slow rate and incorrect stress patterns may persist. ➢ For an individual who has apraxia of speech due to a progressive neurological disease, an SLP should consider AAC early. ❖ Etiologies of Motor Speech Disorders in Children  Cerebral Palsy ➢ Heterogeneous group of non-progressive, permanent disorders of movement and postural development. ➢ Congenital disorder that causes dysarthria in children. ➢ Often results from oxygen deprivation to the brain that occurs either during development of the fetus, during the birth process, or shortly after birth. ➢ Hemorrhages in the brain can also cause CP. ➢ Infections and toxins may also disrupt brain development. ➢ Malnutrition and/or the use of alcohol or drugs by pregnant women can also result in children being born with brain dysfunction. ➢ Accidents during pregnancy and in the neonatal period can result in fetal brain injury. ➢ CP is the most common etiology of chronic physical disability in the pediatric population. ➢ Causes abnormal muscle tone, loss of selective motor control, muscles weakness, and impaired balance. ➢ The type of CP varies with the areas of the CNS that are damaged. ➢ Spastic Cerebral Palsy • For about 60% of individuals with CP, the prominent characteristics include spasticity and increased muscle tone. • Exaggerated stretch reflex: When the muscle is stretched, the opposing muscle may react abnormally by increasing muscle tone to a greater-than-normal degree. • Damaged upper motor neurons are unable to inhibit signals that increase muscle tone. • Movement is jerky, stiff, labored, and slow. • In severe cases, the limbs may be rotated inward, with the arms drawn upward and the head turned to one side. ➢ Athetoid Cerebral Palsy • About 30% of individuals with CP have athetosis – slow, involuntary writhing, most pronounced when the individual attempts volitional movement. • Movement is disorganized and uncoordinated. • Damage is to the BG structures and pathways that inhibit involuntary movements. • Speech and breathing problems are more severe in individuals with athetoid CP than with any other type. • In its most severe form, athetosis causes an individual’s feet to turn inward, the back and neck to arch, and the arms and hands to be overextended above the head. • However, severity varies, and for some individuals athetoid movements may not be present at rest. ➢ Ataxic Cerebral Palsy • Characterized by uncoordinated movement and disturbed balance. • In extreme cases, walking is characterized by a wide stance, with the head pushed forward and arms back, an almost bird-like appearance. • Injury to the cerebellum impairs monitoring of information about balance from the inner ears, as well as proprioceptive information from the muscles.

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Motor Speech Disorders Associated with Cerebral Palsy • Not everyone with CP has motor speech difficulties. • Children with CP may present with atypical motor patterns in the process of learning speech with a faulty motor system. • Speech breathing difficulties are a common problem, particularly in spastic CP. • Inconsistent or inadequate airflow, along with involvement of laryngeal muscles, will affect phonation. • Resonance may be characterized by hypernasality as a result of velopharyngeal dysfunction. • Articulation may be extremely difficult if there is involvement of the tongue, lips, and/or jaw. • Prosodic aspects of speech may also be affected; speech may be characterized as disfluent, nonrhythmic, and very monotonous. • Other issues may also complicate speech production, including intellectual, attention, auditory processing, and language deficits. Lifespan Issues • Early symptoms of CP may include irritability, weak crying and sucking, excessive sleeping, minimal interest in surroundings, and persistence of primitive reflexes beyond the newborn stage. • The parent-child bond may be strained as the child fails to respond in predictable ways. • The care of a child with CP may tax the family and introduce stress into the family environment. • The type of CP may change within the first few years. • Motor delays are often the first sign. • SLPs may participate on an early intervention team to address delays in speech, language, and/or feeding and swallowing. • Variables such as severity, concomitant disorders, parental involvement, and school system flexibility are important in determining the appropriate educational environment. • Many individuals, especially those with mild physical and cognitive difficulties, obtain higher education and/or go into competitive employment. • Other individuals may work and learn in centers run by agencies or the state. • Day treatment programs are available to provide training in daily living and vocational skills for individuals with severe motor deficits and/or cognitive impairment.

EVALUATION OF MOTOR SPEECH DISORDERS ❖ A thorough case history is necessary. ❖ Have the client attempt various speech production tasks specifically designed for purposes of differential diagnosis, along with perceptual and objective measures of the speech production subsystems. ❖ By correctly identifying different speech patterns consistent with a particular type of motor speech disorder, you can provide valuable information for differential diagnosis of underlying neurological conditions. ❖ The purposes of the motor speech evaluation are:  To determine whether a significant and long term problem exists.  To describe the nature of impaired functions, specifically the types of problems, the extent/severity, and the effects of these impairments on everyday functioning.  To identify functions that are not impaired.  To establish appropriate goals and decide where to begin intervention.  To form a well-reasoned prognosis, based on the nature of the disorder, the client’s age, the age or stage of injury or disease, the presence of other conditions, client motivation, and family support. ❖ The SLP will evaluate the structure and function of the oral mechanism, connected speech, and speech in special tasks. ❖ A few commercial tests are available, but most SLPs have a standard assessment protocol for evaluation purposes. ❖ During the oral peripheral mechanism evaluation, note the following:  Symmetry, configuration, color, and general appearance of the face, jaw, lips, tongue, teeth, and hard and soft palate at rest.  Movement of the jaw, tongue, lips, and soft palate.

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 Range, force, speed, and direction of the jaw, lips, and tongue during movement. ❖ Also determine the following:  Lung capacity, respiratory driving pressure, and control during speech production.  Phonatory initiation, maintenance, and cessation.  Pitch and pitch variability.  Loudness and loudness variability.  Volitional pitch-loudness variations.  Velopharyngeal function. ❖ The following speech production tasks can help in differential diagnosis for apraxia of speech:  Imitation of single words of varying lengths.  Sentence imitation.  Reading aloud.  Spontaneous speech.  Rapid repetition of “puh,” “tuh,” “kuh,” and “puh-tuh-kuh” (or “buttercup”).

TREATMENT OF MOTOR SPEECH DISORDERS ❖ Basic principles underlie treatment of motor speech disorders in children and adults, including restoring lost function, using compensatory strategies, and making adjustments for lost function. ❖ Management of Dysarthria  Must address respiration, phonation, resonation, articulation, and prosody.  Increasing respiratory drive might be accomplished by using a pausing/phrasing strategy.  If respiratory muscle weakness impedes the use of that strategy, an abdominal binder can be used.  Patients with severe respiratory weakness and significantly reduced loudness can use voice amplifiers.  LSVT is an evidence-based behavioral approach to increasing phonatory competence in adults with Parkinson disease and for treating respiratory and phonatory deficits in children with spastic cerebral palsy.  CPAP and a palatal lift can be used to improve velopharyngeal function.  Intensive, repetitive speech production drill practice with meaningful words and phrases is an effective way to increase articulatory accuracy and thus improve speech intelligibility.  Slowing speech rate is also an effective means of improving articulatory precision.  Wearing an EPG palate may be beneficial.  Nonspeech oral motor treatments are not recommended.  Speech supplementation, such as using an alphabet board to point to the first letter of each word, increases listener comprehension of speech produced by adults and older children with dysarthria.  For children and adults with severe to profound dysarthria, the use of AAC in conjunction with verbal forms of communication is most beneficial. ❖ Management of Acquired Apraxia of Speech  Integral stimulation: One of the most effective treatments; involved using a “watch me, listen to me, and do what I do” paradigm.  Integral stimulation procedures involve an 8-step continuum for cuing that is used to help a client retrain his or her motor planning/programming abilities.  There is a core set of functional vocabulary words or phrases.  Incorporates principles of motor learning.  Melodic intonation therapy: Focuses on prosody, emphasizing the melody, rhythm, and stress patterns of spoken utterances.  Believed to facilitate motor planning/programming for speech production by accessing functions of the right cerebral hemisphere.  Contrastive stress: The client produces sentences by emphasizing stress on particular words, changing the meaning of the sentence.  Most effective for clients with mild to moderate apraxia of speech who continue to exhibit prosodic abnormalities while having otherwise adequate articulation.

Summary The two major types of motor speech disorders are dysarthria and apraxia of speech. Motor speech disorders offer a special challenge to the affected individual, family, friends, and the SLP. Many clients are in the very frustrating position of being able to formulate a message but unable to produce it intelligibly. Intervention

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methods vary greatly. Changing intervention techniques and promising surgical procedures and drugs will continue to offer hope to individuals with neurogenic speech disorders.

Thought Questions 10.1: How might a motor speech disorder differ for an individual with congenital impairment versus an acquired impairment? 10.2: What areas of the brain do you believe are damaged in each of the different types of cerebral palsy, and why? 10.3: How do the assessment techniques used for dysarthria and apraxia of speech differ, and how are they similar? 10.4: How are treatment techniques for childhood apraxia of speech and acquired apraxia of speech in adults similar, and how and why do they differ?

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CHAPTER 11 DISORDERS OF SWALLOWING Learning Outcomes When you have finished this chapter, you should be able to: 1. Describe the normal and disordered process of swallowing. 2. List and describe the correlates of pediatric and adult dysphagia. 3. List and describe the important components of the swallowing evaluation. 4. Describe evidence-based swallowing treatments for children and adults.

Introduction An SLP is responsible for identifying, evaluating, and treating individuals with feeding and swallowing disorders. SLPs who treat patients with dysphagia are part of a team consisting of multiple professionals and family members. Swallowing disorders increase the risk of choking and may lead to aspiration and pneumonia. Problems or weakness related to the anatomy of swallowing may result in gastroesophageal reflux (GER), the movement of food or acid from the stomach back into the esophagus. Eating is a major social activity. Feeding difficulties in children may stress the parent-child relationship. Among older people, dysphagia may lead to isolation, depression, frustration, and diminished quality of life.

Content Outline NORMAL AND DISORDERED SWALLOWING ❖ Normal Swallowing  Oral Preparation Phase ➢ The tongue cups to hold fluid in a liquid bolus against the front portion of the hard palate. ➢ The tongue and cheeks move food to the teeth for chewing and to mix with saliva to form a solid bolus. ➢ The prepared bolus is held in the mouth by the soft palate, which moves forward and down to touch the back of the tongue and close the passage to the pharynx.  Oral Phase ➢ Once the bolus is formed, the oral stage begins. ➢ The bolus is moved from the front to the back of the mouth. ➢ The pharyngeal swallow reflex is triggered when the bolus reaches the anterior faucial arch. ➢ Oral transit usually takes 1-1.5 seconds.  Pharyngeal Phase ➢ The velum contacts the rear pharyngeal wall to stop the bolus from entering the nasal cavity. ➢ The base of the tongue and the pharyngeal wall move toward one another to create pressure needed to project the bolus into the pharynx. ➢ The pharynx contracts and squeezes the bolus down. ➢ The hyoid bone rises, bringing the larynx up and forward. ➢ The true and false vocal folds close and the epiglottis is lowered, covering the airway. ➢ The pharyngeal phase is complete when the upper esophageal or pharyngeal esophageal segment opens and the food or liquid moves into the esophagus. ➢ The pharyngeal phase usually takes less than 1 second.  Esophageal Phase ➢ The muscles of the esophagus move the bolus in peristaltic contractions into the stomach. ➢ The process usually takes 8-20 seconds. ❖ Disordered Swallowing  Oral Preparation/Oral Phase ➢ If the lips do not seal properly, drooling can occur. ➢ Chewing may be impaired because of poor muscle tone or paralysis involving the mouth or because of missing teeth. ➢ Insufficient saliva will impede adequate bolus formation. ➢ Food may pocket in the cheek.

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The muscles of the tongue might not function purposefully or efficiently enough to move the food to the teeth for chewing and to transport the bolus from the front to the rear of the mouth to prepare for the pharyngeal phase. Pharyngeal Phase ➢ If the swallow is not triggered or is delayed, material may be aspirated. ➢ An open velopharyngeal port can lead to substances going into and out of the nose. ➢ Poor tongue mobility may result in insufficient pressure in the pharynx. Esophageal Phase ➢ If peristalsis is slow or absent, the complete bolus might not be transported to the stomach. ➢ Residue on the esophageal walls can result in infection and nutritional problems.

CORRELATES OF PEDIATRIC AND ADULT DYSPHAGIA ❖ Infants and children with feeding and swallowing disorders may experience malnutrition, inadequate growth, dehydration, ill health, prolonged feeding times, fatigue, difficulty learning, and poor parentchild relationships. ❖ Children with central or peripheral nervous system deficits or immaturity, neuromuscular disease, and craniofacial anomalies are particularly vulnerable to feeding and swallowing disorders. ❖ One study indicated a lifetime dysphagia prevalence rate of 38% in 117 adults between ages 65 and 94 years of age who were living independently. ❖ Lifespan Issues  Feeding and swallowing problems may occur at any point in the lifespan.  Newborns may be unable to suckle and/or ingest nutriment.  As they age, infants may refuse food and develop unhealthy food preferences.  Dysphagia may be related to many diverse conditions. ❖ The outcomes of a swallowing disorder at any age include dehydration, malnutrition, poor health, weight loss, fatigue, frustration, respiratory infection, aspiration, and death. ❖ Pediatric Dysphagia ♦ Feeding disorders can describe difficulties children may have with accepting varied food textures or an age-appropriate diet. ♦ Swallowing disorders generally describe difficulty with eating or swallowing that results from physiological or anatomical issues. ♦ SLPs may collaborate with OTs when treating children who have feeding difficulties related to fear and avoidance of foods with certain textures, smells, or tastes due to sensory processing disorders. ♦ SLPs specialize in the treatment of dysphagia, particularly the oral and pharyngeal phases. ♦ Infants and children with swallowing disorders may experience inadequate growth, ill health, ♦ Prematurity ➢ About 1 out of 10 of all births in the U.S. are preterm, or before 37 weeks gestation. ➢ Premature infants often have difficulty with feeding and swallowing due to immature sucking, and/or a discoordinated suck, swallow, and breathe pattern. ➢ Some infants may require tube feedings until their sucking and swallowing development is sufficient and safe to transition to total oral feeding. ♦ Cerebral Palsy ➢ Because the central nervous system is damaged, children with CP frequently have feeding and swallowing problems that place them at risk for aspiration with potential respiratory consequences. ➢ An infant with spastic CP will exhibit excessive muscle tone, abnormal postures and movements, and possibly a hyperactive gag reflex. ➢ GER is common in infants and children with CP, and ingestion may become painful. ➢ Reduced lip closure, drooling, poor tongue function, exaggerated bite reflex, delayed swallow initiation, and reduced pharyngeal motility are types of oral and pharyngeal problems exhibited by children with CP. ➢ In severe cases, children with CP require gastrostomy tube feedings. ♦ Intellectual Disability and Developmental Delay ➢ Delayed motor coordination in children with ID/DD may interfere with eating and the oral phase of swallowing. ➢ Children may be limited in their ability to express food desires and preferences. ♦ Autism Spectrum Disorder ➢ Children with ASD may have significant feeding problems.

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Behaviors that can interfere with feeding include social withdrawal, impaired communication, stereotypic behaviors, and sensory hypersensitivity. ➢ The types of food that are consumed may be restricted, possibly leading to poor nutrition. ♦ Congenital Structural Abnormalities ➢ Infants with an isolated cleft lip may have difficulty at first with achieving a lip seal on the nipple, but usually adapt well. ➢ Infants with cleft lip and palate have more severe feeding and swallowing difficulties, including an inability to create negative intraoral pressure due to the inability to seal the nasal cavity and nasopharynx from the oral cavity and oropharynx, resulting in an impaired ability to express milk from the nipple, and nasopharyngeal regurgitation along with milk remaining in the nose and mouth. ➢ Some syndromes are associated with cleft palate and/or velopharyngeal dysfunction. ➢ 22q11.2 deletion syndrome (Velocardiofacial syndrome) causes poor feeding endurance and decreases the total volume of oral intake. Palatal abnormalities indicate low tone of the velopharyngeal muscles or velopharyngeal insufficiency, leading to nasal regurgitation during feeding. ➢ Pierre Robin sequence is characterized by a small, underdeveloped jaw (micrognathia), which leads to a retracted and elevated tongue and a cleft palate. Airway obstruction due to the tongue’s position is the primary medical concern for infants with PRS; feeding and swallowing deficits also result. ➢ Treacher Collins syndrome is an inherited disorder that causes severe anatomical abnormalities of the head and face. In addition to feeding and swallowing difficulties, airway compromise due to the small jaw and retracted tongue is the primary concern at birth, and infants with TCS may require a tracheostomy to breathe. ♦ HIV/AIDS ➢ Feeding and swallowing disorders are prevalent in children with HIV/AIDS. ➢ They have difficulty with oral secretions and exhibit odynophagia (painful swallowing). ➢ HIV-positive children often exhibit developmental delays, language impairments, phonological disorders, and poor attention skills. ❖ Adult Dysphagia ♦ Stroke ➢ Dysphagia occurs after stroke in up to 56% percent of patients. ➢ Tongue weakness may make it difficult for the patient to adequately control the bolus and/or propel it posteriorly into the oropharynx. ➢ Swallow initiation may be delayed. ➢ Patients may pocket food inside the cheek when facial weakness is present. ➢ Patients may also have sensory deficits in the larynx and pharynx and a decreased cough reflex, which can result in silent aspiration. ➢ Aspiration pneumonia: A respiratory infection caused when food or liquid enters the lungs. Affects up to 1/3 of stroke patients and often leads to death. ♦ Head and Neck Cancer ➢ Swallowing problems are likely after treatments for cancer. ➢ Dysphagia severity related to tumor size/location and the surgical procedure. ➢ Radiation may result in diminished salivation, taste changes, swelling, and mouth sores. ➢ Chemotherapy can cause nausea, vomiting, and loss of appetite. ♦ Parkinson Disease ➢ More than 80% of individuals with PD develop swallowing difficulties at some point during the course of the disease. ➢ Oral transport may be impaired by a front-to-back rolling pattern of the tongue. ➢ Pharyngeal swallow may be delayed and laryngeal closure may be impaired. ➢ Aspiration can occur when the patient inhales pharyngeal residue. ➢ Esophageal motor abnormalities impede swallowing even early in the disease. ♦ Amyotrophic Lateral Sclerosis (Lou Gehrig’s Disease) ➢ Poor tongue movement is sometimes an early sign of ALS. ➢ Reduced tongue mobility may result in spillage into the airway before the pharyngeal swallow has been triggered. ➢ The larynx might not elevate and close adequately. ➢ Pharyngeal peristalsis is frequently reduced, causing material to remain in the pharynx. ➢ All of these may result in aspiration.

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Individuals with ALS may need to receive the majority of his/her nutrition via percutaneous endoscopic gastrostomy (PEG) tube feedings. Multiple Sclerosis ➢ Multiple sclerosis (MS) is a CNS disorder characterized by relapse and remission. ➢ Delayed swallowing reflex and reduced pharyngeal peristalsis are the primary symptoms. ➢ Feeding difficulties may occur due to hand tremor. Traumatic Brain Injury ➢ Dysphagia occurs in over 90% of patients and can affect the oral preparatory, oral, and/or pharyngeal phases of swallowing. ➢ Impaired attention skills may cause the post-TBI patient to be unaware of food that is presented; highly distractible patients may have reduced intake of food or liquid, placing them at risk for malnutrition or dehydration. ➢ Some patients are so distracted that they may even forget to swallow, placing them at risk of aspiration. ➢ Motor deficits, including reduced range and control of tongue movements and/or delayed or absent swallowing, are common causes of oral-pharyngeal dysphagia post-TBI, as cranial nerves are often damaged following blows to the head. Medications and Nonfood Substances ➢ Medication can cause drowsiness/confusion, interfering with anticipation and oral phases. ➢ Dry mouth is a side effect of more than 300 medications. ➢ High doses of steroids may impede pharyngeal swallowing. ➢ Prolonged use of antipsychotics may cause tardive dyskinesia: involuntary, repetitive facial, tongue, or limb movements. ➢ Smoking and excessive caffeine and alcohol can interfere with normal swallowing. Dementia ➢ The cognitive deficits of dementia may impede attention and orientation to food. ➢ Those with dementia may forget to eat or may eat the same meal multiple times. ➢ Impaired oral preparatory movements may result in poor bolus formation and drooling. ➢ Transport of the bolus may be prolonged. ➢ Delayed pharyngeal swallow and reduced laryngeal elevation can result in aspiration. HIV/AIDS ➢ Opportunistic infections may affect the oral cavity, oropharynx, and/or esophagus. ➢ Bacterial infections can impair the functioning of the cranial nerves involved in swallowing, causing dysphagia. ➢ Esophageal ulcers and esophagitis is a major cause of death in individuals with HIV infection. Social Isolation and Depression ➢ As people enter old age, they may be lonely or unmotivated to cook for themselves. ➢ Depression is associated with diminished interest in food, restlessness, and fatigue. ➢ The throat may feel tight, making swallowing uncomfortable. ➢ Some may feel too tired to eat and are exhausted after they eat, leading to malnutrition.

EVALUATION FOR SWALLOWING ❖ Screening for Dysphagia ♦ A primary indication of dysphagia in infants is failure to thrive. ♦ Full-term infants who are not accepting breast or bottle are signaling feeding problems. ♦ These infants are observed during mealtimes to evaluate breathing and physical coordination, oralmotor functioning, and techniques that enable quantification of nutritive and nonnutritive sucking skill. ♦ Checklists to screen for dysphagia in older individuals are available. ♦ The 3-ounce water swallow test identifies 80-98% of patients who are aspirating (but possibly not those who experience silent aspiration). ♦ The Gugging Swallow Screen can be used with individuals who have had a stroke. It has 100% sensitivity, but specificity is only 50-69%. ♦ Self assessment checklists such as the Eating Assessment Tool may be used. ❖ Clinical Swallow Evaluation  Case History and Background Information ➢ A thorough case history is obtained, including the chief complaint, current physical and neurological status, medical conditions, recent surgeries, or medications the individual may be taking.

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Three areas of concern that might result in a referral: • Difficulties have been observed related to feeding and ingestion of food or liquid. • The client appears to be at risk for aspirating food or liquid into the lungs. • The client appears not to be receiving adequate nourishment. ➢ Obtain information about the location of the swallowing problem, the kinds of foods that are easiest and hardest to swallow, and the nature and severity of the disorder. Caregiver and Environmental Factors ➢ The SLP observes feeding as it occurs normally, paying attention to: ▪ Is the caregiver patient and attentive? ▪ Does feeding take place in a reasonably quiet environment free from distractions? ▪ What position is the individual in when eating or drinking? ▪ How does the client express feeding preferences? Cognitive and Communicative Functioning ➢ Determine alertness/wakefulness, ability to follow directions, and general functioning. Head and Body Posture ➢ Note position of the head and whether the client can position the head given instruction. ➢ Note general body posture and tone. Oral Mechanism ➢ Abnormalities of the lips, teeth, tongue, palate, and velum should be noted. ➢ Look for facial symmetry and note weaknesses (drooping). ➢ Motor difficulties such as tremor, flaccidity, excessive muscle tone, and poor coordination are noted. ➢ Assess motor difficulties and oral reflexes, as well as sensation. ➢ Note drooling, gum and tooth infections, or upper airway obstruction. Laryngeal Function ➢ Indirect signs include hoarse, gurgly, or breathy voice quality before/during/after swallow. ➢ Other signs include: • Inability to rapidly repeat /ha/ with a clear voiced vowel sound • Inability to produce changes in vocal pitch, or inappropriate vocal pitch • Inability to produce a strong cough • Inability to feel the larynx elevate when you place your finger on the client’s thyroid cartilage when the client is asked to swallow. ➢ If any difficulties are observed, refer the client to an otolaryngologist for a laryngeal evaluation. Swallow Trials ➢ If a client is alert and manages his/her saliva without any signs of aspiration or respiratory compromise, swallow trials may be completed by the SLP. ➢ Usually food or liquid is used, although some SLPs prefer to conduct this assessment with only a spoonful of crushed ice or small amounts of water; if a small amount of water is aspirated into the lungs it is generally harmless. ➢ If adequate laryngeal elevation is present, and a strong, protective cough is present, the examination can proceed to other substances of varying textures. ➢ The client’s reaction to the appearance of food and drink is evaluated. ➢ Oral mechanism function is observed throughout the swallow. ➢ Pharyngeal phase swallowing efficiency can be judged in part by noting specific behaviors during food or drink intake. ➢ A small amount (1 tsp.) of thin or thick liquid may be placed in the mouth, and the client is encouraged to swallow. ➢ Inability to cough may suggest difficulty closing the larynx to protect the airway. ➢ Nasal regurgitation reflects inadequate velopharyngeal closure. ➢ Observe the movement of the hyoid bone and thyroid cartilage. ➢ Cervical auscultation: Placing a stethoscope on the client’s neck at the level of the vocal folds to listen to whether the swallow was heard and if it was delayed. ➢ Record the number of times the client swallows for each amount of food or drink. ➢ If vocal quality changes after swallowing, this may indicate residue at the level of the vocal folds. ➢ Note difficult and safe food consistencies. ➢ Determine preferential placement in the mouth for food or liquid.

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Managing a Tracheostomy Tube ➢ A swallowing evaluation may still be conducted when a tracheostomy tube is in place with the physician’s approval. ➢ The cuff is deflated and secretions from the mouth and above the cuff are suctioned. ➢ The patient covers the tube before each swallow to normalize tracheal pressure. ❖ Instrumental Swallow Examination ♦ Although the clinical swallow evaluation is useful in identifying the presence or absence of a swallowing problem, it cannot adequately determine the nature or severity of dysphagia of the pharyngeal phase. ♦ Complete, accurate assessment of swallowing requires the use of instrumentation. ♦ Videofluoroscopic Swallowing Study ➢ AKA – modified barium swallow study: An X-ray procedure used for suspected dysphagia and/or aspiration. ➢ Barium is coated onto or mixed into the food or beverage. ➢ An SLP typically determines the size, texture, and consistency of the food or beverage to be presented and the head and body position of the patient during the study. ➢ A radiologist or X-ray technician use X-ray equipment to observe movement of the barium during the swallow. ➢ The views are digitally recorded for later analysis by the physician and SLP. ➢ The study is useful in determining whether the client should be fed orally or nonorally, what food textures are safest, and what types of treatment are appropriate. ♦ Fiberoptic Endoscopic Evaluation of Swallowing ➢ FEES is used with pediatric and adult patients who are too ill to go to the radiology department for VFSS. ➢ An otolaryngologist (or trained SLP) inserts a flexible fiber-optic laryngoscope through the patient’s nose and into the pharynx. ➢ The patient coughs, holds his/her breath, and swallows foods that have been dyed. ➢ It may reveal premature spillage into the pharynx and residue may be seen after the swallow. ➢ Can provide information about desirable posture, preferred food types, and aspiration. ♦ Scintigraphy ➢ Computerized technique using a specialized gamma scintillation camera that is sometimes used to track the movement of the bolus and measure the amount of residue in the oropharynx, pharynx, larynx, and/or trachea; it can also measure the amount of aspiration. ➢ A radiologist, gastroenterologist, or otolaryngologist performs scintigraphy. ➢ The SLP may position, suggest swallowing procedures, and interpret test results. ➢ A radioactive tracer is mixed with food or liquid. ➢ Radioactive markers may be placed externally for measurement. ➢ Provides insight regarding esophageal function and may help in the determination of the safety of oral feedings. ♦ Ultrasound ➢ Ultrasonography: An imaging technique using inaudible sound waves. ➢ A transducer that generates and receives sound waves is placed below the chin for views of the oral cavity and on the thyroid notch for visualizing the laryngeal area. ➢ The acoustic images are taped. ➢ Assesses oral phase duration and the structure/movement of the tongue and hyoid bone.

TREATMENT OF SWALLOWING DISORDERS ❖ Generally, treatment can be divided into three categories: Compensatory strategies, indirect rehabilitation strategies, and direct rehabilitation strategies. ❖ Feeding Environment ♦ Visual and auditory distractions should be minimized. ♦ The caregiver should have a relaxed, unhurried manner. ♦ When possible, the goal is the development of self-feeding skills. ♦ Utensils for feeding need to be appropriate to the patient’s functioning. ❖ Body and Head Positioning ♦ An upright, 90° hip angle, symmetrical position with postural support is generally needed. ♦ The head and neck must be positioned and prevented from making extraneous movement. ♦ The SLP works with the PT and OT in obtaining optimum positioning for feeding. ♦ Chin tuck: Recommended for patients with delayed pharyngeal swallow.

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Head-back position: Recommended for patients with poor tongue mobility if there is excellent airway closure. ♦ Head tilt and head rotation: Used when an individual has impairment on one side. ♦ Compensatory positioning strategies require patient compliance, adequate cognition, and the physical capability to complete such maneuvers. ❖ Modification of Foods and Liquids  Foods that are hard to chew, small or slick when wet, or are thick and sticky are not recommended for individuals with neuromotor difficulties.  Clients may not tolerate any food by mouth, accept only thin or thick liquids, or require a pureed consistency.  The National Dysphagia Diet specifies the classification of foods based on four food texture levels.  NDD Level 1: Dysphagia – pureed  NDD Level 2: Dysphagia – mechanical altered  NDD Level 3: Dysphagia – advanced  NDD Level 4: Regular  Levels of liquids: thin, nectar-like, honey-like, and spoon-thick.  The texture level of food, liquid level, and amount of food and liquid that clients can manage in their mouths is determined by the VFSS.  Drinking through a straw can cause too much fluid to enter the mouth.  Spoons with a shallow bowl are helpful in limiting food amounts.  Avoid placing food in the mouth until the previous bolus has been swallowed.  Patients may be encouraged to swallow twice per bite or sip.  Foods of varying temperatures may increase the sensory awareness of food. ♦ Placement ➢ Placement should be where there is intact sensation and adequate muscle strength. ❖ Direct and Indirect Rehabilitative Swallowing Treatments ♦ Strengthening Exercises ➢ Swallowing physiology and range of motion may be improved through exercise. ➢ Bite blocks can encourage lowering the mandible. ➢ Flavored gauze or toothettes may be used to stimulate tongue and lip movement. ➢ Exercises to facilitate awareness of laryngeal movement may involve placement of the hand on the neck at the level of the hyoid bone. ➢ Lip strength and seal may be improved by holding a tongue depressor with the lips. ➢ Pushing the tongue against a tongue depressor can strengthen the tongue. ➢ Tongue coordination can be improved by moving the tongue in various ways. ➢ Pharyngeal muscle strengthening involves head-lift exercises. ♦ Effortful Swallow ➢ Used when the tongue does not retract enough to trigger the swallow. ➢ The client is instructed to swallow forcefully and try to feel the tongue moving backward. ♦ Supraglottic and Super-Supraglottic Swallow ➢ A supraglottic swallow is used to teach voluntary closure of the glottis and reduces the depth of misdirected swallows. ➢ Clients are instructed to: • Breathe in and hold breath • Put a small amount of food/liquid in the mouth • Swallow • Cough or clear throat while exhaling • Swallow again ➢ In the super-supraglottic swallow, an effortful breath hold is required to ensure complete glottal closure. ➢ Supraglottic and super-supraglottic swallow techniques are not recommended for individuals with a history of stroke. ♦ Mendelsohn Maneuver ➢ Useful with clients who do not have adequate laryngeal elevation. ➢ The instructions are to: • Place a small amount of food/liquid in the mouth • Chew if necessary • Swallow while placing thumb and forefinger on sides of the larynx • Manually hold larynx high for 3-5 seconds during and after swallowing

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• Let go of the larynx and let it drop ❖ Medical and Pharmacological Approaches ♦ Patients with progressive neurological diseases who are taking medications to improve their condition benefit from taking their drugs before eating. ♦ For those with GERD, over-the-counter medication may help manage oral-pharyngeal dysphagia. ♦ Some medications are available to alleviate dry mouth. ♦ Some medications actually cause or contribute to swallowing disorders. ♦ Prostheses and Surgical Procedures ➢ Patients who lack an intact swallowing mechanism may benefit from a prosthetic device. ➢ A palatal obturator can help velopharyngeal closure during speaking or eating. ➢ Patients requiring a partial or complete glossectomy due to oral cancer may be fitted with a tongue prosthesis. ➢ Growths on the cervical spine that displace the rear pharyngeal wall can be reduced. ➢ The dimensions of the vocal folds can be increased and the larynx can be elevated. ➢ In severe cases of aspiration, the vocal folds may be sutured closed and breathing will occur through a tracheostomy. ➢ Injection of botulinum toxin is sometimes effective in esophageal dysphagia. ♦ Nonoral Feeding ➢ Clients who require more than 10 seconds to swallow a bolus or who aspirate more than 10% will likely require at least some nonoral feeding. ➢ Nasogastric tube (NG tube): A tube is placed through the nose and into the stomach. Not usually used for more than 5 or 6 months. ➢ In pharyngostomy, a feeding tube is inserted into a stoma, or hole in the external neck region, which extends into the pharynx. ➢ Esophagostomy: A feeding tube is placed in the esophagus through a hole in the upper chest/neck area. ➢ Percutaneous endoscopic gastrostomy (PEG): A feeding tube is placed in the stomach through a hole in the abdomen. ❖ Treatment Effectiveness and Outcomes for Swallowing Disorders  Objectives are to improve the intake of food and drink and to prevent aspiration.  Potential success is determined by the cause, severity of aspiration, and onset of treatment.  Early identification and successful intervention reduces the risk of aspiration and death, shortens the length of time patients need to stay in the hospital, and improves quality of life.  Caregivers of youngsters who are at risk are instructed in feeding techniques soon after the child’s birth.  Among elderly people, swallowing disorders are sometimes related to poor dentition, which might be corrected by appropriate dental care.  Overly restrictive diets can lead to poor oral intake and reduced quality of life; therefore, more liberal diets that are still safe are recommended for elderly individuals.

Summary SLPs who want to focus their careers in the area of dysphagia become specially trained to assess and treat swallowing disorders in pediatric and adult populations. They work with infants who are unable to nurse adequately, children with feeding problems, and older people who have dysphagia. The oral preparation, oral, pharyngeal, and/or esophageal phases of swallowing may be impaired, due to multiple causes. Swallowing affects not only nutrition and health, but also social and personal aspects of life. A team approach is used for assessment and intervention. Evaluation includes a careful history and direct observation during feeding. Treatments address the feeding environment, the client’s posture, food textures and liquid consistencies, oral motor function, and specific swallowing techniques. Non-oral feeding may be required in severe cases.

Video Examples Video Example 11.1: Videofluoroscopy Activity suggestion: (Notice how the liquid bolus spills over into the airway)

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Thought Questions 11.1: What special skills and knowledge does the SLP bring to swallowing therapy? 11.2: What connections can you think of between swallowing and speech?

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CHAPTER 12 AUDIOLOGY AND HEARING LOSS Learning Outcomes When you have finished this chapter, you should be able to: 1. Describe statistics regarding the incidence and prevalence of hearing loss as well as the psychosocial consequences of hearing loss. 2. Describe the role of the audiologist, common employment settings, and educational requirements. 3. Describe the mechanics of sound production, including frequency and intensity. 4. Identify key anatomic structures of the auditory system. 5. Associate various auditory disorders with the general types of hearing loss. 6. Identify the components of the audiological test battery, including air conduction, bone conduction, speech audiometry, and pediatric testing. 7. Describe common techniques that are used to reduce the effects of hearing loss on communication, including hearing aids, use of sign language, and communication strategies.

Introduction Hearing loss is common to people of all ages and can impact overall quality of life. It can have a very negative impact on speech and language development, reading, educational achievement, job performance, social interactions, and psychological well-being. It can also have a significant negative impact on family and friends. In this chapter, we review how hearing loss occurs, the ways it impacts people’s lives, how it is diagnosed, and how it is treated.

Content Outline INCIDENCE, PREVALENCE, AND CLASSIFICATION OF HEARING LOSS ❖ ❖ ❖ ❖ ❖ ❖ ❖

Approximately 20% of Americans report some degree of hearing loss. Approximately 3 in 1,000 births results in a child with hearing loss (most common birth defect). Approximately 1 in 1,000 births results in a child with a severe to profound degree of hearing loss. Approximately 83 in 1,000 children in the U.S. have an “educationally significant” hearing loss. Worldwide, 360 million people have disabling hearing loss, including 32 million children. Approximately one third of individuals who are older than 65 years of age have disabling hearing loss. The WHO recommends the following to prevent hearing loss:  Immunizing children to prevent disease and screening to identify disease early  Greater access to medications to treat infections  Improved hygiene practices  Avoidance of medications that damage inner ear structures  Early hearing testing  Better information to young people regarding noise-induced hearing loss ❖ The WHO predicts that 1.1 billion individuals between the ages of 12 and 35 years are at risk of developing hearing loss from their recreational activities. ❖ Classification of Impairment, Disability, and Handicap  Impairment: A loss of structure or function.  Disability: Term that includes the impairment as well as the environmental factors that interfere with functioning.  Activity limitation: The functional consequences associated with a particular impairment. ❖ Effects of Hearing Loss  Children ➢ An individual demonstrating a profound hearing loss would have no access to the speech sounds in our language without amplification. ➢ All degrees of hearing loss in children can interfere with their ability to succeed in school, both academically and socially. ➢ Children with mild hearing loss typically perform well on basic auditory tasks in favorable acoustic environments, but have more difficulty in more challenging environments. ➢ Children with hearing loss must rely more on their memory and attention abilities. ➢ Children with hearing loss are at a great risk for delays in their morphological development.

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Children with unilateral hearing loss have difficulty localizing sound and hearing in noise. Children with profound hearing loss have more difficulty in social interactions, but did better when hearing loss was diagnosed early and amplification was provided early.  Adults ➢ The effects of untreated hearing loss include: • Increased irritability and fatigue due to extra cognitive effort required to process information. • Increased stress. • Greater likelihood of becoming isolated. • Increased risk of injury. • Reduced earning power and less confidence of ability to perform job duties. • Reduced self-esteem. • Overall reduced psychological health. ➢ Parents of children with hearing loss often experience shock, denial, anger, and depression before they are finally able to accept the reality of the situation. ➢ Adults who acquire hearing loss can experience inadequacy, guilt, decreased self-sufficiency, and reduced self-worth. ➢ Professionals must pay attention to these psychosocial issues to determine the full impact of a hearing problem on an individual client and his or her family members. ❖ Deafness, the Deaf Community, and Deaf Culture  When a person’s hearing loss reaches 90dB or greater, the person is considered deaf.  Some individuals who are deaf do not see their deafness as a disability but as a cultural trait.  They make up the Deaf community, and have their own language (American Sign Language).  Deaf culture has a rich history, traditions, folklore, and various contributions to the arts.  Leaders in the Deaf community were originally quite forceful in their opposition to the use of cochlear implants, but it is recently more accepted that this is a personal choice and should be respected.  Our role is not to tell our clients what to do, but rather listen to their goals and priorities and coach them in ways that are consistent with those beliefs and with their culture.

WHAT IS AUDIOLOGY? ❖ The discipline involved in “the prevention of and assessment of auditory, vestibular, and related impairments as well as the habilitation/rehabilitation and maintenance of persons with these impairments.” ❖ Although assessment is a critical part of audiology, treatment and management of a client diagnosed with a hearing problem are equally important. ❖ Prescribing and fitting amplification is another aspect to audiology. ❖ Educational Requirements and Employment for Audiologists  In 2007, the clinical doctorate degree (the Au.D.) became the entry-level degree for clinical audiology practice.  Students who are primarily interested in performing research and/or working at the college level should pursue a Ph.D. in audiology.  More than half of audiologists work in non-residential health care settings.  27% work in hospitals, 11% in schools, 9% in universities, and a small percentage in industry.

FUNDAMENTALS OF SOUND ❖ For sound to occur and be perceived there must be an energy source, an object capable of vibrating, a medium, and a receptor. ❖ Sound is a series of compressions and rarefactions that move outward from a vibrating source. ❖ Amplitude is the distance the vibrating object travels in either direction; determines intensity, measured in decibels (dB). ❖ Frequency refers to the number of cycles of vibration per second, measured in Hertz (Hz).

ANATOMY AND PHYSIOLOGY OF THE AUDITORY SYSTEM ❖ The auditory system can be divided into the outer ear, middle ear, inner ear, the vestibulocochlear nerve, the auditory brain stem, and the auditory cortex of the brain. ❖ The first four areas are referred to as the peripheral auditory system. ❖ The latter two make up the central auditory system.

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❖ The Outer Ear ♦ The outer ear consists of the pinna and the external auditory meatus. ♦ The pinna enhances sound and facilitates localization. ♦ The external auditory meatus is an elliptical tube lined with skin that extends from the concha to the tympanic membrane (eardrum). ♦ The outer external auditory meatus has hair follicles and glands that produce cerumen. ♦ The external auditory meatus can enhance certain high frequency sounds. ❖ The Middle Ear ♦ The tympanic membrane vibrates in response to sound waves that travel down the canal. ♦ The tympanic membrane is composed of three layers of tissue and is a semitransparent pearl gray in color. ♦ The middle ear space is air-filled, lined with mucous membranes, and includes the opening to the Eustachian tube. ♦ The Eustachian tube connects the middle ear with the nasopharynx. ♦ It is normally closed but opens to provide ventilation and equalize pressure. ♦ The malleus, incus, and stapes are the bones (ossicles) of the ossicular chain. ♦ The malleus is embedded in the fibrous layer of the eardrum. ♦ The footplate of the stapes rests against the oval window, a membrane that marks the entrance to the inner ear. ❖ The Inner Ear ♦ The inner ear is a complex structure that includes a number of components. ♦ The cochlea is responsible for providing auditory input to the central auditory system. ♦ The vestibular system is responsible for supplying information about balance. ♦ The cochlea contains auditory sensory receptor cells that respond to auditory stimuli. ♦ It is composed to two labyrinths; the outer labyrinth is composed of bone and filled with a fluid called perilymph and the inner labyrinth is composed of membranous material and contains a fluid called endolymph. ♦ The organ of Corti is in the center of the membranous labyrinth, the floor of which is the basilar membrane. ♦ The basilar membrane is narrower, thinner, and stiffer at the base and wider, thicker, and more flaccid at the apex, enabling it to respond differently to sounds that vary in frequency. ♦ The tectorial membrane is the roof of the organ of Corti. ♦ There are thousands of tiny hair cells in the basilar membrane (receptor cells). ♦ At the top of each hair cell are stereocilia. ♦ As the stereocilia are bent through the movement of the tectorial and basilar membranes, chemical transmitters are released at the base of the hair cells, and neuroelectric energy is generated and transmitted to auditory nerve fibers that form the acoustic branch of the vestibulocochlear, or VIIIth cranial nerve. ♦ The information is directed to the brain stem and eventually the brain. ♦ The vestibular system is made up of bony and membranous sections that contain sensory receptor cells that sense head movement. ♦ Nerve fibers innervating the sensory cells of the vestibular system form the vestibular branch of the VIIIth nerve. ❖ The Central Auditory System ♦ Consists of nuclei, nerve fibers, and nerve tracts; includes pathways that carry auditory information to the brain (ascending) and pathways that receive information from the brain (descending). ♦ Anatomical structures leading to the brain ensure that information about the frequency, intensity, and duration of the auditory stimuli remains intact until it reaches the auditory cortex for interpretation.

TYPES OF HEARING LOSS AND AUDITORY DISORDERS ❖ The outer and middle ears comprise the conductive system. ❖ The cochlea and auditory nerve make up the sensorineural system. ❖ Conductive Hearing Loss ♦ Results from deformation, malfunction, or obstruction of the outer or middle ear. ♦ Usually prevents low- to moderate-intensity sounds from being heard at all and higher-intensity sounds being perceived as much softer than normal. ♦ Impacts audibility, but does not result in a total loss of hearing. ♦ Most conductive losses are not permanent.

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❖ Disorders of the Outer Ear ♦ Anotia: Absence of the pinna on one or both sides. ♦ Microtia: A small, malformed pinna that does not result in loss of hearing sensitivity by itself. ♦ Atresia: Complete closure of the auditory canal; significant hearing loss is inevitable. ♦ Stenosis does not result in hearing loss unless debris or cerumen becomes trapped. ♦ These conditions frequently occur in those with craniofacial disorders. ♦ A common cause is impacted cerumen or a foreign object. ♦ Cerumen protects the ear from foreign bodies and traps dirt and debris, naturally cleansing the external canal as it migrates outward. ♦ Cerumen acts as a lubricant to prevent the skin that lines the canal from drying out and serves as a chemical barrier to bacterial and fungal infection. ♦ Cerumen management is within the audiologist’s scope of practice in many states. ♦ Overuse of cotton swabs can cause external otitis (swimmer’s ear) or a perforation in the tympanic membrane. ♦ The degree of conductive hearing loss from perforations ranges from subtle to significant depending on size and location. ♦ Perforations can heal spontaneously but often need to be repaired by an ENT. ❖ Disorders of the Middle Ear ♦ Otosclerosis: The replacement of healthy bone with spongy bone in the area of the stapes footplate, resulting in reduced mobility of the stapes and hearing loss. ♦ Ossicular discontinuity refers to a break somewhere in the ossicular chain. ♦ Otitis media is an inflammation of the mucous membrane lining in the middle ear cavity. ♦ It generally results from Eustachian tube dysfunction. ♦ When the middle ear is not consistently ventilated, oxygen within the cavity is absorbed into the mucous membrane lining, forming a partial vacuum. ♦ This results in negative middle ear pressure, which causes the eardrum to retract into the middle ear cavity, reducing its ability to vibrate. ♦ The vacuum can lead to the secretion of fluid, known as otitis media with effusion (OME). ♦ If the fluid is sterile, the condition is classified as serous otitis media. ♦ When pus forms, it is known as purulent or suppurative otitis media. ♦ Otitis media is the most frequently diagnosed disorder in the U.S. in children younger than 15 years. ♦ Treating otitis media is a complex process because no one treatment works best for everyone. ♦ Myringotomy: An incision is made in the eardrum and fluid within the middle ear is drained. ♦ Pressure equalization (PE) or tympanostomy tubes: Inserted into the eardrum, which serve the same purpose as the Eustachian tube. ♦ There is disagreement in the literature regarding whether early otitis media with hearing loss has negative effects on a child later in life. ❖ Sensorineural Hearing Loss ♦ Results from the absence, malformation, or damage to the structures of the inner ear. ♦ May be present at birth or develop over time, and is usually permanent. ♦ Hearing loss is predominately in the higher frequency range. ♦ Sounds that are audible are often perceived as being distorted. ♦ Factors that influence the effects of the loss on speech, language, and cognition include the degree of the loss, the age of onset, the age of the person when the loss was identified, and the age of the person when appropriate intervention was done. ♦ Age of onset is congenital or acquired, or prelingual (before 2) or postlingual (after 5). ❖ Disorders of the Inner Ear ♦ Aplasia/dysplasia: Hearing loss due to absence or malformation of inner ear structures during embryonic development. ♦ Usher’s syndrome: Genetic disorder characterized by sensorineural hearing loss and degenerative visual changes. ♦ Waardenburg’s syndrome: Genetic disorder characterized by sensorineural hearing loss and changes in the coloring of the hair, skin, and eyes. ♦ Alport’s syndrome: Marked by sensorineural hearing loss and kidney disease. ♦ Maternal rubella, HIV, and CMV can be causes of congenital sensorineural hearing loss. ♦ Sexually transmitted bacterial diseases seriously damage the CNS of a developing fetus. ♦ Acquired hearing loss may be due to viral or bacterial infections. ♦ Meningitis: Inflammation of the fluids and layers of tissue covering the brain. ♦ Bacterial meningitis requires treatment with potent antibiotics that can be ototoxic.

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Meniere’s disease: Fluctuating and progressive sensorineural hearing loss, tinnitus, vertigo, and a feeling of fullness in the ear. Symptoms typically come and go unpredictably. ♦ Caused by pressure resulting from the buildup of endolymph fluid within the membranous labyrinth of the inner ear. ♦ Treatment may include drug therapy, surgical intervention, or diet regulation. ♦ Auditory neuropathy spectrum disorder: Normal outer hair cell function and abnormal responses from the inner hair cells or auditory nerve fibers. Characterized by a lack of synchrony in the firing of auditory nerve fibers with normal outer hair cell function. ♦ May exhibit pure tone hearing within normal limits to profoundly impaired, and usually have considerable difficulty understanding speech even when the pure tone loss is not significant. ♦ Hearing aids are helpful to some, but cochlear implants are another option. ♦ Vestibular schwannoma/acoustic neuroma: A non-malignant growth that develops on the cells near CN VIII. Symptoms include decreased hearing, tinnitus, balance difficulty, and a plugged feeling on the affected side. Surgery is usually recommended. ♦ Noise-induced hearing loss: A leading cause of acquired sensorineural hearing loss in young and middle-aged adults. ♦ Temporary threshold shift: Temporary hearing loss due to short-term noise exposure; however, even when hearing returns to normal after TTS, permanent damage to the cochlea and auditory nerve can be measured. ♦ A permanent threshold shift causes a loss of high frequency sensitivity due to frequent exposure to high levels of noise. ♦ Poor intelligibility of speech in background noise is common in noise-induced hearing loss. ♦ Hearing loss that occurs through the aging process is called presbycusis. ♦ Due to the loss of cochlear hair cells, reduced responsiveness of the hair cells, or loss of auditory nerve fibers. ♦ 45% of adults between 48 and 92 years of age have some degree of hearing loss. ♦ New research shows that partial recovery of hearing may be possible by stimulating certain cells to function like cochlear hair cells. ❖ Mixed Hearing Loss ♦ Mixed hearing loss is the presence of both conductive and sensorineural hearing loss. ❖ (Central) Auditory Processing Disorders ♦ Interfere with the ability to efficiently and effectively use and interpret acoustic information. ♦ May have difficulty hearing subtle differences between similar sounding words and misunderstanding of speech when presented in noise; in individuals with normal peripheral hearing, this may be an indication of (C)APD. ❖ Hearing Loss Through the Lifespan  Early hearing detection and intervention programs are designed to identify significant hearing loss in newborn babies and follow up with prompt audiological intervention services.  Children who are diagnosed with hearing loss and receive hearing aids and early intervention by 6 months of age develop significantly better language skills.  Newborns and preschoolers are susceptible to hearing loss due to Eustachian tube dysfunction and otitis media.  During the school years, students with auditory processing disorders find themselves struggling to process more complicated language structures.  School-age, adolescent, and college-age students are at risk for noise-induced hearing loss.  By middle age, some adults with a history of early noise exposure begin to experience hearing loss.  Disorders such as Meniere’s disease and otosclerosis are more common in middle-aged individuals.  By middle age, some may experience changes in their auditory processing abilities despite having normal hearing.  In older individuals, age-related changes can affect both the cochlear hair cells and auditory nerve fibers, resulting in reduced speech understanding. ♦

AUDIOLOGICAL ASSESSMENT PROCEDURES ❖ ❖ ❖ ❖

Screening is used to determine which individuals are likely to have a hearing loss. Failing a hearing screening indicates that additional assessment is warranted. Performing hearing screenings is part of the scope of practice of both an audiologist and an SLP. Referral and Case History

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During the interview, the audiologist may ask questions about why the client has come in for the evaluation, whether he or she has been exposed to noise, whether there is a history of ear infections or ear surgery, and what communication situations are difficult for the client. ♦ Formal self-assessment questionnaires assist the audiologist in obtaining the client’s perspective on the types of communication problems he or she is experiencing. ❖ Otoscopic Examination ♦ Conducted with an otoscope, allowing visual inspection of the canal and eardrum. ♦ Alerts the audiologist to any conditions that may interfere with sound conduction during testing. ♦ A video otoscope projects the image of the ear onto a television or computer monitor. ❖ Electroacoustic and Electrophysiological Testing ♦ Electroacoustic measures record acoustic signals from the client’s external auditory canal. ♦ Electrophysiological tests record neuroelectric responses that are generated by the auditory system in response to sound. ♦ Both evaluate the integrity of the peripheral and central auditory systems, without requiring the client to provide any observable behavioral responses. ♦ Acoustic immittance testing is useful in the diagnosis of conductive pathology. ♦ It is performed using an electronic device that assesses the admittance of the middle ear as a function of changes in air pressure within the ear canal. ♦ The process results in a graph called a tympanogram. ♦ Can distinguish between a break in the ossicular chain, otitis media with effusion, or a perforation of the eardrum. ♦ Otoacoustic emissions (OAEs) are low intensity sounds (“echoes”) generated within the cochlea as a result of outer hair cell movement; they can be measured with a microphone. ♦ When OAEs are present, hearing sensitivity is presumed to be normal or no worse than a mild loss. ♦ Important in newborn screening programs. ♦ Electrophysiological tests record neuroelectric responses generated by the auditory system, referred to as auditory evoked potentials (AEPs). ♦ The auditory brain stem response (ABR) is a type of AEP that measures neuroelectric activity of the auditory nerve and structures of the lower brain stem. ♦ ABR can be used to identify neurological issues, such as a tumor on CN VIII or auditory neuropathy/dyssynchrony disorder. ♦ Can be used to estimate the auditory thresholds in individuals who are unable or unwilling to be evaluated using behavioral techniques. ❖ Behavioral Testing ♦ Audiometer: Equipment used for selection, manipulation, and presentation of stimuli during hearing assessment. ♦ Testing is usually carried out in a specially treated sound booth. ♦ Behavioral Observation Audiometry (BOA) ➢ The audiologist presents a stimulus through a loudspeaker and observes a child’s reaction. ➢ The reliability and validity of BOA has been criticized. ➢ Electroacoustic and electrophysiological measures are preferred when assessing children younger than 5 months of age. ♦ Visual Reinforcement Audiometry (VRA) ➢ A child is rewarded for a head-turn response to sound by an animated or lighted toy. ➢ Can be used after 5-6 months of age. ➢ VRA is more reliable than BOA and is an effective tool for accurately assessing hearing sensitivity in young children.  Pure Tone Audiometry ➢ Conditioned play audiometry (CPA): The use of toys such as blocks, puzzle pieces, or stacking rings to engage the child in a listening game. ➢ Pure tone audiometry: One of the most fundamental behavioral tests in the standard audiometric assessment. ➢ Pure tones are sounds that contain energy only at a single frequency. ➢ Standard practice is to test a range of frequencies from 250 Hz to 8000 Hz. ➢ The purpose is to determine a person’s threshold at each test frequency for right and left ears. ➢ Threshold: The lowest intensity at which a person can detect a stimulus 50% of the time. ➢ A tone is presented for 1-2 seconds, and the client is observed for a response (e.g., hand raise).  Degree of Hearing Loss ➢ Typically expressed in decibels (dB).

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The greater the dB value required to reach a person’s threshold, the greater the degree of hearing loss. ➢ The range of normal is different for children and adults. ➢ Auditory closure: The ability to fill in missing pieces of information that are not heard. ➢ Individuals whose degree of hearing loss falls within the slight/mild-severe range are classified as hard of hearing or hearing impaired. ➢ These individuals depend on residual hearing for receptive communication and for learning new concepts. ➢ People whose auditory thresholds fall in the profound range are referred to as deaf. Air Conduction and Bone Conduction Testing ➢ Air conduction testing is administered while a client wears headphones. ➢ Bone conduction testing is administered with a bone oscillator, directly stimulating the cochlea. ➢ By comparing the results of air conduction testing to bone conduction testing, the type of hearing loss can be identified. Speech Audiometry ➢ Speech Recognition Threshold (SRT): The lowest intensity where a person can recognize two-syllable words. ➢ Word Recognition Test (WRT): Assesses how well the client is able to identify one-syllable words presented at some level above threshold. Auditory Processing Assessment ➢ Tests of auditory processing are different from those used during the conventional hearing test, and often involve testing the client’s understanding of speech in challenging conditions, including in a background of noise, as well as when more than one piece of information is presented simultaneously. ➢ Tests of auditory processing should not be done on individuals younger than seven years old or on those who have language or cognitive deficits that could interfere with the test results. ➢ Children with auditory processing difficulty may demonstrate distractibility, difficulty comprehending rapid speech or speech in poor acoustic environments, difficulty following complex auditory directions, or difficulty paying attention. ➢ CAPD remains a controversial diagnosis for a variety of reasons.

HELPING PEOPLE WHO HAVE HEARING LOSS ❖ One of the first and most important things that audiologists can do when meeting a new client is to listen to the client. ❖ Audiologists are in a unique position to provide valuable information to clients about their hearing and ways to decrease their communication difficulties. ❖ Audiologists can, with client permission, provide information to family members, friends, parents, teachers, caretakers, etc. ❖ It is important for audiologists to document a management plan. ❖ Referrals must be made to other professionals as needed. ❖ Aural habilitation/rehabilitation: Intervention aimed at minimizing and alleviating the communication difficulties associated with hearing loss.  Aural habilitation: Conducted with individuals whose hearing loss occurred at an early age and prevented normal development of auditory and spoken language skills.  Aural rehabilitation: Conducted with individuals who lost their hearing later in life, after spoken language skills have fully developed.  “Aural rehabilitation” is frequently used to refer to both habilitative and rehabilitative efforts.  The first step is to identify, describe, and clarify communication problems due to hearing loss. ❖ Counseling  Informational counseling: The process of giving a client information.  Only 50% of information conveyed by health care providers is actually remembered by clients and approximately half of this information is remembered inaccurately; it is important to provide information in writing.  Personal adjustment counseling: Providing assistance to the client and family in dealing with the emotional consequences of hearing loss.  The audiologist must distinguish between the client’s request for factual information and the client’s need for you to acknowledge personal feelings he or she is having about the hearing problem.

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 Referral to a qualified professional counselor should be made in some cases. ❖ Amplification ♦ In most cases, amplification consists of personal hearing aids. ♦ Hearing Aids ➢ Hearing aids come in a variety of styles and sizes. ➢ Every hearing aid contains a microphone, amplifier, receiver, and some type of computer processor. ➢ Most hearing aids dispensed today incorporate sophisticated digital signal processing. ➢ The signal can be manipulated in various ways to improve audibility while maintaining comfort, reducing unwanted background noise, and eliminating acoustic feedback. ➢ The primary goal is to make speech audible to improve intelligibility. ➢ A hearing aid will not return hearing to normal. ➢ The client must be counseled so that his or her expectations for improvement are realistic. ➢ A bone conduction hearing aid may be useful when a conductive loss cannot be medically managed. ➢ A bone anchored hearing aid consists of a screw surgically implanted in the skull and an external device that converts sound to mechanical vibration, stimulating the cochlea. ➢ Companies that sell hearing aids over the internet and expect clients to fit and program the hearing aid themselves are appearing; this is not in the client’s best interest in regard to having a successful hearing aid fitting. ♦ Cochlear Implants ➢ A cochlear implant is a prosthesis that bypasses the damaged hair cells of the cochlea and directly stimulates the surviving auditory nerve fibers with electrical energy. ➢ The external components are a microphone, speech processor, and external transmitter. ➢ The internal components include the receiver-stimulator that is surgically attached to the skull, and the electrode array that is inserted into the cochlea. ➢ Bilateral implantation has become more common. ➢ The signal is transmitted across the skin via FM waves to the internal receiver-stimulator and finally to the individual electrodes implanted in the cochlea. ➢ The resulting neural impulses are transmitted to the brain in the usual manner. ➢ Bimodal hearing; A cochlear implant is used on one ear and a hearing aid is used on the other. ➢ A hybrid device exists that houses both hearing aid and cochlear implant technology within the same unit. ➢ Children as young as 12 months can undergo cochlear implant surgery. ➢ Post-lingually deafened adults tend to benefit extensively. ➢ Children implanted at an early age and who receive intensive auditory therapy demonstrate significant gains in speech perception, language acquisition, speech production, and literacy development. ❖ Hearing Assistive Technology/Assistive Listening Devices ♦ Hearing Assistive Technology: Assistive devices used to overcome problems hearing in various situations. ♦ A microphone is positioned close to the desired sound source. ♦ The signal can be delivered wirelessly. ♦ FM system: The talker speaks into a microphone attached to a transmitter that broadcasts on a designated frequency or channel. ♦ Sound field amplification: Loudspeakers are used rather than a broadcast to one receiver. ♦ Video conferencing, email, text messaging, and synchronous chat can be helpful for those who have difficulty using the phone. ♦ A new cell phone program called MobilASL can broadcast communication between ASL signers. ♦ Assistive devices are helpful for individuals who want to be alerted to sounds occurring from a distance via a signal such as a flashing light. ♦ Connectivity: Being connected not only with other devices but also with other people in ways that were not possible in the past due to hearing loss. ♦ Tele-audiology: The use of electronic and telecommunications technology to provide distance audiology services. ❖ Auditory Training and Auditory Communication Modality ♦ The goal of auditory training is to maximize a person’s use of residual hearing. ♦ Neural plasticity: For the purposes of this chapter - Physiological and functional changes within the central nervous system in response to auditory stimulation.

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By providing certain types of auditory input on a regular basis, we hope to change the way the central auditory system works and improve the individual’s ability to make effective use of speech and language information. ♦ A popular program used with adults who have hearing loss and are wearing hearing aids is the Listening and Communication Enhancement program. ❖ Visual Communication Modality  There is a continuum for the options in visual approaches, with manually coded English on one end and ASL on the other.  In MCE, much of the vocabulary comes from ASL, but the word order is the same as English, and grammatical markers are added.  Pidgin Signed English: New users of PSE tend to communicate using a structure that is more English-like, and more experienced users incorporate more features of ASL.  Fingerspelling: Hand shapes used to visually represent each of the 26 letters in the English alphabet. ❖ Treatment and Management of (Central) Auditory Processing Disorders ♦ Environmental accommodations refer to changes we can make to the environment that will improve the listener’s ability to receive auditory information clearly. ♦ Compensatory strategies strengthen broader cognitive areas, such as attention and language. ♦ Direct therapy consists of intensive auditory training designed to strengthen the specific auditory deficits identified during assessment. ♦ There is a lack of evidence that direct therapy alone can result in changes in the functional communication abilities of students with CAPD. ♦ Even if an auditory processing diagnosis is valid and does apply to a student, one of the primary methods of supporting this student’s listening and learning will be by increasing his language competence.

Summary The profession of audiology is a diverse field that offers the opportunity to work with many populations in a wide variety of settings. The audiologist is responsible for assessing auditory and vestibular function and for providing aural habilitation/rehabilitation services. Audiologists are also concerned with problems affecting the central auditory system. When describing hearing loss, audiologists use terminology such as conductive, sensorineural, mixed, and central to identify the portion of the auditory system that is affected. The degree of hearing loss is expressed in decibels. When evaluating the auditory system, audiologists use a variety of assessments. Informational and personal adjustment counseling are critical to the process. Aural habilitation/rehabilitation refers to the services and procedures designed to minimize and resolve communication difficulties presented by a hearing loss.

Thought Questions 12.1: Do you believe that deafness is a cultural difference, or do you view it as a disability? 12.2: What kinds of information might you provide to a teenager who is exposing him/herself to very loud levels of music on a regular basis? 12.3: How might the recommendations that we might make for a person with a hearing loss be similar to those that we might make for a person with unexplained listening deficits?

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CHAPTER 13 AUGMENTATIVE AND ALTERNATIVE COMMUNICATION Learning Outcomes When you have finished this chapter, you should be able to: 1. Define augmentative and alternative communication (AAC). 2. Describe various types of aided and unaided AAC systems, access methods, and AAC output. 3. Identify a number of considerations in AAC assessment 4. Describe methods for AAC system selection and the concept of feature matching. 5. Explain how interactive competence and communicative competence are critical in AAC assessment and intervention practices across the lifespan.

Introduction Augmentative and alternative communication (AAC) includes all forms of communication other than oral speech that are used to express thoughts, needs, wants, and ideas. AAC includes how people use things such as speech-generating devices to make known their wants and needs. We must consider both the communication technologies used to support individuals with complex communication needs and the interactive competence of everyday communication partners. “AAC involves attempts to study and when necessary compensate for temporary or permanent impairment, activity limitations, and participation restrictions of individuals with severe disorders of speech/language production and/or compensation, including spoken and written modes of communication” (ASHA, 2005a). Approximately 4 million people in the United States are not able to use natural speech to express their wants and needs. It is necessary for helping professionals across disciplines to collaboratively support individuals with CCN in their pursuit of efficient and effective communication with others.

Content Outline DEFINING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION (AAC) ❖ AAC includes things such as speech-generating devices (SGD) to make needs and wants known. ❖ When viewing or defining AAC, it is necessary to consider not just the things a person uses to get a message across but the interplay between the communication technologies used to support the individuals with complex communication needs (CCNs) and the interactive competence of everyday communication partners. ❖ AAC is part of any communication culture, community, group, or setting in which people interact. ❖ AAC includes anything that supplements an existing communication system. ❖ Who Uses AAC?  It is estimated that approximately 4 million people in the U.S. are not able to use natural speech to express their wants and needs.  Estimates of the prevalence of AAC use in the U.S. range from 0.8% to 1.3% of the total population.  There is no typical person who relies on AAC.

TYPES OF AAC ❖ ❖ ❖ ❖

Unaided systems do not involve external equipment. Aided systems involve the use of equipment. Combinations of aided and unaided systems are possible. Symbols (anything that stands for or represents something else) are central to the process of classifying AAC systems. ❖ Unaided AAC: Gestures and Vocalizations ♦ Use of gesture, body movement, or an observable signal with a communication partner. ♦ Manual Sign Systems ➢ Includes ASL, Signed English, Signing Exact English, Tactile Signing, and Amer-Ind. ➢ Iconic signs look like what they represent. ➢ Transparent signs are easily guessable, explainable, and memorable. ➢ Opaque signs are difficult to interpret. ➢ Fingerspelling refers to the manual alphabet.

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Unaided systems are not appropriate for every individual who needs either to enhance or replace the current communication method. ➢ Motor impairments make it difficult to use manual sign systems. ➢ Not all communication partners will understand manual sign systems. Aided AAC ♦ Range in terms of the representations used within a system, the input and output modes of a system, and the degree to which the symbols are transparent to others. ♦ Grouped as no-tech, low-tech, mid-tech, or high-tech.  Aided Symbols: Tangible Symbols ➢ Visual schedules can use tangible symbols and are organized according to the daily activities that occur in an individual’s life.  Aided Symbols: Pictorial Symbols ➢ Symbols may include pictures, various representational systems, and/or line drawings. ➢ Some symbol systems have been specifically designed for AAC use. ➢ Symbolic systems are relatively rule governed and generative, allowing for symbol combination and the creation of new symbols.  Aided Symbols: Orthography and Orthographic Symbols ➢ Includes systems such as Braille, fingerspelling, writing, and other ways a person uses symbols for language. Combinations of Aided and Unaided Systems  People invariably use multiple methods or modes of communication.  AAC is no exception. Access  Access might include touching buttons, pointing to symbols, or holding an object.  Care must be exercised in choosing the appropriate interface between a client and device.  Direct selection: Individuals may select an item directly by pointing with a finger, hand, head pointer, or optical head pointer or by activating a joystick; may also use eye gaze.  Direct selection methods can be difficult for those with severe motor problems.  Efficiency is the speed with which a person is able to use an AAC system to send a message.  Effectiveness is the degree to which a person is able to use an AAC system to achieve his or her communication goal.  Indirect selection methods include scanning and partner-assisted selection/scanning.  Scanning involves the individual assembling a message through a series of switch activations in which choices are presented sequentially.  In partner-assisted scanning, the options are presented by another person.  Auditory scanning is similar, but in addition to the symbols being presented visually, there is also an auditory cue present.  Scanning can be extremely slow and laborious.  Efficiency can be enhanced by placing symbols so that those that are most frequently used are scanned most frequently or by using different scanning methods (linear scanning vs. row/column scanning, etc.). Output  Voice output communication (VOC) can be either recorded or digitized, synthesized, or both.  Comprehension of synthesized speech requires increased focused attention by the partner.  Partners tend to respond more slowly to synthesized speech.  Intelligibility can be increased through training.

ASSESSMENT CONSIDERATIONS ❖ It is important to understand an individual’s cognitive-communicative strengths, the everyday communication routines, and the barriers and/or facilitators to the individual’s successful communication. ❖ Linguistic competence is an individual’s language ability across all dimensions of language. ❖ Operational competence is how a person uses an AAC system. ❖ Social competence relates to how well a person manages the social aspects of communication, such as turn taking, topic maintenance, and using balanced and reciprocal interactions. ❖ Strategic competence is a person’s ability to solve problems. ❖ Specific Assessment Considerations  AAC assessments ideally include multi-contextual observations of an individual with CCN.

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Observations along with structured or standardized assessments are used to provide a comprehensive evaluation.  An OT or PT can aid in motor assessment.  Visual and auditory acuity and perception are important for system selection and intervention.  An SLP may need to educate caregivers about the benefits of AAC.  An SLP should collect a list of client preferences and possible symbols to train. ❖ AAC System Selection or Feature Matching  Consider the client’s motor and cognitive abilities, the potential size of the client’s vocabulary, the ease in learning and using the system, the acceptability of the system to the user and potential communication partners, and the flexibility and intelligibility of the system.  Also consider the aesthetics of the system, overall size, arrangement and size of the symbols, placement and organization of the symbols, and the output of the system. ❖ AAC Symbol Selection  Decisions related to choosing an appropriate symbol system flow from the method of communication chosen.  The SLP might consider the gestural or signing system used most frequently in the client’s school or workplace and in the local community, the availability of teaching materials, and the ease in using these materials.  Selection of aided symbol systems may be guided by the potential user’s cognitive abilities, the ease of learning different graphic AAC systems, and the willingness of potential communication partners. ❖ AAC Vocabulary Selection  The best guideline is to select vocabulary that reflects the user’s needs, desires, likes, and preferences and is functional or useful.  Several lists of potential vocabulary are available.  The order of teaching signs or symbols must also be guided by a client’s immediate needs.

INTERVENTION CONSIDERATIONS ❖ It is important that services be a team effort but not fragmented. ❖ Some important considerations are as simple as the location of symbols on a communication board, whereas others involve the teaching of complex syntactic constructions. ❖ Children with ID do not seem to induce English word order rules from the language spoken around them and apply these rules to their sign output. ❖ They occasionally change the form of the signs creatively. ❖ Use of longer grammatical utterances is slow if users are forming them from single symbols. ❖ One option is to pre-store potential utterances in the device. ❖ Modeling is one method for teaching production of multi-symbol messages. ❖ In milieu teaching, an SLP might perform an action while asking, “What am I doing?” ❖ Intervention must include both short-range and long-range needs of a client. ❖ Keep in mind the following:  Establish a positive AAC culture  Understand AAC as critical to literacy development  Use everyday experiences as teaching context  Individualize the content  Teach partners to modify their interaction style  Consider positioning for those with motor impairments  Use meaningful interactions ❖ Abandonment of AAC is usually related to loss of facilitator/partner support. ❖ Classroom integration requires collaboration between the teacher and SLP. ❖ AAC training for the educational team is a key element in success. ❖ Intervention will be most effective if caregivers also use AAC with speech (augmented input). ❖ A child may become dependent on one or two skilled interaction partners within the family. ❖ The SLP must identify opportunities for communication, create a need for communication, and maximize the instructional benefit of these opportunities. ❖ One promising method for children with ASD is aided language modeling (ALM), consisting of engaging children in interactive play and providing models of AAC symbol use during play. ❖ Access to appropriate AAC systems is an important factor in facilitating employment. ❖ Everyday events and routines provide scripts; use of scripts frees up cognitive energy to be used for other aspects of the situation.

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Optimal use occurs when AAC is used willingly and at every opportunity. Community-based training wherein the client uses AAC in public may lead to optimal use. The AAC user must be involved in real communication with meaningful outcomes. Evidence-Based Practice (EBP) in AAC ♦ Little long-term research exists. ♦ Improved speech intelligibility coming from high-tech systems doesn’t necessarily lead to a person’s participation in social interactions. ♦ Scanning as an access method is difficult for young children. ♦ For children with ASD or ID, AAC intervention does not impede speech production. ♦ For children with ASD, the gains in overall communication from the use of sign are modest. ♦ Although many individuals who use AAC can comprehend and express a wide range of grammatical structures, they tend to produce shorter utterances when they use graphic symbolbased AAC systems. ♦ Few studies have investigated the effectiveness of AAC-specific aspects of intervention in a family context.

Summary AAC includes anything that supplements an existing communication system. AAC may enhance an individual’s speech or may become the primary means of communication. Decisions on the appropriate type of AAC may need to be revised as the user’s abilities or needs change. Involvement of everyday communication partners in the assessment and intervention planning process cannot be overstated. The SLP and other team members use the data from an assessment to make decisions about the appropriate AAC method, symbol system, and potential vocabulary. In planning interventions, the SLP must be concerned with the linguistic, operational, social, and strategic competencies of a person using AAC and his or her partners.

Video Examples Video Example 13.1: Activity suggestions: Think about how many other ways a person might access AAC or an activity with others in order to participate in a learning activity. Which types of aided and unaided communication did you observe the student and the teacher using in this video? Would you describe the student’s AAC system(s) as high-tech, mid-tech, low-tech, or no-tech and why? Video Example 13.2: Activity suggestion: Think about how many ways the teacher has created a culture in the classroom that promotes the use of multiple modes of communication, modeling for all students involved in the teaching lesson, and individualized supports for each student with CCN.

Thought Questions 13.1: What is Augmentative and Alternative Communication (AAC)? 13.2: Why is it important to consider various forms of aided and unaided AAC systems for people with complex communication needs? 13.3: How do interactive competence and communicative competence relate to AAC assessment and intervention planning for people with CCN? 13.4: What are some major considerations in AAC assessment?

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CHAPTER 1 THE FIELD, THE PROFESSIONALS, AND THE CLIENTS 1.

A communication disorder may affect a. Hearing b. Language c. Speech d. All of the above

“Atypical production of speech sounds, interruption in the flow of speaking, or abnormal production and/or absence of voice quality” is the definition of a a. Speech disorder b. Language disorder c. Hearing disorder d. Central auditory processing disorder

“Impairment in comprehension and/or use of spoken, written, and/or other symbol systems” is the definition of a a. Speech disorder b. Language disorder c. Hearing disorder d. Central auditory processing disorder

“A result of impaired sensitivity of the auditory system” is the definition of a a. Speech disorder b. Language disorder c. Hearing disorder d. Central auditory processing disorder

“Deficits in the processing of information from audible signals” is the definition of a a. Speech disorder b. Language disorder c. Hearing disorder d. Central auditory processing disorder

Attempts taught by SLPs to compensate and facilitate for impaired communication using various methods. a. Dialects b. Augmentative/alternative communication c. Multilingualism d. All of the above

The professionals who measure hearing and identify, assess, manage, and prevent disorders of hearing and balance are a. Audiometers b. Hearing aid dispensers c. Audiologists d. Aural rehabilitation professionals

The professionals who identify, assess, treat, and prevent expressive and receptive communication disorders, as well as provide services for swallowing disorders and dialect modification are a. Speech correctionists b. Speech-language pathologists c. Speech teachers d. Speech scientists

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The professionals who extend knowledge of human communication processes and disorders and usually hold doctorate degrees are a. Audiologists b. Speech, language, and hearing scientists c. Speech-language pathologists d. Professionals aides

10.

The entry-level degree for an audiologist is currently a. Bachelor’s degree in audiology b. Master’s degree in audiology c. Doctoral degree (AuD, PhD, or EdD in audiology) d. Associate’s degree in audiology

11.

The degree required for speech/language pathologists to earn the ASHA CCC is currently a. Associate’s degree b. Bachelor’s degree c. Master’s degree d. Bachelor’s degree plus a teaching certificate

12. Explain how people with disabilities have been treated throughout history.

13.

Related professionals include a. Occupational therapists b. Physical therapists c. Social workers d. All of the above

14.

On average… a. 1 in 5 people has a disability b. 1 in 10 people has a disability c. 1 in 20 people has a disability d. 1 in 50 people has a disability

15.

Infants are screened for hearing loss and other disabilities a. As soon as they are born b. Within the first week of birth c. Within the first month of birth d. If they show signs of abnormal development

16.

What do speech, language, and hearing scientists do?

17.

Almost half of all SLPs are employed a. In school systems b. In healthcare c. In private practice d. All of the above combined

18.

In addition to the entry-level degree, what else do audiologists need in terms of credentials?

19.

School-age children with communication difficulties often experience a. Academic difficulties b. Social difficulties c. Neither of the above d. A&B

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20.

In addition to the entry-level degree, what else to SLPs need in terms of credentials?

21.

How many Americans sustain a traumatic brain injury each year? a. 500,000-750,000 b. 1.5-2 million c. 2-4 million d. None of the above

22.

What are the assumptions of evidence-based practice?

23.

Hearing loss may affect at least a. 25% of older adults b. 50% of older adults c. 75% of older adults d. Nearly all older adults

24.

What is involved in clinical decision-making?

25.

The best source(s) of clinical evidence is/are a. Company websites b. Magazine articles c. Professional, peer-reviewed journals d. All of the above

26.

What are the three key elements of efficacy?

27.

Efficacy is a. The quickest and least effortful method resulting in the greatest positive benefit b. The probability of benefit from an intervention under ideal conditions c. Both of the above d. Neither of the above

28.

What are some factors that affect clinical decision making?

29.

Effectiveness is a. The quickest and least effortful method resulting in the greatest positive benefit b. The probability of benefit from an intervention under ideal conditions c. Both of the above d. Neither of the above

30.

Name and briefly describe four federal mandates affecting people with disabilities.

31.

The first professional journal related to communication was called a. The Voice b. Speech Correction c. Journal of the National Association of Teachers of Speech d. None of the above

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32.

_____________________ was the precursor to ASHA. a. The National Education Association b. The American Academy of Speech Correction c. American Coalition of Citizens with Disabilities d. The Education for All Handicapped Children Agency

33.

Audiology became a profession in a. The 1890s b. The 1920s c. The 1940s d. The 1950s

34.

Audiology experienced a boom in which decade due to WWII veterans who were experiencing noiseinduced hearing loss? a. The 1910s b. The 1920s c. The 1940s d. The 1950s

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CHAPTER 1 – Answer key THE FIELD, THE PROFESSIONALS, AND THE CLIENTS

1. D 2. A 3. B 4. C 5. D 6. B 7. C 8. B 9. B 10. C 11. C 12. Explain how people with disabilities have been treated throughout history. Children who were malformed or had obvious physical disabilities were sometimes abandoned. Older adults were abandoned, deprived of food, or killed when they could no longer contribute. Some people with disabilities were considered to have special powers. In the late 1700s to early 1800s, individuals were classified and grouped according to their disorder so that they could be helped. Special residences for individuals with deafness, blindness, mental illness, and intellectual limitations were established, although there were not necessarily any therapeutic services. 13. D 14. A 15. A 16.

Acceptable responses: Speech scientists may be involved in basic research exploring anatomy, physiology, and physics of speech-sound production Investigate the causes, prevention, and treatment of various speech impairments Development of computer-generated speech Language scientists may investigate the ways children learn language Conduct cross-cultural studies of language and communication Study how languages are changing Examine language disabilities and the nature of language disorders in children and adults Hearing scientists investigate the nature of sound, noise, and hearing They may help develop equipment for hearing assessment Develop techniques for testing infants or those with physical or psychological impairments Develop and improve assistive listening devices Concerned with conservation of hearing and limiting environmental noise

17. A 18.

In addition to the entry-level degree, what else do audiologists need in terms of credentials? Educational requirements are 3-5 years of professional education beyond the bachelor’s degree ASHA CCC-A: Requires doctorate, professional experience, national exam State license is often needed and is frequently identical to ASHA CCC

19. D

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20.

In addition to the entry-level degree, what else to SLPs need in terms of credentials? Public schools require at least a bachelor’s degree, but most states require a master’s degree. Requirements vary from state to state. ASHA CCC-SLP: Requires master’s degree or doctorate, professional experience, professional development, national exam State license often needed and is frequently identical to ASHA CCC. There may also be additional requirements for the state’s department of education school certification

21. B 22.

What are the assumptions of evidence-based practice? Clinical skill grows from experience and current available data The SLP or audiologist seeks new therapeutic information to improve efficacy

23. A 24.

What is involved in clinical decision-making? Combination of scientific evidence, clinical experience, and client needs

25. C 26.

What are the three key elements of efficacy? It refers to an identified population, not specific individuals The treatment should be focused and the population should be clearly identified The research should be conducted under optimal intervention conditions, although actual clinical conditions may be less than ideal

27. B 28.

What are some factors that affect clinical decision making? Clinician’s expertise, experience, attitude, and motivation Client/family values and characteristics Service delivery variables

29. A 30.

Name and briefly describe four federal mandates affecting people with disabilities. 1975: Education for All Handicapped Children Act (EAHCA) (Public Law 94-142): Mandated that a free and appropriate public education (FAPE) must be provided for all handicapped children between ages 5 and 21. 1986: Education of the Handicapped Amendments (Public Law 99-457): Extended age of those served to cover children between the ages of birth and 5 years. 1990: Individuals with Disabilities Act (IDEA): Addressed the multicultural nature of the U.S. 2004: Established birth to 6 programs as well as new early intervention services

31. A 32. B 33. B 34. C

96 .

CHAPTER 2 TYPICAL AND DISORDERED COMMUNICATION 1.

Which of the following is the most accurate definition of the term 'communication'? a. It is an exchange between senders and receivers. b. It is another word for speech. c. It is the process of self-expression. d. It is the exclusively human quality to talk to other humans.

____________________ is how cultural identity, setting, and participants influence communication. a. Communication b. Sociolinguistics c. Psycholinguistics d. Multiculturalism

Our cultural identity refers to a. Our language b. Our cultural communities c. Both of the above d. None of the above

Grammar refers to a. The rules of a language b. The recognition by a native speaker of whether something is said “right” or “wrong” c. Only the sound system of a language d. The process of producing the acoustic representation of language

What does it mean that languages are generative and dynamic?

What are the three primary components of language? a. Phonology, morphology, syntax b. Form, content, use c. Semantics, syntax, pragmatics d. Phonology, phonotactic rules, morphology

Form consists of a. Phonology, morphology, syntax b. Semantics, syntax, pragmatics c. Phonology, phonotactic rules, morphology d. None of the above

Briefly explain how phonology and phontactic rules differ.

Briefly explain morphology, morphemes, free morphemes, and bound morphemes.

10.

_____________________ is how words are arranged in a sentence and the ways in which one word may affect another. a. Syntax b. Semantics c. Morphology d. Pragmatics

97 .

11.

Content consists of a. Syntax and semantics b. Pragmatics c. Semantics d. Morphology and phonology

12.

______________ refers to the content or meaning of language, whereas _______________ refers to the pieces of meaning that define a particular word a. Morphemes, morphology b. Morphology, morphemes c. Semantic features, semantics d. Semantics, semantic features

13.

Use consists of a. Syntax and semantics b. Pragmatics c. Semantics d. Morphology and phonology

14.

_________________ is how and why we use language; it varies with culture. a. Syntax b. Communication c. Speech d. Pragmatics

15.

Speech consists of articulation and fluency. Briefly describe both.

16.

Voice can reveal things about the speaker and the message. ______________ is a listener’s perception of how high or low a sound is, ______________________ is the basic tone that an individual uses most of the time, and ____________________ is the pitch movement within an utterance. a. Habitual pitch, pitch, intonation b. Intonation, pitch, habitual pitch c. Pitch, intonation, habitual pitch d. None of the above

17.

About 2/3 of human meaning exchange is a. Verbal b. Vocal c. Nonverbal d. Nonvocal

18.

___________________ refer to how you look, your clothes, your possessions, music you listen to, etc. a. Kinesics b. Proxemics c. Artifacts d. Tactiles

19.

__________________ refer to the way we move our body, or body language. a. Kinesics b. Proxemics c. Artifacts d. Tactiles

20.

98 .

21.

__________________ refer to the physical distance between people as it affects communication. a. Kinesics b. Proxemics c. Tactiles d. Chronemics

22.

__________________ refer to touching behaviors. a. Kinesics b. Proxemics c. Tactiles d. Chronemics

23.

_________________ refer to the effect of time on communication. a. Kinesics b. Proxemics c. Tactiles d. Chronemics

24.

___________________ is the cause or origin of a problem, and may be used to classify a communication problem. a. Dialect b. Etiology c. Congenital disorder d. None of the above

25.

_____________________ disorders are present at birth, whereas _____________________ disorders are the result of illness, accident, or environmental circumstances later in life. a. Etiological, dialectal b. Genetic, accidental c. Congenital, acquired d. Primary, secondary

26.

Briefly describe disorders of form and potential etiologies.

27.

Briefly describe disorders of content and potential etiologies.

28.

Briefly describe disorders of use and potential etiologies.

29.

______________________ is a speech disorder caused by paralysis, weakness, or poor coordination of the speech musculature. a. Dysarthria b. Apraxia c. Dysphagia d. Stuttering

30.

_____________________ is a speech disorder that is due to neuromotor programming difficulties. a. Dysarthria b. Dysphagia c. Aphasia d. Apraxia

99 .

31.

In disorders of ______________, the smooth, uninterrupted flow of speech is affected. a. Articulation b. Voice c. Language d. Fluency

32.

Provide examples of the following: Fillers, hesitations, repetitions, and prolongations.

33.

What is stuttering?

34.

What are some habits that can affect normal voice production? What are other causes of voice disorders?

35.

___________________ is the term for excessive yelling, screaming, or loud singing. It can result in hoarseness or another voice disorder. a. Vocal hygiene b. Vocal abuse c. Vocal strain d. Vocal exertion

36.

What is deafness?

37.

Name three interventions for deafness.

38.

What are the ways in which hearing loss can be categorized?

39.

A hearing loss that is caused by damage to the outer or middle ear. a. Conductive b. Sensorineural c. Mixed d. None of the above

40.

A hearing loss that is due to problems with the inner ear and/or auditory nerve. a. Conductive b. Sensorineural c. Mixed d. None of the above

41.

Describe auditory processing disorders. Include symptoms, etiology, and population affected.

42.

Explain the following phrase: “Communication disorders are often secondary to other disabilities.” Give examples.

43.

_____________________ is the number/percentage of people within a specified population who have a particular disorder or condition at a given point in time. a. Incidence b. Prevalence c. Impaired population d. None of the above

100 .

44.

What percentage of the U.S. population has a communication disorder? a. 1% b. 4% c. 9% d. 17%

45.

Impairments of speech-sounds and fluency are more common in ________ than _________ and more common in __________ than ___________. a. Children, adults, males, females b. Adults, children, males, females c. Children, adults, females, males d. Adults, children, females, males

46.

Describe the process of communication disorders assessment.

47.

____________________ distinguish(es) an individual’s difficulties from the broad range of possible problems. a. Etiological factors b. Genetic markers c. Predisposing causes d. Diagnosis

48.

_________________________ refers to working with a client for a time to obtain a clearer picture of strengths and weaknesses. a. Response to intervention b. Constraint-induced therapy c. Diagnostic therapy d. The cycles approach

49.

A prognosis is a. An informed prediction of an outcome b. A trigger for a disorder c. A factor that continues or adds to a problem d. None of the above

50.

_________________________ tests yield scores that are used to compare a client with a sample of similar individuals. a. Dynamic assessment b. Criterion referenced c. Norm-referenced d. All of the above

51.

_________________________ tests evaluate a client’s strengths and weaknesses with regard to particular skills. a. Dynamic assessment b. Criterion referenced c. Norm-referenced d. None of the above

52.

Name factors that influence intervention.

53.

What are five objectives of intervention?

101 .

54.

Baseline data is a. A measurement of the client’s accuracy before beginning intervention b. The data from a normative sample c. Test scores from norm-referenced tests d. None of the above

55.

What is the A, B, C, and D of behavioral objectives?

56.

Behavior modification includes a. Behavior and rewards b. Stimulus and reinforcement c. Extinguishing and punishing d. None of the above

57.

In incidental teaching, a. The SLP provides a stimulus and reinforces the response if it is correct b. The parent is responsible for providing therapeutic intervention after instruction c. The SLP follows the client’s lead and teaches along the way d. The child is encouraged to learn language skills from other children in the environment

58.

What are the functions of support groups for communication disorders?

59.

If therapy has been effective, the client is successful in a. Generalizing the learned skills b. Self-correcting c. Experiencing automaticity d. All of the above

60.

Briefly describe the follow-up and maintenance process.

102 .

CHAPTER 2 – Answer key TYPICAL AND DISORDERED COMMUNICATION 1. A 2. B 3. C 4. A 5.

What does it mean that languages are generative and dynamic? Generative means that each utterance is freshly created Dynamic means that languages change over time

6. B 7. A 8.

Briefly explain how phonology and phontactic rules differ. Phonology is the sound system of a language, whereas phonotactic rules specify how sounds may be arranged in words.

Briefly explain morphology, morphemes, free morphemes, and bound morphemes. Morphology involves the structure of words Morphemes are the smallest grammatical units of a language Free morphemes may stand alone as words Bound morphemes change the meaning of the original words and can only be attached to free morphemes

10. A 11. C 12. D 13. B 14. D 15.

Speech consists of articulation and fluency. Briefly describe both. Articulation is the way speech sounds are formed. Fluency is the smooth, forward flow of communication, influenced by rhythm and rate. Rate is the speed at which we talk. Rate and rhythm are both components of prosody.

16. D 17. C 18. C 19. A 20.

Briefly (in 6-10 sentences) explain communication through the lifespan. Be sure to touch on how infants learn language, potential complicating factors, and how we end up being competent communicators. Infants must first learn the rudiments of communication and begin to master speech. The early establishment of communication between children and caregivers fosters the development of speech and language, which influence the quality of communication. This is fostered by physical, cognitive, and social development. The key to becoming a communicator is being treated as one. The process of learning speech and language is a social one that occurs through interactions of children and the people in their environment. In different cultures, the type of child-caregiver interaction, the model of language presented to the child, and the expectations for the child differ, but each is sufficient for the learning of the language of the culture. Every person’s speech and language continues to change until the end of life. A competent communicator continues to adapt to changes in the language and in the communication process.

21. B 22. C 23. D 24. B 25. C

103 .

26.

Briefly describe disorders of form and potential etiologies. Errors in sound use constitute a disorder of phonology. Incorrect use of past tense or plural markers is an example of a disorder of morphology Syntactical errors include incorrect word order and run-on sentences May be due to sensory limitations, perceptual difficulties, limited exposure to correct models, etc.

27.

Briefly describe disorders of content and potential etiologies. Limited vocabulary, misuse of words, or word-finding problems Difficulty understanding and using abstract language May be due to limited experience, concrete learning style, strokes, head trauma, or certain illnesses.

28.

Briefly describe disorders of use and potential etiologies. Pragmatic impairments may stem from limited or unacceptable conversational, social, and narrative skills; deficits in spoken vocabulary; and/or immature or disordered phonology, morphology, and syntax Might include difficulty staying on topic, providing inappropriate or incongruent responses to questions, or continually interrupting the conversational partner.

29. A 30. D 31. D 32.

Provide examples of the following: Fillers, hesitations, repetitions, and prolongations. Fillers: “er,” “um,” “ya know” Hesitations: unexpected pauses Repetitions: “g-g-g-go” Prolongations: “wwwwwwell”

33.

What is stuttering? When these speech behaviors (fillers, hesitations, repetitions, prolongations) exceed or are qualitatively different from the norm or are accompanied by excessive tension, struggle, and fear.

34.

What are some habits that can affect normal voice production? What are other causes? Physical tension, coughing, throat clearing, smoking, and drinking alcohol Disease, trauma, allergies, neuromuscular disorders, endocrine disorders

35. B 36.

What is deafness? When a person’s ability to perceive sound is limited to such an extent that the auditory channel is not the primary sensory input for communication. It may be congenital or acquired.

37.

Name three interventions for deafness. Three of the following: Total communication, assistive listening devices, cochlear implants, auditory training

38.

What are the ways in which hearing loss can be categorized? Temporary or permanent In terms of severity, laterality, and type Severity may range from mild to severe (or profound) The loss can be bilateral or unilateral The type of loss can be conductive, sensorineural, or mixed

39. A 40. B

104 .

41.

Describe auditory processing disorders. Include symptoms, etiology, and population affected. Individuals with APD may have normal hearing but difficulty understanding speech. Difficulty keeping up with conversation, understanding speech in noise, discriminating and identifying speech sounds, and integrating speech with nonverbals. Etiology is often unknown, but can be due to tumor, disease, or brain injury. Can occur in children or adults. May coexist with other disorders.

42.

Explain the following phrase: “Communication disorders are often secondary to other disabilities.” Give examples. Children or adults may have a disorder that causes a communication disorder. For example, children with cleft palate (primary) often have communication impairments associated with the cleft. Individuals with cerebral palsy (primary) often have difficulty in various areas of speech.

43. B 44. D 45. A 46.

Describe the process of communication disorders assessment. Systematic process of obtaining information from many sources, through various means, and in different settings to verify and specify communication strengths and weaknesses, identify possible causes of problems, and make plans to address them. If a problem is identified, an SLP may make a diagnosis. A screening is not a diagnostic evaluation.

47. D 48. C 49. A 50. C 51. B 52.

Name factors that influence intervention. Nature and severity of the disorder, the age and status of the client, environmental considerations, and personal/cultural characteristics of the client and clinician.

53.

What are five objectives of intervention? The client should show improvement and this should generalize What has been learned should be largely automatic The client must be able to self-monitor The client should make optimum progress in the minimum amount of time Intervention should be sensitive to the personal and cultural characteristics of the client

54. A 55.

What is the A, B, C, and D of behavioral objectives? Actor: Who is expected to do the behavior? Behavior: What is the observable and measurable behavior? Condition: What is the context or condition of the behavior? Degree: What is the targeted degree of success?

56. B 57. C 58.

What are the functions of support groups for communication disorders? They can provide an avenue to practice what has been learned in therapy, share feelings about the disability, and maintain communication skills once formal treatment has been terminated.

59. D

105 .

60.

Briefly describe the follow-up and maintenance process. Upon dismissal, the client or family should be encouraged to return if there is a need. A regular follow-up schedule can be established. Booster treatment may be provided if needed.

106 .

CHAPTER 3 OVERVIEW OF THE ANATOMY AND PHYSIOLOGY OF THE SPEECH PRODUCTION MECHANISM 1.

The study of the structures of the body and the relationship of these structures to one another is a. Anatomy b. Physiology c. Kinesiology d. Biology

The study of the functions of organisms and bodily structures is a. Anatomy b. Physiology c. Kinesiology d. Biology

The three physiological subsystems for speech are a. Respiratory, laryngeal, articulatory/resonating b. Respiratory, articulatory, propagating c. Muscular, aerodynamic, and acoustic d. Aerodynamic, acoustic, and receptive

The ____________________ is an acoustic filter that allows certain frequencies to pass while blocking other frequencies. a. Respiratory system b. Laryngeal system c. Articulatory/resonating system d. Propagating system

The _____________________ is the driving force for speech. a. Respiratory system b. Laryngeal system c. Articulatory/resonating system d. Propagating system

The _______________________ has anatomical structures that vibrate, setting air molecules in the vocal tract into multiple frequencies of vibration. a. Respiratory system b. Laryngeal system c. Articulatory/resonating system d. Propagating system

The pulmonary apparatus consists of the a. Lungs b. Trachea c. Pulmonary airways d. All of the above

107 .

The chest wall (thorax) consists of the a. Rib cage b. Abdominal wall c. Bronchi d. A&B e. A&C

Inspiratory muscles are generally ______________________, whereas expiratory muscles are generally ___________________. a. Contracted, relaxed b. Controlled, reflexive c. Above the diaphragm, below the diaphragm d. Below the diaphragm, above the diaphragm

10.

Describe the structure and function of the diaphragm

11.

Expiratory muscles a. Assist the diaphragm’s movement back to its relaxed, dome-shaped configuration b. Are in direct contact with the diaphragm c. Are important for tidal breathing purposes only d. None of the above

12.

Explain the process of inspiration as it relates to respiration.

13.

Explain the process of expiration as it relates to respiration.

14.

Describe the speech breathing process.

15.

Which of the following is true? a. Resting tidal breathing rate decreases from birth to adulthood, related to more alveoli b. Maximum lung capacity is reached in early childhood and remains constant until early adulthood c. Respiratory function is not significantly affected by exercise, health, or smoking d. None of the above

16.

_____________________ is an air valve composed of cartilages, muscles, and other tissues; the main sound generator for speech production. a. Thyroid b. Vocal folds c. Larynx d. Pharynx

17.

The primary biological function(s) of the larynx is/are a. To produce speech b. To protect the airway c. To serve as an attachment point for inspiratory muscles d. All of the above

108 .

18.

The larynx is oriented a. On top of the trachea, appearing to be suspended from the hyoid bone b. On top of the trachea, suspended from the thyroid cartilage c. Directly inferior to the base of the tongue, but superior to the pharynx d. None of the above

19.

The larynx consists of a. The thyroid cartilage b. The arytenoids c. The cricoid cartilage d. All of the above

20.

_____________________________ is the largest laryngeal cartilage; it forms the front and sides of the laryngeal skeleton. a. Thyroid cartilage b. Arytenoid cartilage c. Cricoid cartilage d. Hyoid cartilage

21.

The anatomical name for the “Adam’s apple” is the a. Thyroid notch b. Thyroid prominence c. Thyroid protrusion d. Thyroid eminence

22.

What are the front and back attachments of the vocal folds?

23.

The vocal folds appear to be ivory bands of tissue that ______________ during respiration and _____________ during phonation. a. Adduct, abduct b. Abduct, adduct c. Elevate, depress d. Depress, elevate

24.

Describe lifespan issues of the laryngeal system.

25.

The articulatory/resonating system consists of a. The lungs, vocal folds, and nasal cavity b. The larynx, pharynx, and oral cavity c. The oral cavity, nasal cavity, and pharyngeal cavity d. The pharyngeal cavity, laryngeal cavity, and lungs

26.

The ____________________ is a resonant acoustic tube that shapes the sound energy produced by the respiratory and laryngeal systems into speech sounds. a. Vocal tract b. Larynx c. Cricoid cartilage d. Nasal cavity

109 .

27.

The facial skeleton and cranium consist of ______________ bones. a. 17 b. 22 c. 29 d. 32

28.

Adults have _______________ teeth. a. 17 b. 22 c. 29 d. 32

29.

The _________________ is a muscular hydrostat. a. Tongue b. Hyoid c. Uvula d. Velum

30.

Velopharyngeal closure refers to a. Elevation of the uvula into the nasal cavity b. Contact of the velum with the lateral and posterior pharyngeal walls c. Contact of the uvula and the epiglottis d. Elevation of the hard palate

31.

Explain why velar elevation is necessary.

32.

The bones of the skull reach adult size a. By age 8 b. By age 15 c. By age 22 d. The bones of the skull are constantly changing in size throughout the lifespan

33.

Newborns have a. More than twice the number of skull bones than adults b. Half the number of skull bones than adults c. The same number of skull bones as adults d. None of the above

34.

At what ages are primary and secondary dentition complete? a. 6 months, 18 years b. 3 years, 22 years c. 3 years, 18 years d. 6 months, 22 years

35.

What is the outcome of the increase in length and volume of the oral cavity?

36.

Describe the voice production process.

110 .

37.

__________________________ is/are the number of cycles of vocal fold vibration per second. a. Periodicity b. Frequency c. Harmonics d. Vibratory periods

38.

_________________________ are whole-number multiples of the fundamental frequency. a. Harmonics b. Vibratory periods c. Habitual pitches d. Vocal registers

111 .

CHAPTER 3 – Answer key OVERVIEW OF THE ANATOMY AND PHYSIOLOGY OF THE SPEECH PRODUCTION MECHANISM 1. A 2. B 3. A 4. C 5. A 6. B 7. D 8. D 9. D

10.

Describe the structure and function of the diaphragm Main muscle of inspiration Dome-shaped structure composed of a thin, flat, nonelastic central tendon and a broad rim of muscle fibers that radiate up to the edges of the central tendon The central tendon is in direct contact with each lung Contracts during inspiration, pulling down and forward, increasing lung volume

11. A 12.

Explain the process of inspiration as it relates to respiration. Diaphragm contracts, rib cage and lungs expand, lung volume increases and alveolar pressure drops, causing air to rush in and equalize with atmospheric pressure

13.

Explain the process of expiration as it relates to respiration. Decrease in the size of the rib cage wall, compression of the lungs, increase in pressure in the lungs, air rushes out to achieve equilibrium with atmospheric pressure. Does not require active muscle contraction.

14.

Describe the speech breathing process. Contraction of the diaphragm leads to rapid, forceful inspirations Inspirations are much shorter than expirations The amount of air inspired is greater than during resting tidal breathing Inspiratory and expiratory muscles are both activated during speech

15. A 16. C 17. B 18. A 19. D 20. A 21. B 22.

What are the front and back attachments of the vocal folds? Front attachment: Midline of the thyroid cartilage Back attachment: Arytenoid cartilages via the vocal ligament

23. B 24.

Describe lifespan issues of the laryngeal system. The larynx is small and high in the neck in newborns. It reaches its final position between 10 and 20 years of age. The laryngeal cartilages increase in size and become less pliable with age. The vocal folds increase in length differentially for males and females. Female laryngeal cartilage never completely ossifies. The vocal folds atrophy and lose elasticity. In men, this is noted as an increase in pitch, and in women as decreased pitch with the contribution of hormone-related changes in menopause.

25. C

112 .

26. A 27. B 28. D 29. A 30. B

31.

Explain why velar elevation is necessary. To prevent air or food from escaping through the nose and to build up air pressure for production of pressure sounds. Any air that escapes through the nose during speech can result in a nasal quality.

32. A 33. A 34. C 35.

What is the outcome of the increase in length and volume of the oral cavity? It influences the overall resonant characteristics by lowering the frequencies at which the vocal tract naturally resonates.

36.

Describe the voice production process. Speech production begins with phonation. The air pressure that builds up beneath adducted vocal folds is tracheal/alveolar pressure. The air pressure from below displaces the lower edges of each vocal fold laterally, followed by the lateral displacement of the upper edges of each vocal fold. The elastic properties result in the vocal folds colliding, closing off the airway.

37. B 38. A

113 .

CHAPTER 4 CHILDHOOD LANGUAGE IMPAIRMENTS 1.

What are language impairments?

At what age do rituals and game playing emerge? a. At birth b. 3-4 months c. 6-9 months d. 12-18 months

At about 8 to 9 months, infants develop _________________ in interactions. a. Reciprocity b. Stimulus-response sequence c. Object permanence d. Intentionality

How is intention to communicate noted?

The first meaningful word occurs around ________________. a. 6 months b. 12 months c. 18 months d. 24 months

Define “representation” and “symbolization” and explain why they are important.

Speech perception at 6 months is related to later _______________________. a. Reading abilities b. Speaking fluency c. Word/phrase understanding and production d. Writing abilities

By ____________________, children produce about 50 single words and begin to combine words predictably. a. 12 months b. 18 months c. 24 months d. 36 months

By age 2, children have an expressive vocabulary of about a. 50-100 words b. 100-150 words c. 150-300 words d. 300-500 words

10.

Each child has a personal dictionary, or _________________ that reflects his/her environment. a. Semantic corpus b. Lexicon c. Both of the above d. None of the above

114 .

11.

If a preschool-aged child says “doggies are yucky,” “kitties are yucky,” etc., they are using a. Lexical retrieval b. Repetition c. Reformulation d. Substitution

12.

Preschool-aged children can recount the past and remember short stories because of a. Improved pragmatics b. Increased memory c. Improved caregiver models d. Increased comprehension

13.

What is reformulation? a. Caregivers repeat the child’s utterances in mature form b. Children repeat phrases using the same word in each sentence c. Children are taught to self-correct their errors d. None of the above

14.

How long can preschool-aged children maintain a conversation? a. 1-2 turns b. 2-3 turns c. 5-6 turns d. 7-8 turns

15.

In preschool-aged children, a. Comprehension of words is more advanced than expression b. Expressive vocabularies are larger than receptive vocabularies c. Comprehension of words is equal to expression d. None of the above

16.

___________________ is inferring meaning from context and using the word in a similar manner. a. Reformulation b. Figurative language c. Fast mapping d. Metalinguistics

17.

About 90% of adult syntax is acquired by age a. 5 b. 8 c. 12 d. 15

18.

Language becomes more complex as it becomes longer, and can be calculated in a. Mean length of utterance b. Syntactical complexity units c. Morphological counts d. None of the above

19.

In what order do wh- words develop?

115 .

20.

_________________________ allow(s) the child to consider language in the abstract, make judgments about its correctness, and create verbal contexts. a. Pragmatics development b. Generalization c. Representation d. Metalinguistic skills

21.

For school-aged children, language development a. Increases dramatically b. Slows and begins to stabilize c. Can decrease because of poor peer models d. None of the above

22.

Describe the changes in language use during adolescence.

23.

______________________ are sayings that do not always mean what they seem to mean, as in idioms. a. Figurative language b. Implicitures c. Multiple meanings d. All of the above

24.

By high school, children understand approximately a. 10,000 words b. 20,000 words c. 40,000 words d. 60,000 words

25.

Multiple word meanings are acquired a. During the preschool years b. During adolescence c. During adulthood d. None of the above

26.

By age ______________, children can use most verb tenses, possessive pronouns, and conjunctions. a. 3 b. 5 c. 7 d. 10

27.

Risk factors for _______________ include being male, low SES, not being a single child, older maternal age at birth, moderately low birth weight, low quality parenting, receipt of no day care or for less than 10 hr/week, and hearing or attention problems. a. Autism b. Down syndrome c. Cognitive impairment d. Being a late talker

28.

Children who are identified as late talkers at 24-31 months a. Tend to recover spontaneously b. Are diagnosed with cognitive impairments by school-age c. Still have a weakness in language-related skills in late adolescence d. None of the above

29.

Intellectual disability consists of what three characteristics?

116 .

30.

Severity of intellectual disability is usually based on a. IQ b. Adaptive behaviors c. Language abilities d. Sustained attention measures

31.

Explain some areas in which individuals with intellectual disabilities will have difficulty.

32.

When should intervention begin for those with intellectual disability? a. During the toddler years b. When the child is preschool aged c. As soon as possible d. Intervention does not help those with intellectual disabilities

33.

Educational options for those with intellectual disabilities include a. Regular education with support b. Self-contained, special classrooms c. Developmental centers for profound ID d. All of the above

34.

Children with Down syndrome and Fragile X both have a. Mild language delays b. Moderate-severe language delays c. Profound language delays d. Very different levels of language delay

35.

_________________________ are a heterogeneous group of disorders that are manifested by significant difficulties in the development and use of listening, speaking, reading, writing, reasoning, or mathematical abilities. a. Learning disabilities b. Cognitive impairments c. Speech/language impairments d. Syndromes

36.

Approximately ______________ of all individuals have LD. a. 1% b. 3% c. 15% d. 20%

37.

___________________________ is an underlying neurological impairment in executive function that regulates behavior, causing impulsiveness. a. Autism b. Cluttering c. Specific language impairment d. Attention Deficit Hyperactivity Disorder

38.

In __________________________, children become fixed on a single task or behavior and repeat it compulsively.

39.

Children with LD a. Exhibit poor ability to attend selectively b. Concentrate on inappropriate or unimportant stimuli c. A&B d. None of the above

40.

Describe lifespan issues that affect individuals with learning disabilities.

117 .

41.

Aspect(s) of language that can be affected in children with LD: a. Form b. Content c. Use d. All of the above

42.

What percentage of middle class U.S. children have delayed language development? a. 10-15% b. 20-25% c. 1-2% d. 3-7%

43.

What are the characteristics of a child who has a specific language impairment (SLI)?

44.

______________________ is an active process that allows limited information to be held in a temporary accessible state while cognitive processing occurs. a. Short term memory b. Working memory c. Long term memory d. None of the above

45.

___________________________ refers to the organizing and directing function of the brain.

46.

Lifespan issues of children with SLI include a. Negative perception by peers b. Poor social skills c. Perceiving themselves negatively d. All of the above

47.

Children with SLI have difficulty a. Extracting regularities from language b. Registering different contexts for language c. Constructing word-referent associations for lexical growth d. All of the above

48.

Expressively, children with SLI may a. Speak more rapidly b. Have fewer speech disruptions c. Both A & B d. None of the above

49.

Children with SLI have difficulty with ____________________, which indicates language processing deficits in phonological working memory where words are held while processed. a. Phonotactic rules b. Grammatical morphemes c. Multiple meaning words d. Social interactions

50.

What are the characteristics of children with Autism spectrum disorder (ASD)?

118 .

51.

Children with ASD are identified by the time they are a. Born b. 6 months old c. 2-3 years old d. 5-7 years old

52.

The incidence of ASD among children is a. 1 in 55 b. 1 in 88 c. 1 in 110 d. 1 in 230

53.

Approximately 25% of children with ASD exhibit a. ID b. ADHD c. SLI d. All of the above

54.

Incidence of ASD is higher in a. Males b. Those who have a family history of autism c. A&B d. None of the above

55.

Which are options for education and employment for those with ASD? a. Regular education b. Special education c. May hold competitive employment d. All of the above

56.

Between __________ and __________ of individuals with ASD remain nonspeaking throughout their lives. a. 2%, 5% b. 15%, 30% c. 25%, 60% d. 50%, 80%

57.

Some individuals with ASD may have immediate or delayed ______________ or use entire verbal routines, called _____________________. a. Speaking, special stories b. Echolalia, formuli c. Recall, social scripts d. Repetition, scripts

58.

_____________________ is diffuse brain damage as a result of external force. a. Traumatic brain injury b. Encephalopathy c. Meningitis d. Lobectomy

59.

Approximately _________________ children and adolescents in the U.S. have experienced a TBI. a. 100,000 b. 500,000 c. 1 million d. 2 million

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60.

Variables related to degree of impairment related to TBI include a. Extent and site of lesion b. Age at onset c. Age of the injury d. All of the above

61.

Psychological maladjustment or acting-out behaviors called ____________________ may occur after TBI. a. Social disinhibition b. Confabulation c. Anosognosia d. Prosopagnosia

62.

Describe lifespan issues related to TBI.

63.

Deficits in ________________ are most likely to remain long after the injury in TBI. a. Syntax b. Semantics c. Pragmatics d. Morphology

64.

___________________ is relatively unaffected in TBI. a. Form b. Content c. Use d. None of the above

65.

Individuals who have sustained TBI have difficulty with a. Word retrieval b. Object description c. Narration d. All of the above

66.

What are the language characteristics of children who have been neglected or abused?

67.

Language features of children with FASD include a. Language delay b. Echolalia c. Poor comprehension d. All of the above

68.

In _____________________, children do not speak in specific situations although they speak in others. a. Deafness b. Selective mutism c. Language delay d. Autism

69.

What can be expected in language development in those who receive a cochlear implant?

120 .

70.

______________________________ is the persistent difficulty in the social use of verbal and nonverbal communication and may include problems in all of those areas.

71.

Describe at least three language characteristics of individuals with social communication disorder (SCD).

72.

What are the goals of assessment?

73.

Explain special assessment considerations for bilingual children, English language learners, and dialectal speakers.

74.

Screening tests are used to a. Determine the presence or absence of a language problem b. Qualify a student for special education services c. Quantify the degree of language impairment d. Guide treatment decisions

75.

After a referral and screening, the following procedures may be part of assessment a. Case history and interview b. Observation c. Testing d. Sampling e. All of the above

76.

______________________ refers to the movement between two languages. a. Bilingualism b. Code switching c. Parallelism d. Dialect changing

77.

_______________________ is probing performance to identify possible intervention procedures. a. Diagnostic therapy b. Response to intervention c. Dynamic assessment d. Language sampling

78.

What factors are important in target selection and sequence of training?

79.

What are the basic tenets of good teaching behavior for language intervention in children?

80.

Adults with ________________ will most likely require continued intervention for language and communication deficits throughout the lifespan. a. ADHD b. ASD/ID c. SLI d. FAS

121 .

CHAPTER 4 – Answer key CHILDHOOD LANGUAGE IMPAIRMENTS 1.

What are language impairments? A heterogeneous group of developmental and/or acquired disorders and/or delays principally characterized by deficits and/or immaturities in the use of spoken or written language for comprehension and/or production purposes that may involve the form, content, and/or use of language in any combination. Language differences are not disorders and so do not require clinical intervention; however, elective intervention is possible at a client’s request.

2. B 3. D 4.

How is intention to communicate noted? In multiple ways, such as gesture, eye contact, consistent sound/intonation patterns for specific intentions, and persistent attempts to communicate.

6. B 6.

Define “representation” and “symbolization” and explain why they are important. Representation is the process of having one thing stand for another. Symbolization is using an arbitrary symbol to stand for another. Learning to represent and symbolize is strongly related to cognitive abilities.

7. C 8. B 9. C 10. B 11.D 12. B 13. A 14. B 15. A 16. C 17. A 18. A

19.

In what order do wh- words develop? What and where are first, followed by who, which and whose, and finally when, why and how

20. D 21. B

22.

Describe the changes in language use during adolescence. Conversational skills continue to develop and narratives expand into mature storytelling Learn effective ways to introduce new topics, to continue, and to end conversations They can make relevant comments and adapt roles and moods to fit situations Teens demonstrate more affect and discuss topics infrequently mentioned at home The number of turns on topic increases Interrupting increases but is in the form of asking questions or otherwise moving a topic along Narratives, both in conversation and in writing, gain the elements needed.

23. A 24. D 25. B 26. B 27. D 28. C

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29.

Intellectual disability consists of what three characteristics? Substantial limitations in intellectual functioning Significant limitations in adaptive behaviors Originates before age 18

30. A

31.

Explain some areas in which individuals with intellectual disabilities will have difficulty. Individuals with mild to moderate ID can sustain attention as well as mental-age-matched non-ID peers but have difficulty scanning and selecting stimuli to which to attend. The more severe the ID, the more difficulty the person will have in discriminating likeness and difference. Organization of information is challenging. Memory or retrieval of information is poor and slow. Individuals with Down syndrome have greater difficulty with successive processing as opposed to simultaneous processing.

32. C 33. D 34. B 35. A 36. B 37. D 38. perseveration 39. C 40.

Describe lifespan issues that affect individuals with learning disabilities. As preschoolers, children with LD may exhibit little interest in language or books. Linguistic demands of the classroom are often well above oral language abilities. Many require the services of special educators, SLPs, and reading specialists. Children with LD can be successful in the regular classroom if some adaptation is made. Some seem to outgrow aspects of their disability, although some require lifelong adaptations. Other adults continue to have difficulty.

41. D 42. A 43. What are the characteristics of a child who has a specific language impairment (SLI)? Typical nonverbal intelligence but deficits in a variety of nonverbal tasks, suggesting impaired or delayed cognitive functioning. Language performance is significantly lower than intellectual performance on nonverbal tasks. SLI affects more males than females and there is an increased prevalence of SLI in families with a history of speech/language problems. Do not exhibit perceptual difficulties. Have different neuroanatomical structure and function. Many showed marked deficits in working memory. Auditory sequential memory and problem solving in complex reasoning tasks are affected. Reduced verbal working memory suggests limited capacity for language processing. 44. B 45. executive function 46. D 47. D 48. D 49. B

123 .

50.

What are the characteristics of children with Autism spectrum disorder (ASD)? Many children with ASD have abnormal social interactions and failure in the give-and-take of conversation; poorly integrated verbal and nonverbal communication, including eye contact and body language; difficulty adjusting to different social situations and stereotypical motor patterns; and echolalia. Motor patterns of behavior may include rocking and fascination with lights or spinning objects. May insist on certain routines or be preoccupied with specific objects, foods, or clothing. May have an adverse reaction to some sounds or textures. Eye and face detection processing may be delayed. Overall processing has been characterized as a gestalt in which unanalyzed wholes are stored and later reproduced in identical fashion.

51. C 52. B 53. A 54. C

55. D 56. C 57. B 58. A 59. C 60. D 61. A

62.

Describe lifespan issues related to TBI. After the accident, the individual may be unconscious. After regaining consciousness, disorientation and memory loss can occur. May be accompanied by physical disability and personality changes. Neural recovery is often unpredictable and irregular. Young children often recover quickly but experience difficulties learning new information and may exhibit severe, long-lasting problems. Older children have more to recover from memory but less new information to learn. Even those who seem to have recovered may lack subtle cognitive/social skills.

63. C 64. A 65. D 76.

What are the language characteristics of children who have been neglected or abused? Pragmatics is the greatest area of difficulty, although all areas of language can be affected. In general, they are less talkative and have fewer conversational skills than their peers. They are less likely to volunteer information or discuss emotions or feelings. Utterances are shorter and less complex.

67. D 68. B

124 .

69.

70. 71.

72.

73.

What can be expected in language development in those who receive a cochlear implant? Children who receive cochlear implants have relatively typical language development. Those implanted later have an initial advantage of maturity that enhances language growth, but those implanted earlier begin to develop spoken language at an ever-increasing rate that eclipses those implanted earlier. Social communication disorder (SCD) Describe at least three language characteristics of individuals with social communication disorder (SCD). Problems with communication for social purposes, including deficits in interactional skills, social cognition, pragmatics, and language. Social cognition includes understanding and regulating our emotions as they affect others, and involved Theory of Mind. ToM is an evolving notion in children that others have a mind and emotions that differ from their own and that these must be considered in communication. Children with SCD may be very literal in their interpretations of indirect language. Conversations may be incoherent, with frequent abrupt topic shifts. Words and meanings may be misunderstood unless explicitly stated, and syntax may not reflect a child’s intended meaning; this may result in frequent communication breakdowns. What are the goals of assessment? An SLP’s task is to distinguish between children who have a disorder and those who do not. Assessment should be sufficiently broad and deep so that all areas of possible concern are identified and described as accurately as possible. Explain special assessment considerations for bilingual children, English language learners, and dialectal speakers. 21% of the U.S. school-age population speaks a language other than English at home. Any assessment of children with culturally and linguistically diverse backgrounds must recognize the relationship of the risk for LI and SES. Children from low-SES backgrounds with poorer maternal education have an increased incidence of LI. ELLs and children with dialectal differences are more likely to be identified as needing special education services. Diagnostic methods for children from culturally and linguistically diverse backgrounds vary widely, and no single measure is adequate. Diagnosis includes published tests, language samples, and dynamic assessments that are more open-ended and include descriptions of a child’s use of both English and the first language.

74. A 75. E 76. B 77. C 78.

What factors are important in target selection and sequence of training? The goal is the effective use of language to communicate within everyday interactions. The child’s abilities are an important determiner of the method selected. Training should be within meaningful communication contexts when possible.

79.

What are the basic tenets of good teaching behavior? Model the desired behavior Cue the client to respond Respond to the client in the form of reinforcement and/or corrective feedback Plan for generalization of the learned feature to the everyday environment

80. B

125 .

CHAPTER 5 SPEECH SOUND DISORDERS 1.

_______________ specify acceptable sequences and locations of speech sounds. a. Distinctive features b. Phonotactic rules c. Morphemes d. Phonological classes

Consonant phonemes are classified according to a. Place b. Manner c. Voicing d. All of the above

Name the places of articulation.

Name the manners of articulation.

What determines which vowel is actually produced?

__________________ is when two vowels are said in close proximity. a. A glide b. A liquid c. A diphthong d. An approximate

By ______________, infants are able to imitate tone and pitch and begin babbling. a. 2 months b. 3 months c. 4-6 months d. 7-8 months

At 6-7 months, babbling changes into _____________. a. Single words b. Variegated babbling c. Reduplicated babbling d. None of the above

Young children use _______________ to simplify a difficult word. a. Echolalia b. Phonological patterns c. Articulatory errors d. Sound-meaning relationships

126 .

10.

Toddlers may demonstrate the following error(s): a. Omission of final consonants b. Reduction of multisyllabic words c. Sound substitutions d. All of the above e. None of the above

11.

Most of the phonological patterns that toddlers use disappear by age a. 3 b. 4 c. 6 d. 7

12.

Children who experience phonological difficulties a. Discontinue the use of immature phonological patterns earlier than their peers b. Are always unintelligible c. Continue the use of phonological patterns d. Express more interest in literacy activities

13.

_______________________ are changes in pronunciation as a result of morphological changes. These take several years to master, extending into adulthood. a. Morphophonemic contrasts b. Morphological changes c. Morpheme units d. Morphological features

14.

By age ________, children have acquired consonant clusters. a. 5 b. 6 c. 7 d. 8

15.

A/an _____________ ends in a vowel, whereas a ______________ ends in a consonant.

16.

_________________ are disorders of how speech sounds are used in the language. a. Phonological disorders b. Articulation disorders c. Voice disorders d. Resonance disorders

17.

Name the four types of articulation errors.

18.

Seventy-five percent of children outgrow their speech sound errors by age ________. a. 5 b. 6 c. 8 d. 10

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19.

Speech-sound disorders can have a negative impact on a. Academics b. Professional relationships c. Personal relationships d. All of the above

20.

Speech _____________ over time for those who lose their hearing after learning to talk. a. Maintains b. Deteriorates c. Improves d. All of the above; it depends on the individual

21.

Name three types of sounds that are often difficult for children with cleft palate to produce.

22.

About 90% of children with __________________ have impaired speech production skills. a. Cerebral palsy b. Deafness c. Childhood apraxia of speech d. Cleft lip

23.

________________ is a neurological speech sound disorder that affects the ability to plan and/or program the movement sequences necessary for accurate speech production. a. Cerebral palsy b. Childhood apraxia of speech c. Language impairment d. Aphasia

24.

What are the speech characteristics of childhood apraxia of speech?

25.

Which of the following are good prognostic indicators for verbal communiction in CAS? a. Normal or near-normal cognition b. Good receptive language c. A & B d. None of the above

26.

The most readily apparent difficulties are _______________ for those who persist with motor programming difficulties. a. In monosyllabic words b. Substitution errors c. In consonant blends d. None of the above

27.

What is the overall goal of elective therapy for accent modification?

28.

In assessment of phonology and articulation, _________________ is appropriate for young children and for those whose speech is markedly unintelligible. a. A sound error inventory b. A speech sound inventory c. A phonological process analysis d. None of the above

29.

________ refers to how easy it is to understand the individual.

128 .

30.

In general, lack of consistency is a/an __________________ prognostic factor. a. Neutral b. Positive c. Negative d. Unimportant

31.

___________________ is the ability to produce the target phoneme when given focused auditory and visual cues. a. Consistency b. Focused stimulation c. Stimulability d. Echolalia

32.

______________ refers to the ability to perceive differences in another person’s speech, whereas _________ refers to the ability to judge one’s own ongoing speech.

33.

Factors in target selection for articulation and phonology include a. Phoneme frequency b. Likelihood of success c. A & B d. None of the above

34.

The following approaches are language-based approaches: a. Traditional motor approach b. Sensory-motor approach c. A&B d. None of the above

35.

__________________ is not appropriate for children who have severe speech delays and require more direct, structured speech practice. a. Language-based approaches b. Traditional motor approach c. Sensory-motor approach d. Cycles approach

36.

__________________ starts with the most stimulable phonological patterns and progresses through multiple times until all phonological processes have been addressed. a. Multiple oppositions approach b. Cycles approach c. Metaphon approach d. Complexity approach

37.

Discuss the theory behind the complexity approach.

38.

Describe Dynamic and Tactile Cueing, an evidence-based treatment for childhood apraxia of speech.

129 .

39.

_________________ is an intensive treatment originally designed to increase loudness in patients with Parkinson disease and is now used with various neurologically-based motor speech disorders. a. Dynamic Cueing b. Temporal Cueing c. Minimal pair contrasts d. Lee Silverman Voice Treatment

130 .

CHAPTER 5 – Answer key SPEECH SOUND DISORDERS 1. B 2. D

Name the places of articulation. Bilabial, labiodental, interdental, linguadental, alveolar, palatal, velar, glottal

Name the manners of articulation. Obstruents include stops, fricatives, and affricates Resonants include nasals and approximants Approximants include glides and liquids

What determines which vowel is actually produced? Which part of the tongue is elevated (front, center, back), its height (high, mid, low), and the amount of tension (tense, lax). Lip rounding or retraction can influence the sound.

6. C 7. C 8. C 9. B 10. D 11. B 12. C 13. A 14. D

15.

A/an ___open syllable___ ends in a vowel, whereas a ___closed syllable___ ends in a consonant.

16. A 17.

Name the four types of articulation errors. Substitutions, omissions, distortions, additions

18. B 19. D 20. B 21. High pressure consonants, fricatives, and affricates 22. A 23. B 24.

What are the speech characteristics of childhood apraxia of speech? Speech is often unintelligible, segmented/choppy, disfluent, or lacking in prosodic variation. Children may be aware that speech is difficult and are often unwilling to try to talk. May have inconsistent errors on consonants and vowels in repeated productions, lengthened and disrupted transitions between sounds and syllables, and inappropriate prosody. May have limited consonant and vowel repertoires, exhibit groping or trial and error behaviors, omit or inappropriately add sounds, and have difficulty with running speech. May have concomitant expressive language and phonological impairments.

25. C 26. D 27.

What is the overall goal of elective therapy for accent modification? Improve intelligibilty and communicative effectiveness. Articulatory patterns of a first language may be firmly established and difficult to eliminate.

28. B

131 .

29.

___Speech intelligibility_____ refers to how easy it is to understand the individual.

30. B 31. C 32.

__Interpersonal error sound discrimination___ refers to the ability to perceive differences in another person’s speech, whereas __intrapersonal error sound discrimination___ refers to the ability to judge one’s own ongoing speech.

33. C 34. D 35. A 36. B 37.

Discuss the theory behind the complexity approach. Training more difficult sounds leads to generalization of untreated, less complex sounds. Considered more efficient. It may take longer initially to train production of more complex targets. Success depends on severity, frustration level, and overall goal of therapy.

48. DTTC is an intensive, motor-based drill-type treatment for children with severe CAS. Treatment targets include a small number of functional words and phrases. Target words are practiced slowly and produced simultaneously with the clinician. Moves to direct imitation, delayed imitation, and spontaneous productions. The clinician may use tactile cues. The goal is to produce the word correctly spontaneously, both in and out of the clinic. 5-10 minutes of home practice daily with family members is recommended. 39. D

132 .

CHAPTER 6 DEVELOPMENTAL LITERACY IMPAIRMENTS 1.

__________________ is the use of visual modes of communication, specifically reading and writing. a. Literacy b. Composition c. Decoding d. Phonological awareness

What percentage of children with language impairments have difficulty in the area of literacy?

Decoding is a. Knowledge of sounds/syllables and the sound structure of words b. Segmenting a word and blending the sounds together to form a word c. The ability to manipulate sounds d. Active analysis and synthesis of information

______________________ skills are essential for decoding before age 10. a. Syntactical b. Morphological c. Phonological d. Semantic

Phonological awareness is a. Knowledge of sounds/syllables and the sound structure of words b. Segmenting a word and blending the sounds together to form a word c. The ability to manipulate sounds d. Active analysis and synthesis of information

Phonemic awareness is a. Knowledge of sounds/syllables and the sound structure of words b. Segmenting a word and blending the sounds together to form a word c. The ability to manipulate sounds d. Active analysis and synthesis of information

By about 10 years of age, awareness of and knowledge about which of the following is a better predictor of decoding ability? a. Morphological structure b. Ability to use context c. Phonological awareness d. Metacognition

Describe the levels of text comprehension.

__________________ is knowing what to do and how to do it. a. Critical literacy b. Dynamic literacy c. Comprehension d. Metacognition

10.

List skills involved in executive functioning.

133 .

11.

Dialogic reading is a. Reading a child’s book word-for-word b. An interactive method of reading picture books c. The most effective way to teach toddlers to read d. Not recommended until age 5

12.

Describe the process of print awareness.

13.

What are the best predictors of of kindergarten reading status?

14.

What is mature literacy?

15.

Risk of reading problems is greatest for children with a history of problems in a. Articulation b. Expressive/receptive language c. A&B d. None of the above

16.

Poor reading comprehenders have deficits in a. Oral language comprehension b. Phonological abilities c. A & B d. None of the above

17.

Describe the three types of specific learning disorder in literacy.

18.

Children with ________________ have poor comprehension but typical to above-average word recognition ability; can occur in some children with ASD a. Alexia b. Dysgraphia c. Hyperlexia d. Echolalia

19.

Why are many children with language impairments at risk for reading impairments?

20.

As adolescents, poor readers exhibit deficits in a. Vocabulary b. Grammar c. Verbal memory d. All of the above

21.

There is __________________ between children’s nonmainstream dialect use and reading achievement. a. A strong negative correlation b. No measurable correlation c. A slight positive correlation d. None of the above

22.

Reading assessment should include a. Standardized measures b. Oral language samples c. Written story retelling d. All of the above

134 .

23.

Name some informal forms of assessment for phonological awareness.

24.

In addition to phonological awareness, assessment of which of the following should be included in assessment of developmental reading? a. Word recognition b. Morphological awareness c. Text comprehension d. Executive function e. All of the above

25.

Name three guidelines for reading assessment that guide how evaluations should be conducted.

26.

How can executive functioning be assessed in regard to developmental reading?

27.

Describe the preliteracy skills of meaning foundation and form foundation.

28.

When should phonological awareness intervention begin? a. During the babbling phase b. In preschool or kindergarten c. Whenever a child shows interest in reading d. Not until the child is two grade levels behind their peers

29.

Goals for word recognition intervention are a. Teach decoding skills b. Develop a vocabulary of written words c. Improve reading comprehension d. All of the above

30.

Postreading activities for text comprehension might include a. Prediction activities b. Introduction of key vocabulary c. Decoding practice d. Story organizers

31.

Which of the following is used by more advanced readers? a. Whole-word recognition b. Distancing from the text c. Bridging inferences d. Looking up unknown vocabulary

32.

What are the four elements of the writing process?

33.

Approximately how many spelling words are explicitly taught in elementary school? a. 1,000 b. 4,000 c. 8,000 d. 10,000

34.

How does mature literacy differ from emerging literacy in terms of writing?

135 .

35.

Preliterate attempts at spelling are a. Scribbling with occasional letters b. Correct pencil grasp and formation of at least five letters c. Correctly spelling one’s name d. Not expected until kindergarten

36.

In what way(s) does/do adults spell? a. Letter-by-letter b. By sub-syllable unit c. A&B d. None of the above; it is a subconscious process

37.

When do writers develop the cognitive abilities needed for mature writing? a. In early adolescence b. By junior year of high school c. By early adulthood d. By middle age

38.

Children with LD may have difficulties with which of the following writing processes? a. Spelling b. Executive functioning c. Text generation d. All of the above

39.

What is the best method for assessing developmental writing in young elementary school children? a. Expository writing b. Narrative samples c. Spelling analysis d. None of the above

40.

What is the best method for assessing developmental writing in adolescents? a. Expository writing b. Narrative samples c. Spelling analysis d. None of the above

41. 42.

Describe the assessment possibilities for text generation. How should spelling words be chosen for intervention?

43.

Explain the pros and cons of teaching children to use spell checkers to aid spelling.

44.

Children with LD who receive training in _______________ along with word processing make greater gains in the quality of their writing. a. Decoding b. Phonological awareness c. Executive functioning d. Multisensory stimulation

45.

__________________ is the common event sequences and elements of a narrative. a. Story grammar b. Narration c. Brainstorming d. None of the above

46.

Describe four ways that narrative text generation can be facilitated in writing intervention.

47.

What are the six steps of Em-POWER, an intervention technique for writing?

136 .

CHAPTER 6 – Answer key DEVELOPMENTAL LITERACY IMPAIRMENTS 1. A 2. As many as 60% 3. C 4. A 5. C 6. B 7. A 8.

Describe the levels of text comprehension. At the basic level, the reader is primarily concerned with decoding. Meaning is actively constructed from words and sentences and from personal meaning and experiences. Critical literacy is active analysis and synthesis of information and an ability to explain content. Dynamic literacy is relating content to other knowledge through reasoning; comparing/contrasting, integrating, and using ideas for raising problems and solving them.

9. D

10.

Explain what executive functioning is. Self-regulation that includes the ability to attend; set reasonable goals; to plan and organize to achieve goals; to initiate, monitor, and evaluate performance in relation to goals; and to revise plans and strategies based on feedback

11. B 12.

Describe the process of print awareness. Early on, it consists of knowledge of the meaning and function of print, basic concepts concerning the direction print proceeds across a page and through a book, and recognition of some letters. Begins to develop around age 3. Later, it includes recognizing words as discrete units, being able to identify letters, and using terminology such as letter, word, and sentence.

13.

What are the best predictors of kindergarten reading status? Oral language, alphabet knowledge, and print concept knowledge.

14.

What is mature literacy? Mature readers use very little cognitive energy determining word pronunciation. Language and experience are used to understand the text, which is monitored to ensure the information makes sense. Prediction of the next word or phrase aids quick processing. Reading is interactive and one of the ways adults increase vocabulary and knowledge.

15. C 16. A 17. Describe the three types of specific learning disorder in literacy. A language-based disorder that may affect comprehension and/or speech sound discrimination A speech/motor disorder that may affect speech sound blending and motor coordination Visuospatial disorder that may affect letter form discrimination The language based disorder is the most common 18. C

137 .

19.

Why are many children with language impairments at risk for reading impairments? In general, they begin with less language and have difficulty catching up. Have poor comprehension skills because they lack language knowledge that would enable them to integrate what they read. Have poor metalinguistic skills. Possess linguistic processing difficulties.

20. D 21. A 22. D 23.

Name some informal forms of assessment for phonological awareness. Address rhyming, syllabication, segmentation, phoneme isolation, deletion, substitution, and blending

24. E 25. Three of the following: Materials should be age and developmentally appropriate; tasks should be of various types to assess different levels of processing; several measures should be used; cultural and linguistic background must be considered; unfamiliar tasks need to be demonstrated and trained; reading deficits are not limited to children with emergent literacy skills; observation and interpretation of test behaviors is important. 26.

How can executive functioning be assessed in regard to developmental reading? Self-regulation in reading can be assessed by: Interview questions about different strategies used for different reading tasks Think-alouds or verbalizing thoughts accompanying reading Error or inconsistency detection while reading

27.

Describe the two-prong intervention model for developmental reading impairment. Meaning foundation refers to vocabulary and sentence-level skills, whereas form foundation refers to learning about the alphabet and becoming aware of phonological units within spoken words.

28. B 29. D 30. D 31. B 32.

What are the four elements of the writing process? Spelling Executive function Text construction (going from ideas to writing) Memory

33. B 34.

How does mature literacy differ from emerging literacy in terms of writing? For some mature writers, speaking and writing become consciously separate. The writing of adults contains longer, more complex sentences and uses more abstract nouns and more metalinguistic words.

35. A 36. C 37. C 38. D 39. B 40. A 41.

Writing analysis can include total number of words and number of different words used. Other measures include word choice, clause and sentence length, and coherence.

138 .

42.

How should spelling words be chosen for intervention? Words selected for intervention should be individualized and reflect the curriculum, the child’s desires, words attempted but in error, and error patterns

43.

Explain the pros and cons of teaching children to use spell checkers to aid spelling. Spell checkers help less for children with LD than for children developing typically. If children with literacy impairments are taught to spell phonetically when unsure of the correct spelling, spell checkers generate more correct suggestions.

44. C 45. A 46.

Four of the following: Writing can be guided through brainstorming, story guides, prompts, acronyms, and story maps, as well as explicit instruction in story grammar or structure.

47.

What are the six steps of Em-POWER, an intervention technique for writing? Treats writing as a problem-solving task involving six steps: Evaluate, Make a Plan, Organize, Work, Evaluate, and Rework

139 .

CHAPTER 7 ADULT LANGUAGE IMPAIRMENTS 1.

Describe how language use changes through adulthood.

Describe how language content changes through adulthood.

Describe how language form changes through adulthood.

The ________________ is the basic unit of the nervous system. a. Dendrite b. Cell c. Glioma d. Neuron

What are the three main parts of a neuron?

A nerve is a. A collection of neurons b. Another name for a neuron c. Only found in the brain d. All of the above

The space across which electrochemical impulses pass between neurons is the a. Dendrite b. Axon c. Synapse d. Cleft

The brain consists of the a. Cerebrum b. Cerebellum c. Brain stem d. All of the above

The sensory and motor functions of the cerebrum are mostly a. Unilateral b. Bilateral c. Contralateral d. Mulitlateral

10.

The wrinkled appearance of the cerebral cortex is due to hills and valleys called a. Gyri and fissures b. Gray matter and white matter c. Hemispheres and vermis d. None of the above

11.

What are the four lobes of the brain?

12.

The functions of the cerebellum include a. Control of fine, complex motor activities b. Maintaining muscle tone c. Participation in language processing and higher cognitive activities d. All of the above

140 .

13.

In most individuals, linguistic information is processed a. In the right hemisphere b. In the left hemisphere c. Bilaterally d. In the frontal lobes

14.

Nonlinguistic and paralinguistic information are processed primarily a. In the right hemisphere b. In the left hemisphere c. Bilaterally d. In the frontal lobes

15.

Incoming auditory information is held in working memory in ______________ in the frontal lobe while it is processed. a. Wernicke’s area b. Broca’s area c. The hippocampus d. The supplementary motor area

16.

Most incoming linguistic processing occurs in __________________ in the left temporal lobe, assisted by the angular gyrus for words and the supramarginal gyrus for grammar. a. Wernicke’s area b. Broca’s area c. The hippocampus d. The central sulcus

17.

Broca’s area sends programming information to the ___________________, which sends signals to the motor neurons for speech. a. Pontine angle b. Thalamus c. Motor cortex d. Basal ganglia

18.

The aphasic population is extremely diverse, but which characteristics are common to all aphasias? a. Deficits in naming and fluency b. Difficulty in auditory comprehension and word retrieval c. Difficulty with reading and writing d. All of the above

19.

Severity of aphasia is related to a. Cause, extent, location, and age of brain injury b. Age of the client c. General health of the client d. All of the above

20.

Name five concomitant or accompanying deficits associated with aphasia and provide definitions.

21.

Name the types of fluent aphasia

22.

Individuals who have fluent, sometimes incoherent speech and speak in a rapid-fire manner with few pauses and opportunity for turn taking most likely have which type of aphasia? a. Wernicke’s b. Anomic c. Conduction d. Transcortical sensory

141 .

23.

Individuals who have fluent, relatively preserved language abilities aside from word retrieval most likely have which type of aphasia? a. Wernicke’s b. Anomic c. Transcortical sensory d. Subcortical

24.

Individuals who have fluent, abundant, and quick conversations filled with paraphasia most likely have which type of aphasia? a. Wernicke’s b. Conduction c. Transcortical sensory d. Subcortical

25.

Individuals who have fluent conversation filled with word errors most likely have which type of aphasia? a. Conduction b. Anomic c. Transcortical sensory d. Subcortical

26.

Name the types of nonfluent aphasia.

27.

Individuals who speak in short sentences with agrammatism, have labored speech and writing, and demonstrate articulation and phonological errors most likely have which type of aphasia? a. Broca’s b. Transcortical motor c. Global/Mixed d. Crossed aphasia

28.

Individuals who demonstrate difficulty initiating speech or writing and severely impaired speech most likely have which type of aphasia? a. Broca’s b. Transcortical motor c. Global/mixed d. Crossed aphasia

29.

Individuals who have profound language impairments in all modalities most likely have which type of aphasia? a. Broca’s b. Transcortical motor c. Global/mixed d. Crossed aphasia

30.

The most common cause of aphasia is a. Stroke b. Heart attack c. Traumatic brain injury d. Anoxia

31.

As a result of stroke _______________ people become aphasic each year. a. 10,000 b. 50,000 c. 100,000 d. 500,000

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32.

Name and describe the types/factors related to ischemic stroke.

33.

Name and describe the types/factors related to hemorrhagic stroke.

34.

How do the patterns of recovery vary with the type of stroke?

35.

_________________________ is a degenerative disorder of language with preservation of other mental functions and of activities of daily living. a. Neural infection b. Primary progressive aphasia c. Mild cognitive impairment d. Amyotrophic lateral sclerosis

36.

Factors that increase the risk of stroke include a. Smoking b. Poor diet c. Lack of exercise d. All of the above

37.

After acute care, an individual who has a stroke may require a. Rehabilitative hospitalization b. Outpatient rehabilitation c. Nursing home care d. All of the above

38.

The most frequent linguistic gains after stroke are in a. Syntax b. Auditory comprehension c. Lexical retrieval d. Repetition

39.

Maximum spontaneous recovery after stroke occurs a. In the first 3 months b. In the first 6 months c. In the first 3 weeks d. In the first month

40.

When do assessment and intervention begin after stroke? a. As soon as the individual enters the rehabilitation hospital b. Not until neuroimaging is complete c. As soon as the client’s condition permits d. When the client can verbalize that he/she wants therapy and can state their needs

41.

Formal testing for aphasia is usually a. Postponed until the client is stable b. Conducted weekly to determine change c. Is not necessary d. Conducted as soon as the client is alert

42.

What is the overall goal of treatment for aphasia?

143 .

43.

Using gestures and pantomime might have a positive effect on a. Syntactical structure b. Noun retrieval c. Social interaction d. Auditory comprehension

44.

Evidence-based practice in aphasia shows that a. Cross-modality generalization is most effective b. “Bridging” is most effective c. Conversational techniques are most effective d. We cannot definitively say which interventions methods are best

45.

_________________ of individuals with right hemisphere brain damage exhibit one or more communication impairments, but many do not receive treatment. a. 10-15% b. 25-47% c. 50-78% d. None of the above

46.

Name the common characteristics of RHBD.

47.

The right hemisphere is important for activation of __________________________. a. Distant word and sentence meanings b. Visual comprehension c. Phonological information d. All of the above

48.

Affected areas of pragmatics in individuals with RHBD include a. Topic maintenance b. Appreciation of the communication situation c. Determination of listener needs d. All of the above

49.

Paralinguistic deficits include difficulty comprehending and producing a. Narratives b. Emotional language c. Topics of conversation d. All of the above

50.

___________________ is the reduced ability or inability to produce or comprehend affective aspects of language. a. Prosopagnosia b. Anosognosia c. Aprosodia d. Voice immodulation disorder

51.

Which procedures may be used in assessment with individuals with RHBD? a. Portions of aphasia batteries b. Interviewing c. Observations d. All of the above

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52.

For ___________________, clients may imitate a sentence in unison with the SLP, or use cognitivelinguistic treatment in which cues are used to modify this domain. a. Expressive aprosodia b. Receptive aprosodia c. A & B d. None of the above

53.

For interpretation of ______________________, a semantic intervention approach may be used where word meaning and connotations are mapped and diagrammed. a. Receptive aprosodia b. Figurative language c. Tangentiality d. Complex syntax

54.

Intervention for activating meanings and for suppression of noncontextual ones can be accomplished through ________________________, where a client is given sentences to activate different meanings prior to being given a word. a. time constraints b. sequencing c. contextual pre-stimulation d. None of the above

55.

___________________ is a disruption in normal functioning caused by a blow or jolt to the had or a penetrating injury. a. Traumatic brain injury b. Stroke c. Edema d. Meningitis

56.

Annually, _______________ people sustain TBI in the U.S. a. 500,000 b. 750,000 c. 900,000 d. 1.5 million

57.

Explain the following terms: edema, hypoxia, infarction, and hematoma.

58.

TBI may affect a. Orientation b. Memory c. Executive function d. All of the above

59.

Language may be affected in __________ of individuals with TBI. a. 25% b. 50% c. 75% d. 100%

60.

What are the two most commonly reported language symptoms in TBI?

61.

What is the most disturbed language area in TBI? Describe the related deficits.

145 .

62.

Approximately 1/3 of individuals with TBI demonstrate a. Dysthymia b. Dyslexia c. Dysgraphia d. Dysarthria

63.

Describe lifespan issues related to TBI recovery from injury to later stages of recovery.

64.

Discuss assessment considerations in TBI.

65.

Those with TBI recover in a ______________ fashion.

66.

Describe cognitive rehabilitation and its two approaches.

67.

The late stages of recovery from TBI include a. Sensorimotor stimulation b. A focus on orientation c. Reducing confusion d. None of the above

68.

Fewer than _____________ of the elderly experience cognitive impairment. a. 1% b. 3% c. 10% d. 15%

69.

_________________ is an umbrella term for a group of both pathological conditions and syndromes that result in declining of memory and at least one other cognitive ability that is significant enough to interfere with daily life activities. a. Aphasia b. TBI c. Cognitive impairment d. Dysarthria

70.

____________________ include Alzeheimer’s and Pick’s diseases and resemble those of focal impairments such as aphasia and RHBD, including visuospatial deficits, memory problems, judgment and abstract thinking disturbances, and language deficits in naming, reading and writing, and auditory comprehension. a. Cortical cognitive impairments b. Subcortical cognitive impairments c. Focal cognitive impairments d. Diffuse cognitive impairments

71.

Communication disorders associated with cognitive impairment progress over time and include a. Anomia b. Comprehension deficits c. The eventual inability to express oneself via speech and language d. All of the above

72.

What are the lifespan issues associated with Alzheimer’s disease?

73.

What is the SLP’s role in assessment of cognitive impairment?

74.

What is the focus of intervention for communication in cognitive impairment?

75. How are cognitive training and cognitive stimulation as used in management of cognitive impairment different?

146 .

CHAPTER 7– Answer key ADULT LANGUAGE IMPAIRMENTS 1.

Describe how language use changes through adulthood. Adults are effective communicators and skilled conversationalists who use a variety of styles. Competent communicators sense their role and adjust language and speech accordingly. The number of communicative intentions increases gradually. Changes in writing and reading abilities are not dramatic. Narratives improve into middle age and senior years, decreasing after the late seventies.

Describe how language content changes through adulthood. Adults use between 30,000 and 60,000 words expressively. Specialized vocabularies develop for various aspects of life. Some words fade from the language and new words are added. Multiple definitions and figurative meanings are expanded. Seniors experience some deficits in accuracy and speed of word retrieval and naming.

Describe how language form changes through adulthood. Adults continue to acquire prefixes, morphophonemic contrasts, and some irregular verbs. Conversations become more cohesive through more effective use of linguistic devices. In general, written language is more complex than spoken language. Complex sentence production declines with advanced age, related to word retrieval. Decline in oral/written language comprehension, understanding complex syntax, and inferencing.

4. D

What are the three main parts of a neuron? Cell body, axon, dendrite

6. A 7. C 8. D 9. D 10. A 11.

What are the four lobes of the brain? Frontal, temporal, parietal, and occipital

12. D 13. B 14. A 15. B 16. A 17. C 18. B 19. D

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20.

Name five concomitant or accompanying deficits associated with aphasia and provide definitions. Hemiparesis: Weakness on one side of the body Hemiplegia: Paralysis on one side of the body Hemisensory impairment: A loss of the ability to perceive sensory information on one side of the body Hemianopsia: Blindness in the visual field of each eye contralateral to the site of a deep lesion Dysphagia: Difficulty chewing or swallowing Agnosia: Difficulty understanding incoming sensory information Agrammatism: Omission of grammatical elements Agraphia: Difficulty writing Alexia: Reading problems Anomia: Difficulty naming Jargon: Meaningless or irrelevant speech with typical intonational patterns Neologism: A novel word Paraphasia: Word substitutions found in clients who may talk fluently and grammatically Verbal stereotype: An expression repeated over and over

21.

Name the types of fluent aphasia Wernicke’s, anomic, conduction, transcortical sensory

22. A 23. B 24. B 25. C 26.

Name the types of nonfluent aphasia. Broca’s, transcortical motor, global/mixed

27. A 28. B 29. C 30. A 31. C

32.

Name and describe the types/factors related to ischemic stroke. Cerebral arteriosclerosis: Thickening of the walls of the cerebral arteries in which elasticity is lost or reduced, the walls become weakened, and blood flow is restricted. Embolism: Obstructed blood flow caused by blood clot, fatty materials, or air bubble Thrombosis: Plaque buildup or blood clot formed on site and does not travel, causing blood flow to be restricted Transient ischemic attack: Temporary condition with symptoms mirroring a stroke; blood flow to a portion of the brain is blocked or reduced, but then returns after a short interval.

33.

Name and describe the types/factors related to hemorrhagic stroke. Aneurysm: A saclike bulging in a weakened artery wall Arteriovenous malformation: Poorly formed tangle of arteries and veins; malformed arterial walls may be weak and give way under pressure.

34.

How do the patterns of recovery vary with the type of stroke? Ischemic: Noticeable improvement with the first weeks, but slows after 3 months Hemorrhagic: Most rapid recovery is at the end of the first month and into the second.

35. B 36. D 37. D 38. B 39. A 40. C

148 .

41. A 42.

What is the overall goal of treatment for aphasia? To aid in the recovery of language and to provide strategies to compensate for persistent language deficits.

43. B 44. D 45. C 46.

Name the common characteristics of RHBD. Neglect of information from the left side Unrealistic denial of illness or limb involvement Impaired judgment and self-monitoring Lack of motivation Inattention

47. A 48. D 49. B 50. C 51. D 52. A 53. B 54. C 55. A 56. D 57. Explain the following terms: edema, hypoxia, infarction, and hematoma. Edema: Swelling due to increased fluid. Can lead to increased intracranial pressure. Hypoxia: Oxygen deprivation. Infarction: Death of tissue deprived of oxygen supply. Hematoma: Focal bleeding. 58. D 59. C

60.

What are the two most commonly reported language symptoms in TBI? Anomia and impaired comprehension

61.

What is the most disturbed language area in TBI? Describe the related deficits. Pragmatics is the most disturbed language area in TBI. They may have an inability to inhibit behavior, demonstrate errors of judgment, have rambling/incoherent speech, poor turn-taking skills, poor affective language abilities, and inappropriate laughter or swearing.

62. D

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63.

Describe lifespan issues related to TBI recovery from injury to later stages of recovery. Most adults with TBI are young and have experienced an auto or motorcycle accident. Several stages of recovery exist and clinical intervention varies with each. Most individuals will not reach full recovery. Initially, the individual may be nonresponsive and need total assistance in a hospital. Gradually, the individual may be nonresponsive and need total assistance in a hospital. Gradually, the individual begins to respond to stimuli and recognize familiar individuals. As the client becomes more alert, he or she may be confused or agitated. The individual may have incoherent, inappropriate, or emotional language. Later, the individual can remain alert for short periods of time and hold brief conversations. The individual becomes oriented to person and place, although time is still problematic. They can be socially inappropriate, uncooperative, unrealistic in their expectations, and unaware of the needs and feelings of others. Frustration may build with greater understanding of their condition and limitations. In the later stages of recovery, the individual can initiate and carry out familiar tasks. Finally, the individual may be able to consistently act in a socially appropriate manner, respond appropriately to others, and to plan, initiate, and complete familiar/unfamiliar tasks. Periodic depression may occur and irritability may reappear at times. Most will have some lingering deficits, especially in pragmatics.

64.

Discuss assessment considerations in TBI. The SLP assesses communication, cognitive-communication functioning, and swallowing. Assessment must be ongoing and varies with each stage. Few comprehensive tools exist for assessment of language skills in individuals with TBI. Sampling is essential because pragmatic behavior varies across communication contexts. 65.

Those with TBI recover in a ____plateau__________ fashion.

66.

Describe cognitive rehabilitation and its two approaches. Cognitive rehabilitation increases functional abilities by improving processing capacity. Restorative approach: Rebuild neural circuitry and function through repetitive activities. Compensatory approach: Develop alternatives for functions that will not be recovered.

67. D 68. D 69. C 70. A 71. D 72.

What are the lifespan issues associated with Alzheimer’s disease? Often the person who will be afflicted with AD is unaware and/or ignores early signs. At present, there are no cures, but some early drug therapies seem to lessen the effects. In the early stages, the individual experiences memory loss. As the disease progresses, memory loss increases and vocabulary decreases. In the most advanced stages, all intellectual functions including memory are severely impaired and almost all individuals reside in nursing homes.

73.

What is the SLP’s role in assessment of cognitive impairment? SLPs usually identify changes in language performance that may signal intellectual deterioration and aspects of behavior amenable to change.

74.

What is the focus of intervention for communication in cognitive impairment? Intervention can help maintain the client at his or her highest level of performance and help others maximize the client’s participation in conversation. Emphasize the use of intact cognitive abilities to compensate for deficient ones.

75. How are cognitive training and cognitive stimulation as used in management of cognitive impairment different? Cognitive training can be used to improve specific cognitive functions, such as attention, memory, and executive functions. Cognitive stimulation is less direct and is usually conducted in groups; it can be used to enhance cognitive and social functioning and might involve relaxation exercises or music therapy.

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CHAPTER 8 FLUENCY DISORDERS 1.

The lifetime incidence of stuttering is as high as a. 8% b. 12% c. 20% d. 25%

Describe and give examples of normal disfluencies.

Describe and give examples of stuttering disfluencies.

Which of the following are secondary characteristics that can accompany speech disfluencies? a. Eye blinking b. Facial grimacing c. Exaggerated movements of the head, shoulders, and arms d. All of the above

_____________________ is the most common form of stuttering; it begins in the preschool years. a. Psychogenic stuttering b. Developmental stuttering c. Acquired stuttering d. None of the above

______________________ is typically associated with neurological disease or trauma. a. Psychogenic stuttering b. Developmental stuttering c. Neurogenic stuttering d. Acquired stuttering

Developmental stuttering usually occurs on ____________ words, whereas they occur on ____ ________ words in neurogenic stuttering.

Onset of developmental stuttering is between what ages? a. 1-3 b. 2-5 c. 6-10 d. 8-15

In the younger preschool age group of the developmental framework of stuttering, which of the following is true? a. Most children are unaware or are not bothered by disfluencies b. Stuttering is essentially chronic or habitual c. There is evidence of fear, embarrassment, or avoidance d. Stuttered words may have associated audible vocal tension and rising pitch.

10.

In the older teens and adults age group of the developmental framework of stuttering, which of the following is true? a. Most children are unaware or are not bothered by disfluencies b. Stuttering is essentially chronic or habitual c. There is evidence of fear, embarrassment, or avoidance d. The person has developed a self-concept as a person who stutters

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11.

The ___________________ theory of stuttering proposes an actual physical cause for stuttering. a. Behavioral b. Psychological c. Organic d. Somatogenic

12.

The __________________ theory of stuttering asserts that stuttering is a learned response to conditions external to the individual. a. Behavioral b. Psychological c. Organic d. Somatogenic

13.

The ___________________ theory of stuttering contends that stuttering is a neurotic symptom. a. Behavioral b. Psychological c. Organic d. Somatogenic

14.

Name and explain three of the current conceptual models of stuttering.

15.

More than 10 disfluencies per ______________ spoken words may indicate that the child has a fluency problem. a. 15 b. 50 c. 100 d. 200

16.

17.

Standardized tests a. Exist but are not effective for assessment of stuttering b. May be used c. Do not exist d. Are normed only for children ages 3-18

18.

Describe indirect approaches for stuttering therapy and the target population.

19.

If stuttering does not decrease within __________________ after initiating indirect treatment for stuttering, direct treatment may be recommended. a. 2 weeks b. 6 weeks c. 10 weeks d. 3 months

20.

Describe direct approaches for stuttering therapy and the target population.

Name three indicators that are generally associated with the natural recovery of stuttering without treatment.

152 .

21.

___________________ is a fluency shaping technique that aims to reduce speech rate; the slowing of speech rate is accompanied by a substantial decrease in stuttering. a. Light articulatory contacts b. Prolonged speech c. Pausing/phrasing d. Response-contingent stimulation

22.

___________________ is a fluency shaping technique that lengthens naturally occurring pauses and adds pauses. a. Light articulatory contacts b. Prolonged speech c. Pausing/phrasing d. Response-contingent stimulation

23.

_________________ is a fluency shaping technique that reduces speech rate and physical tension before and during occurrences of stuttering, promoting smooth speech. a. Prolonged speech b. Light articulatory contacts c. Pausing/phrasing d. Response contingent stimulation

24.

_________________ is a fluency shaping technique that requires pausing briefly after stuttering. a. Prolonged speech b. Response contingent stimulation c. Pausing/phrasing d. Light articulatory contacts

25.

Describe the Lidcombe program for stuttering treatment.

26.

In ____________________, the individual modifies the stuttered word during the actual occurrence of stuttering. a. Cancellation phase b. Pull-out phase c. Preparatory sets d. None of the above

27.

In ___________________, the individual prepares to use fluency producing strategies before attempting the word. a. Cancellation phase b. Pull-out phase c. Preparatory sets d. None of the above

28.

In __________________, the individual completes the stuttered word and then pauses deliberately for a minimum of 3 seconds. a. Cancellation phase b. Pull-out phase c. Preparatory sets d. None of the above

29.

Selection of intervention techniques depends on a. Severity b. Motivation c. Specific needs of the client d. All of the above

153 .

30.

What is the efficacy of stuttering intervention with preschool-age children?

31.

Stuttering intervention across all age groups results in an average improvement for about ___________ of all cases, with preschool-age children improving more quickly and easily than people who have a longer history with stuttering. a. 30% b. 50% c. 70% d. 90%

32.

Describe the effect of stuttering on an individual in the workplace.

154 .

CHAPTER 8 - Answers FLUENCY DISORDERS 1.

Describe and give examples of normal disfluencies. At age 2, whole-word repetitions, interjections, and syllable repetitions are common. Revisions are the dominant disfluency type when the child reaches 3 years. Normal disfluencies persist throughout the course of one’s life. Fluent speakers may repeat whole multisyllabic words, interject a word or phrase, repeat phrases, or revise sentences.

Describe and give examples of stuttering disfluencies. Stuttering or stuttered speech involves certain core behaviors, including repetitions of sounds, syllables, or one-syllable words, prolongations of sounds, or blocks, where an inappropriate stop in the flow of air or voice occurs during speech production.

4. D 5. B 6. C

Developmental stuttering usually occurs on ___content_________ words, whereas they occur on ____function________ words in neurogenic stuttering.

8. B 9. A 10 D

11. C 12. A 13. B 14.

Name and explain three of the current conceptual models of stuttering. Covert repair hypothesis: stuttering is a reaction to a flaw in the speech production plan. Poorly developed phonological encoding skills cause errors in the speech production plan. Stuttering is a “normal” repair reaction to an abnormal phonetic plan. Demands and capacities model: Stuttering develops when the demands to produce fluent speech exceed the child’s physical and learned capacities. Fluency depends on motor skills, language production, maturity, and cognitive development. Children who stutter presumably lack one or more of these capacities. The Packman and Attanasio 3-factor model suggest that there are three factors that cause moments of stuttering: a deficit in the neural processing of language and inherent instability of the speech production system; triggers, or certain features of spoken language that are associated with greater speech motor demands that negatively affect an already unstable speech production system; and modulating factors, such as physiological arousal in an individual that can alter the threshold at which a stuttering moment occurs.

15. C 16. Name three indicators that are generally associated with the natural recovery of stuttering without treatment. Three of the following: Decrease in stuttering behaviors during the 12 months after the initial onset; the child is female; no family history of stuttering or relatives who stuttered have fully recovered; receptive and expressive language and phonological skills are typical for the child’s age; cognitive abilities are within the typical range for the child’s age; the child has an outgoing, carefree personality and is therefore less sensitive to potential stressors in his/her environment. 17. B

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18.

Describe indirect approaches for stuttering therapy and the target population. Focus on the child, the child’s parents, and the child’s environment. The SLP shares information and teaches parents to provide a slow, relaxed speech model for the child. Play-oriented activities that encourage slow and relaxed speech are a central component. There is no explicit discussion about the child’s fluent or stuttering speaking behaviors. The goal is to facilitate fluency through environmental manipulation and is often effective for younger preschool children over a period of 1-2 months.

19. B 20.

Describe direct approaches for stuttering therapy and the target population. Involve explicit and direct attempts to modify the child’s speech and speech-related behaviors. Children are taught to identify “hard” and “easy” speech produce by the SLP first, and then in their own speech. Then the SLP teaches strategies to increase easy speech and change from hard to easy speech when required.

21. B 22. C 23. B 24. B

25.

Describe the Lidcombe program for stuttering treatment. The Lidcombe program can reduce stuttering to zero or near-zero levels in children younger than age 6. It involves parent-administered verbal contingencies for stutter-free speech and stuttering, as well as requests for self-correction. Verbal contingencies are first administered daily during structured play, then during unstructured interactions. Weekly visits with the SLP involve direct measurement of stuttering and ensures the program is implemented correctly by the parent. Parents provide a weekly stuttering rating.

26. B 27. C 28. A 29. D 30. What is the efficacy of stuttering intervention with preschool-age children? Indirect and direct treatment approaches have both been found to be effective, and might be more effective when combined. Those in a parent-conducted program maintained their fluent speech in long-term clinical follow-up studies. 31. C 32.

Describe the effect of stuttering on an individual in the workplace. Stuttering can have a negative impact in the workplace, and is a vocationally disabling condition because employers view it as a disorder that decreases employability and opportunities for promotion.

156 .

CHAPTER 9 VOICE AND RESONANCE DISORDERS 1.

____________________ is the quality of the voice that is produced from sound vibrations in the pharyngeal, oral, and nasal cavities. a. Prosody b. Resonance c. Frequency d. None of the above

Velopharyngeal dysfunction is failure of the velopharyngeal mechanism to separate the ___________ and ______________ cavities during speech and swallowing. a. Oral, nasal b. Oral, pharyngeal c. Pharyngeal, laryngeal d. Laryngeal, oral

___________________ is the perceptual correlate of fundamental frequency associated with the rate of vocal fold vibration. a. Resonance b. Vocal pitch c. Vocal loudness d. Decibels

_________________ is the perceptual correlate of intensity. a. Resonance b. Vocal pitch c. Vocal loudness d. Decibels

Vocal pitch is measured in __________, whereas vocal loudness is measured in _________.

Fundamental frequency for men is around ______, women are around ______, and children can be up to _______.

________________ is a result of not varying habitual speaking frequency. a. Strained vocal quality b. Harshness c. Monopitch voice d. Monotone voice

Modifications in the length and ____________ of the vocal folds are necessary to produce pitch change. a. Tension b. Width c. Height d. All of the above

157 .

The loudness of conversational speech is around __________. a. 30 dB b. 45 dB c. 60 dB d. 100 dB

10.

For voice disorders, deviations may be in which of the following? a. Quality b. Pitch c. Loudness d. None of the above e. All of the above

11.

Voice disorders in children are usually related to ____________________ and are typically temporary. a. Genetic factors b. Trauma to the neck area c. Vocal misuse/abuse d. Illnesses such as the cold and flu

12.

Describe vocal nodules, the affected population, the effects on the voice, and treatment.

13.

______________________ are reddened ulcerations on the posterior surface of the vocal folds in the region of the arytenoid cartilages. a. Vocal nodules b. Vocal polyps c. Contact ulcers d. Pedunculated polyps

14.

_____________________ are fluid filled lesions that develop when blood vessels rupture and swell. a. Vocal polyps b. Vocal nodules c. Contact ulcers d. None of the above

15.

Compare and contrast acute and chronic laryngitis.

16.

Voice symptoms of Parkinson disease include a. Monopitch b. Monoloudness c. Breathiness d. All of the above

17.

Unilateral or bilateral vocal fold paralysis is caused by damage to the recurrent branch of a. CN V b. CN VII c. CN VIII d. CN X

158 .

18.

Voice therapy after surgery for vocal fold paralysis is aimed at a. Increasing vocal fold closure and loudness b. Decreasing vocal fold closure and loudness c. Increasing vocal fold closure and decreasing loudness d. Decreasing vocal fold closure and decreasing loudness

19.

_____________________ is the preferred treatment for neurological or idiopathic spasmodic dysphonia. a. Surgery b. Injection of Botox c. Vocal fold prosthesis d. Collagen injection

20.

The vocal characteristics of congenital laryngeal webbing include a. High pitch b. Hoarseness c. A & B d. None of the above

21.

Discuss three alternative methods of producing voice after removal of the larynx due to laryngeal cancer.

22.

_________________ are voice disorders that result from emotional suppression. a. Spastic dysarthrias b. Chronic laryngitis c. Conversion disorders d. None of the above

23.

A ________________ is an abnormal opening in an anatomical structure caused by a failure of the structures to fuse or merge correctly early in embryonic development. a. Cleft b. Granuloma c. Glottis d. Nasal emission

24.

_______________________ occurs when the velopharyngeal mechanism fails to decouple the oral and nasal cavities. a. Hyponasality b. Glottal stopping c. Hypernasality d. None of the above

25.

_________________ can occur when there is a blockage somewhere in the nasopharynx or nasal cavity, causing an insufficient amount of nasal resonance. a. Hypernasality b. Hyponasality c. Nasal emission d. None of the above

159 .

26.

A __________________ is a lens and light source that can be used to view the laryngeal structures. a. Fluoroscope b. Nasometer c. Laryngometer d. None of the above

27.

What information does the SLP gather for the case history of a voice evaluation?

28.

The perceptual portion of the voice evaluation examines a. Pitch b. Loudness c. Voice characteristics d. All of the above

29.

______________________ is a motion picture X-ray recorded on DVD, which permits the imaging of velopharyngeal function from three different perspectives. a. Multi-view videofluoroscopy b. Nasometer c. Endoscope d. None of the above

30.

________________ is recommended for voice disorders associated with benign structural abnormalities that result from and are maintained by vocal misuse or abuse. a. Voice therapy b. Permanent vocal rest c. Collagen injections d. Surgical removal

31.

When direct intervention is recommended for voice disorders, what is the goal of therapy?

32.

Why is psychiatric referral often not needed for voice disorders associated with psychological or stress conditions?

33.

In addition to raising vocal pitch in males transitioning to female or lowering pitch in females transitioning to males, which of the following is/are additional therapeutic technique(s) in the transgender population? a. Training males transitioning to female to place their tongue more anteriorly when speaking b. Training females transitioning to male to use a more breathy voice quality c. Training males transitioning to female to increase vocal intensity d. All of the above

34.

Children born with cleft palate often undergo surgical closure of the cleft around what age? a. 3-6 months b. 6-9 months c. 9-12 months d. 12-18 months

35.

Surgical repair of a cleft lip occurs a. Before 3 months of age b. Around 6 months c. Around 9 months d. After 12 months

160 .

36.

Describe three types of prosthetics used in management of resonance disorders.

37.

________________ is a method that can be used to strengthen the muscles of the velum in cases of mild hypernasality following surgical repair of a cleft palate. a. Electropalatography (EPG) b. Continuous positive airway pressure (CPAP) c. A & B d. None of the above

38.

Children with VPD may also have disorders of _________________, for which intervention should begin as soon as possible. a. Pragmatics b. Syntax c. Articulation d. Morphology

39.

For voice disorders associated with misuse/abuse, some neurological disorders, and psychological or stress conditions, voice treatment has been shown to be _______________. a. Ineffective b. Mildly effective c. Reasonably effective d. Highly effective

40. ________________________ refers to age-related changes in the larynx that can lead to perceptual changes in pitch, pitch range, loudness, and voice quality in older adults. a. Puberphonia b. Mutational falsetto c. Spasmodic Dysphonia d. Presbyphonia

41.

Name the structures of the velopharyngeal mechanism.

42.

Which percentage of adults in the U.S. have a voice disorder? a. 1-2% b. 3-9% c. 10-14% d. 15-25%

43.

At what point is a voice disorder said to exist?

44.

Which professionals (at a minimum) are required to conduct a voice evaluation?

45. During a resonance evaluation, a _________________ can be used to measure the relative amplitude of acoustic energy being emitted via the nose and mouth during phonation. a. Nasograph b. Nasendoscopy procedure c. Nasometer d. Videofluoroscope

161 .

CHAPTER 9 – Answer key VOICE AND RESONANCE DISORDERS 1. B 2. A 3. B 4. C 5.

Vocal pitch is measured in ___hertz_______, whereas vocal loudness is measured in ____decibels___.

Fundamental frequency for men is around ___125 Hz___, women are around ___250 Hz___, and children can be up to ___500 Hz____.

7. D 8. A 9. C 10. E 11. C

12.

Describe vocal nodules, the affected population, the effects on the voice, and treatment. Localized growths resulting from frequent, hard vocal fold collisions. Generally bilateral, occurring at the juncture of the anterior one-third and posterior two-thirds of the vocal folds. Nodules are soft and pliable at first, and can become hard and fibrous. Most common in adult women between 20 and 50 years old. Can also occur in children (mostly boys) prone to excessive loud talking or screaming. The primary perceptual voice symptoms are hoarsness and breathiness. May complain of a sore throat and an inability to use the upper third of the pitch range. Newly formed nodules are often treated with vocal rest. Consulting an SLP for voice therapy and education is usually recommended. Longstanding nodules may require surgical removal followed by voice therapy.

13. C 14. A 15.

Compare and contrast acute and chronic laryngitis. Acute laryngitis is a temporary swelling of the vocal folds that can result in hoarseness. Chronic laryngitis results from vocal abuse during acute laryngitis, and can lead to serious deterioration of vocal fold tissue.

16. D 17. D 18. A 19. B 20. C 21.

Discuss three alternative methods of producing voice after removal of the larynx due to laryngeal cancer. Esophageal speech: Uses the esophagus as a vibratory source Electrolarynx: A prosthetic vibratory device Tracheo-esophageal puncture or shunt: Directs air into the esophagus, allowing the speaker to use respiratory air and the cricopharyngeous muscle for voice production.

22. C 23. A 24. C 25. B 26. D

162 .

27.

What information does the SLP gather for the case history of a voice evaluation? Description of the voice problem, when it started, the duration, what the client believes might e causing it, how it affects daily life activities, the person’s social and vocational use of the voice, and his or her overall physical and psychological condition.

28. D 29. A 30. A 31.

When direct intervention is recommended for voice disorders, what is the goal of therapy? Teach the client to eliminate the vocally abnormal or abusive behavior by producing a voice that balances respiratory, laryngeal, and articulatory/resonatory subsystems.

32.

Why is psychiatric referral often not needed for voice disorders associated with psychological or stress conditions? Voice treatment can be effective if the individual is convinced there is nothing physically wrong via specific voicing techniques. The voice can return to normal in minutes or over several sessions.

33. A 34. C 35. A 36.

Describe three types of prosthetics used in management of resonance disorders. A palatal obturator is similar to a retainer and can be used to cover a defect such as a fistula until further surgery is warranted. A speech bulb obturator can be used when the velum is too short to contact the posterior pharyngeal wall or when the velum is immobile. A palatal lift can be used to elevate the velum in cases where the velum is immobile.

37. B 38. C

39. C 40. D

41.

Name the structures of the velopharyngeal mechanism. The velum, the lateral pharyngeal walls, and the posterior pharyngeal wall.

42. B 43.

At what point is a voice disorder said to exist? When one or more perceptual aspects of voice such as pitch, loudness, or voice quality are outside range of normal for an individual’s age, sex, cultural background, or geographic location. 44.

Which professionals (at a minimum) are required to conduct a voice evaluation? Otolaryngologist and an SLP

45. C

163 .

the

CHAPTER 10 MOTOR SPEECH DISORDERS 1.

The frontal lobes house the ________________. a. Direct activation pathway b. Basal ganglia c. Primary motor cortex d. A&B

The __________________ originate(s) in the primary motor cortex and is responsible for rapid, discrete, volitional movement of the limbs and articulators for speech. a. Pyramidal tract or direct activation pathway b. Extrapyramidal tract or indirect activation pathway c. Basal ganglia control circuit d. A&C

The __________________ is important for regulating reflexes and maintaining posture and muscle tone, providing the necessary framework to facilitate movement. a. Pyramidal tract or direct activation pathway b. Cerebellum c. Extrapyramidal tract or indirect activation pathway d. A&C

The direct and indirect activation pathways form the

How do the basal ganglia modulate motor activity?

Describe the motor speech production process beginning with the motor plan.

The ______________________ consists of 12 pairs of cranial nerves and 31 pairs of spinal nerves. a. Central nervous system b. Peripheral nervous system c. Vertebral column d. Brain stem

The nerves are especially important for speech production, whereas the majority of _____________nerves are important for breathing purposes.

Special control systems in the ________ govern breathing for life.

10.

Dysarthria can affect the a. Speed of movement b. Range of movement c. Timing of movement d. All of the above

11.

Which of the following speech domains may be affected in dysarthria? a. Respiration b. Phonation c. Resonance d. Articulation e. All of the above

164 .

12.

__________________ is a category of dysarthria that usually results from lesions in the cranial and spinal nerves or in the muscle unit itself. May result in reduced respiratory drive for speech breathing, continuously breathy voice quality, reduced pitch and loudness levels, monopitch, hypernasality, and imprecise articulation. a. Spastic dysarthria b. Flaccid dysarthria c. Hyperkinetic dysarthria d. Hypokinetic dysarthria

13.

__________________ is an idiopathic condition that results in unilateral damage to the facial nerve that usually resolves spontaneously. Flaccid dysarthria is usually mild, with mild articulatory imprecision as the primary speech characteristic. a. Bell’s palsy b. Progressive bulbar palsy c. Myasthenia gravis d. Muscular dystrophy

14.

___________________ is a neurological disease that causes degeneration of lower motor neurons, resulting in flaccid paralysis of muscles and eventual muscle atrophy. Speech sounds weak, hypernasal, monopitched, and articulation is imprecise. a. Bell’s palsy b. Progressive bulbar palsy c. Myasthenia gravis d. Muscular dystrophy

15.

______________________ are visible, isolated twitches in resting muscle due to spontaneous firing of nerve impulses in response to nerve degeneration. a. Discrete activations b. Fasciculations c. Vascillations d. Neural firings

16.

_____________________ is an autoimmune disease that affects the nuromuscular junction. It is characterized by rapid weakening of the muscles due to inadequate transmission of nerve impulses to the muscles, but strength is regained quickly after a short period of rest. Imprecise articulation and hypernasality gets worse with prolonged speaking but dramatically improves with 1-2 minutes’ rest. a. Myasthenia gravis b. Muscular dystrophy c. Bell’s palsy d. Progressive bulbar palsy

17.

_____________________ is a category of dysarthria that typically results from bilateral upper motor neuron lesions in the cerebral hemispheres or a single lesion in the brain stem. Reflexes become more hyperactive, muscle tone increases at rest, and there is increased resistance to passive stretch. a. Spastic dysarthria b. Flaccid dysarthria c. Hyperkinetic dysarthria d. Ataxic dysarthria

18.

What are the movement and speech characteristics associated with spastic dysarthria?

165 .

19.

_____________________ is a category of dysarthria that is due to damage in the cerebellum or cerebellar control circuitry. It results in incoordination and reduced muscle tone. a. Spastic dysarthria b. Hyperkinetic dysarthria c. Ataxic dysarthria d. Hypokinetic dysarthria

20.

What are the speech and motor characteristics of ataxic dysarthria?

21.

________________________ results in slow movements with reduced range of motion due to the effects of rigidity. The most common cause is a degeneration of dopaminergic neurons in the brain stem, which prevents proper functioning of the basal ganglia. a. Flaccid dysarthria b. Hyperkinetic dysarthria c. Ataxic dysarthria d. Hypokinetic dysarthria

22.

What are the speech and movement characteristics of hypokinetic dysarthria?

23.

_____________________ is an idiopathic degenerative neurological disease that results in hypokinetic dysarthria in 90% of cases. a. Myasthenia gravis b. Huntington’s chorea c. Parkinson disease d. Amyotrophic lateral sclerosis

24.

___________________ is a category of dysarthria that is due to damage of the basal ganglia circuitry; the indirect pathway and/or structures of the basal ganglia that help to inhibit unwanted movements are damaged. a. Hyperkinetic dysarthria b. Hypokinetic dysarthria c. Ataxic dysarthria d. Flaccid dysarthria

25.

Which of the following are abnormal involuntary movements that may be seen in hyperkinetic dysarthria? a. Tics b. Dystonia c. Chorea d. All of the above

26.

What are the speech characteristics of hyperkinetic dysarthria?

27.

What is Huntington’s chorea? Describe the speech and motor characteristics, as well as effects on mood and personality.

28.

In _______________________, both upper and lower motor neurons degenerate, causing mixed flaccid and spastic dysarthria. a. Traumatic brain injury b. Primary progressive aphasia c. Alzheimer’s disease d. Amyotrophic lateral sclerosis

29.

How might acquiring dysarthria change an adult’s life?

166 .

30.

_________________ is a neurological speech disorder that generally occurs following damage to the left cerebral hemisphere, particularly motor and premotor areas. Speech is characterized by groping attempts to find the correct articulatory position, great variability over repeated attempts, sound substitutions, omissions, additions, and difficulty sequencing sounds in multisyllabic words. a. Dysarthria b. Apraxia of speech c. Aphasia d. Dementia

31.

For individuals who recover after acquiring apraxia of speech, which is the most common residual deficit? a. Articulation of nasal consonants b. Prosodic abnormalities c. Difficulty socializing d. None of the above

32.

_____________________ is a congenital disorder that causes dysarthria in children. It causes abnormal muscle tone, loss of selective motor control, muscle weakness, and impaired balance. a. Childhood apraxia of speech b. Cerebral palsy c. Down syndrome d. Fragile X syndrome

33.

In ___________________, individuals have increased muscle tone, exaggerated stretch reflex, and motor movements may be jerky, stiff, labored, and slow. a. Athetoid cerebral palsy b. Ataxic cerebral palsy c. Spastic cerebral palsy d. Flaccid cerebral palsy

34.

In _____________________, individuals have slow, involuntary writhing. Movement is disorganized and uncoordinated, and speech and breathing problems can be significant. a. Athetoid cerebral palsy b. Ataxic cerebral palsy c. Spastic cerebral palsy d. Flaccid cerebral palsy

35.

In __________________, movement is uncoordinated and balance is disturbed. a. Athetoid cerebral palsy b. Ataxic cerebral palsy c. Spastic cerebral palsy d. Flaccid cerebral palsy

36.

What are options for education and employment for those with cerebral palsy?

37.

What are the purposes of the motor speech evaluation?

38.

The following is noted in an oral peripheral mechanism evaluation: a. Symmetry, configuration, color, and general appearance of the face, jaw, lips, tongue, teeth, and hard and soft palate at rest. b. Movement of the jaw, tongue, lips, and soft palate. c. Range, force, speed, and direction of the jaw, lips, and tongue during movement. d. All of the above

39.

What speech tasks might be used for differential diagnosis of apraxia of speech?

167 .

40.

Which techniques can be used to improve respiratory drive? a. Using a pausing/phrasing strategy b. Using an abdominal binder c. Using a palatal lift d. A & B e. B & C

41.

Intensive, repetitive speech production drill practice with meaningful words and phrases is an effective way to increase _________________. a. Articulatory accuracy b. Speech intelligibility c. A&B d. None of the above

42. 43.

are NOT recommended as a treatment technique for motor speech disorders. ____________________ is an effective treatment for acquired apraxia of speech. It involves a hierarchy of cueing to help a client retrain his or her motor planning/programming abilities. a. Integral stimulation b. Melodic intonation therapy c. Contrastive stress therapy d. None of the above

44. In _______________________, there is a focus on prosody, emphasizing the melody, rhythm, and stress patterns of spoken utterances. This treatment technique for acquired apraxia of speech is thought to access functions of the right hemisphere. a. Integral stimulation b. Melodic intonation therapy c. Contrastive stress therapy d. Lee Silverman Voice Treatment

168 .

CHAPTER 10 – Answer key MOTOR SPEECH DISORDERS 1. C 2. A 3. C 4.

The direct and indirect activation pathways form the

upper motor neuron system

How do the basal ganglia modulate motor activity? The basal ganglia modulate the activity of the primary motor cortex and indirectly influence movement. Depending on which pathway is involved, damage to the basal ganglia will either result in reduced and/or slowed movement (Parkinson disease) or in abnormal, involuntary movements (Huntington’s chorea).

Describe the motor speech production process beginning with the motor plan. First, the movement plan/program is retrieved from memory. The plan is sent to the motor control areas. It is then transmitted with precise timing along the nerves to muscles and structures of the speech mechanism, resulting in sequences of acoustic signals that are recognized as speech sounds. Nerve impulses are modified to ensure precise, smooth muscle movement. Typical movement patterns are purposeful and efficient and are under the control of the individual. Motor responses are initiated, changed, and coordinated on the basis of both external and internal sensory information. For speech production, auditory and proprioceptive feedback help ensure proper coordination of the speech mechanism.

7. B 8.

The cranial nerves are especially important for breathing purposes, whereas the majority of spinal nerves are important for breathing purposes.

Special control systems in the ___brain stem_____ govern breathing for life.

10. D 11. E 12. B 13. A 14. B

15. B 16. A 17. A 18.

What are the movement and speech characteristics associated with spastic dysarthria? Movements of the articulators become slowed and reduced in force and range of motion. Spasticity at the level of the larynx results in a strain-strangled voice quality.

19. C 20.

What are the speech and motor characteristics of ataxic dysarthria? Ataxic dysarthria reflects the effects of incoordination and the improper timing of movements, causing irregular breakdowns in articulation and abnormalities of prosody. Movements are inaccurate, jerky, and lacking smoothness.

21. D 22.

What are the speech and movement characteristics of hypokinetic dysarthria? Individuals with hypokinesia feel stiff and find it difficult to get movements started. Once started, they struggle to stop. Reduced range of motion is the hallmark feature. Speech rate becomes very fast and disfluencies are common. Loudness levels gradually diminish.

23. C

169 .

24. A 25. D 26.

What are the speech characteristics of hyperkinetic dysarthria? Hyperkinetic dysarthria is essentially the production of motorically normal speech that is interrupted in some fashion by abnormal involuntary movements. Speech is characterized by variable speech rate, irregular articulatory breakdowns, and significant prosodic abnormalities.

27.

What is Huntington’s chorea? Describe the speech and motor characteristics, as well as effects on mood and personality. It is an inherited progressive disease that results in degeneration of structures in the basal ganglia. Initial symptoms include involuntary choreatic movements and changes in behavior. Later, involuntary movements worsen and become more generalized. Significant changes in mood and personality become evident with subsequent development of depression and dementia.

28. D 29.

How might acquiring dysarthria change an adult’s life? For some, even a slight speech abnormality can be cause for embarrassment and depression. In more severe cases, individuals may be frustrated as loved ones and acquaintances attempt to communicate for them by finishing their sentences or ordering for them in restaurants. This may cause them to socialize less. In the later stages of progressive degenerative diseases, and individual with dysarthria may be unable to live independently and may need daily living assistance or institutional care.

30. B 31. B 32. B 33. C 34. A 35. B 36.

What are options for education and employment for those with cerebral palsy? Many individuals, particularly those with mild physical and cognitive difficulties, obtain higher education and/or go into competitive employment. Other individuals may work and learn in centers run by agencies or the state. Day treatment programs are available to provide training in daily living and vocational skills for individuals with severe motor deficits and/or cognitive impairment.

37.

What are the purposes of the motor speech evaluation? To determine whether a significant and long term problem exists To describe the nature of impaired functions, specifically the types of problems, the extent/severity, and the effects of these impairments on everyday functioning To identify functions that are not impaired To establish appropriate goals and decide where to begin intervention To form a well-reasoned prognosis, based on the nature of the disorder, the client’s age, the age or stage of injury or disease, the presence of other conditions, client motivation, and family support.

38. D 39.

What speech tasks might be used for differential diagnosis of apraxia of speech? Imitation of single words of varying length Sentence imitation Reading aloud Spontaneous speech Rapid repetition of “puh,” “tuh,” “kuh,” and “puh-tuh-kuh” or “buttercup”

40. D 41. C

170 .

42.

Nonspeech oral motor treatments disorders.

are not recommended as a treatment technique for motor speech

43. A 44. B

171 .

CHAPTER 11 DISORDERS OF SWALLOWING 1.

Swallowing disorders increase the risk of choking and may lead to _______________. a. Obesity b. Aspiration c. Intubation d. Improved nutrition

_______________________ is the movement of food or acid from the stomach back into the esophagus.

The outcomes of a swallowing disorder at any age include a. Malnutrition b. Ill health c. Fatigue d. Respiratory infection e. All of the above

In the ______________________ phase of swallowing, the tongue and cheeks move food to the teeth to form a solid bolus. a. Oral preparation b. Oral c. Pharyngeal d. Esophageal

In the ______________________ phase of swallowing, the base of the tongue and the pharyngeal wall move toward one another to create pressure needed to project the bolus into the pharynx. a. Oral preparation b. Oral c. Pharyngeal d. Esophageal

In the _____________________ phase of swallowing, the bolus is moved from the front to the back of the mouth. a. Oral preparatory b. Oral c. Pharyngeal d. Esophageal

In the ____________________ phase of swallowing, muscles move the bolus in peristaltic contractions into the stomach. a. Oral preparation b. Oral c. Pharyngeal d. Esophageal

Which of the following can occur in disorders of the oral preparation/oral phase of swallowing? a. Insufficient saliva impedes adequate bolus formation b. Poor tongue mobility may result in insufficient pressure in the pharynx c. If the swallow is not triggered or is delayed, material may be aspirated d. Residue on the esophageal walls can result in infection and nutritional problems

172 .

Which of the following can occur in disorders of the pharyngeal phase of swallowing? a. If the lips do not seal properly, drooling can occur b. The muscles of the tongue might not function purposefully or efficiently enough to move food to the teeth c. An open velopharyngeal port can lead to substances going into and out of the nose d. If peristalsis is slow or absent, the complete bolus might not be transported to the stomach

10.

Infants and children with swallowing disorders might experience the following: a. Inadequate growth b. Difficulty learning c. Poor parent-child relationships d. All of the above

11.

Describe the types of feeding and swallowing difficulties premature infants can experience.

12.

Children with _______________have behaviors that can interfere with feeding, including social withdrawal, impaired communication, stereotypic behaviors, and sensory hypersensitivity. a. Cerebral palsy b. Intellectual disability c. Autism spectrum disorder d. HIV/AIDS

13.

Children with ________________ have difficulty with oral secretions and exhibit odynophagia. a. Cerebral palsy b. Intellectual disability c. Autism spectrum disorder d. HIV/AIDS

14.

15.

_________________ is the cause for about a third of deaths following stroke. a. Aspiration pneumonia b. Malnutrition c. Denial of illness d. All of the above combined

16.

Radiation for cancer of the mouth, throat, or larynx may result in a. Diminished salivation b. Mouth sores c. Reduced swallowing reflex d. All of the above

173 .

17.

The primary symptoms of dysphagia in __________________ are reduced pharyngeal peristalsis and delayed swallowing reflex. a. Stroke b. HIV/AIDS c. Multiple sclerosis d. Parkinson disease

18.

_______________________ is sometimes an early sign of amyotrophic lateral sclerosis. a. Poor tongue movement b. Pharyngeal phase dysphagia c. Reduced laryngeal elevation d. Loss of food during the oral phase

19.

In ________________, oral transport may be impaired by a front-to-back rolling pattern of the tongue. a. Parkinson disease b. Spinal cord injury c. Amyotrophic lateral sclerosis d. Stroke

20.

__________________ refer(s) to involuntary, repetitive facial, tongue, or limb movements. a. Tardive dyskinesia b. Tremor c. Fasciculations d. Fibrillations

21.

The cognitive effects of _________________ may impede attention and orientation to food. a. Dementia b. ALS c. Stroke d. Spinal cord injury

22.

How can depression and social isolation in advanced age result in dysphagia?

23.

A primary indication of dysphagia in newborns is a. Failure to thrive b. Irritability c. Cognitive impairment d. Lack of attachment

24.

The ___________________ identifies 80-98% of patients who are aspirating, but possibly not those who experience silent aspiration. a. Dysphagia checklist b. Bedside swallow evaluation c. Videofluoroscopic swallow study d. 3-ounce water swallow test

25.

What are the three areas of concern that might result in a dysphagia referral?

174 .

26.

What does the SLP pay attention to when observing feeding as it occurs normally?

27.

When assessing laryngeal function specifically, the SLP should look for which of the following? a. Hoarse, gurgly, or breathy voice quality before/during/after the swallow b. Motor difficulties, such as tremor c. General body position and tone d. All of the above

28.

A swallow trial is contraindicated if a. The client has a history of aspiration b. The client is not alert c. A & B d. None of the above

29.

During swallow trials, an inability to cough may indicate a. Difficulty closing the larynx to protect the airway b. Inadequate velopharyngeal closure c. A&B d. None of the above

30.

After physician approval is granted, describe the process involved in conducting a swallowing evaluation with an individual who has a tracheostomy tube.

31.

In ______________________, a flexible laryngoscope is placed through the nose and into the pharynx so that the swallow can be examined. a. Videofluoroscopy b. Scintigraphy c. Fiber-optic endoscopic evaluation of swallowing d. Ultrasound

32.

In ____________________, barium is coated onto or mixed into the food or beverage so that the movement of the bolus can be examined via X-ray. a. Videofluoroscopy b. Scintigraphy c. Fiber-optic endoscopic evaluation of swallowing d. Ultrasonography

33.

In ____________________, a transducer that generates and receives sound waves is placed below the chin for views of the oral cavity and on the thyroid notch for visualizing the laryngeal area. a. Videofluoroscopy b. Scintigraphy c. Fiber-optic endoscopic evaluation of swallowing d. Ultrasonography

34.

The __________________ position is recommended for patients with delayed pharyngeal swallow. a. Chin tuck b. Head back c. Head tilt d. Head rotation

175 .

35.

The _________________ position is recommended for patients with poor tongue mobility if there is excellent airway closure. a. Chin tuck b. Head back c. Head tilt d. Head rotation

36.

What are the four diet level for dysphagia and the levels of liquid?

37.

What factors should be considered for placement of food and liquid in the mouth?

38.

Swallowing physiology and range of motion can be improved through ______________. a. Exercise b. Electrical stimulation c. Surgery d. None of the above

39.

_________________ is used when there is pharyngeal or oral residue. a. Double or multiple swallow b. Effortful swallow c. Supraglottic swallow d. Super-supraglottic swallow

40.

__________________ is used to teach voluntary closure of the glottis and reduces the depth of misdirected swallows. a. Effortful swallow b. Double swallow c. Multiple swallow d. None of the above

41.

What is the procedure for the supraglottic swallow?

42.

When is the Mendelsohn maneuver used and what is the procedure?

43.

Surgical procedures that may help with dysphagia include a. Removing growths on the cervical spine b. Suturing the vocal folds shut c. Elevating the larynx d. All of the above

44.

Clients who require more than ______ seconds to swallow a bolus or who aspirate more than _________ will likely require at least some nonoral feeding. a. 5, 5% b. 10, 10% c. 20, 20% d. 40, 40%

176 .

45.

______________________ is a feeding tube inserted into a stoma, which extends into the pharynx. a. Nasogastric tube b. Pharyngostomy c. Esophagostomy d. Percutaneous endoscopic gastrostomy tube

46.

______________________ is a feeding tube placed into the esophagus through a hole in the chest. a. Nasogastric tube b. Pharyngostomy c. Esophagostomy d. Percutaneous endoscopic gastrostomy tube

47.

_______________________ is a feeding tube placed in the stomach through a hole in the abdomen. a. Nasogastric tube b. Pharyngostomy c. Esophagostomy d. Percutaneous endoscopic gastrostomy tube

48.

What are the benefits of early identification and successful intervention for dysphagia?

177 .

CHAPTER 11 - Answers DISORDERS OF SWALLOWING 1. B 2. Gastroesophageal reflux (GER) 3. E 4. A 5. C 6. B 7. D 8. A 9. C 10. D 11. Describe the types of feeding and swallowing difficulties premature infants can experience. Premature infants often have difficulty with feeding and swallowing due to immature sucking and/or a discoordinated suck, swallow, and breathe pattern. 12. C 13. D

14.

Explain how structural and physiological abnormalities such as those seen in cleft lip/palate, Pierre Robin syndrome, Treacher Collins syndrome, and velocardiofacial syndrome negatively affect feeding and swallowing. Children with cleft lip or palate are unable to create negative intraoral pressure, resulting in an impaired ability to express milk from the nipple, and nasopharyngeal regugitation along with milk remaining in the nose and mouth. Congenital abnormalities of the jaw, as in Pierre Robin syndrome, or of the face, as in Treacher Collins syndrome, negatively both feeding and swallowing; airway compromise may also be present. Velocardiofacial syndrome causes poor feeding endurance and velopharyngeal insufficiency.

15. A 16. D 17. C 18. A 19. A 20. A 21. A 22.

How can depression and social isolation in old age result in dysphagia? As people enter old age, they may be lonely or unmotivated to cook for themselves. Depression is associated with diminished interest in food, restlessness, and fatigue. The throat may feel tight, making swallowing uncomfortable. Some may feel too tired to eat and are exhausted after they eat, leading to malnutrition.

23. A 24. D

25.

What are the three areas of concern that might result in a dysphagia referral? Difficulties have been observed related to feeding and ingestion of food or liquid The client appears to be at risk for aspirating food or liquid into the lungs The client appears not to be receiving adequate nourishment

178 .

26.

What does the SLP pay attention to when observing feeding as it occurs normally? Is the caregiver patient and attentive? Does feeding take place in a reasonably quiet environment free from distractions? What position is the individual in when eating or drinking? How does the client express feeding preferences?

27. A 28. C 29. A 30. After physician approval is granted, describe the process involved in conducting a swallowing evaluation with an individual who has a tracheostomy tube. The cuff is deflated and secretions from the mouth and above the cuff are suctioned. The patient covers the tube before each swallow to normalize tracheal pressure. 31. C 32. A 33. D 34. A 35. B 36.

What are the four diet level for dysphagia and the levels of liquid? NDD Level 1: Dysphagia – pureed NDD Level 2: Dysphagia – mechanical soft NDD Level 3: Dysphagia – advanced NDD Level 4: Regular Levels of liquids: thin, nectar-like, honey-like, and spoon-thick

37.

What factors should be considered for placement of food and liquid in the mouth? Placement should be where there is intact sensation and adequate muscle strength. This can be affected by oral surgery, radiation, or neurological problems.

38. A 39. A 40. D 41.

What is the procedure for the supraglottic swallow? Breathe in and hold breath Put a small amount of food or liquid in the mouth Swallow Cough or clear throat while exhaling Swallow again

42.

When is the Mendelsohn maneuver used and what is the procedure? The Mendelsohn maneuver is useful for clients who do not have adequate laryngeal elevation. Procedure: Place a small amount of food or liquid in the mouth Chew if necessary Swallow while placing the thumb and forefinger on the sides of the larynx Manually hold larynx high for 3-5 seconds during and after swallowing Let go of the larynx and let it drop

43. D 44. B 45. B 46. C 47. D 48. What are the benefits of early identification and successful intervention for dysphagia? Reduces the risk of aspiration and death, shortens the length of time patients need to stay in the hospital, and improves quality of life.

179 .

CHAPTER 12 AUDIOLOGY AND HEARING LOSS 1.

Approximately __________ of the U.S. population has some degree of hearing loss. a. 5% b. 12% c. 20% d. 53%

Approximately _________ in 1,000 births results in a child with a severe to profound degree of hearing loss. a. 1 b. 3 c. 7 d. 10

Define the classifications of impairment, disability, and activity limitation.

Describe at least two ways children can be affected by various types of hearing loss.

When a person’s hearing loss reaches ______________ or greater, the person is considered deaf. a. 60 dB b. 90 dB c. 60 Hz d. 90 Hz

Those who are deaf and do not see their deafness as a disability but as a cultural trait are part of the ____ _________.

Audiologists may prescribe and fit ___________________. a. Auditory brainstem stimulators b. Cochlear implants c. Amplification d. All of the above

More than half of audiologists work in ________________. a. Schools b. Industry c. Hearing aid centers d. Non-residential healthcare settings

Sound is a series of compressions and _______________ that move outward from a vibrating source. a. Rarefactions b. Waves c. Amplifications d. None of the above

10.

_________________ is the distance the vibrating object travels in either direction; determines intensity. a. Frequency b. Amplitude c. Pitch d. Wavelength

11.

What are the major components of the auditory system?

180 .

12.

The _____________________ make(s) up the peripheral auditory system. a. Outer ear b. Middle ear c. Inner ear d. Vestibulocochlear nerve e. All of the above

13.

The outer ear consists of the pinna and the ____________. a. Cerumen b. Eustachian tube c. External auditory meatus d. Nasopharynx

14.

What is the external auditory meatus and and what is its function?

15.

The ___________________ is air-filled, lined with mucous membranes, and includes the opening to the Eustachian tube. a. Ear canal b. Middle ear space c. Nasopharynx d. Cochlea

16.

The _____________, ________________, and ______________ are the bones of the ossicular chain.

17.

The footplate of the stapes rests against the _______________, a membrane that marks the entrance to the inner ear. a. Oval window b. Tympanic membrane c. Pinna d. Cochlear window

18.

The ________________ is responsible for providing input to the central auditory system. a. Auditory cortex b. Outer ear c. Concha d. None of the above

19.

The outer labyrinth of the cochlea is filled with a fluid called ________, whereas the inner labyrinth is filled with a fluid called ___________.

20.

The __________________is the roof of the organ of Corti. a. Tectorial membrane b. Basilar membrane c. Stereocilia d. Vestibulocochlear nerve

21.

Describe the anatomy of the basilar membrane and how it responds to sound.

22.

How does information get from the cochlea to the vestibulocochlear nerve?

23.

What anatomical structures make up the central auditory system and what is its job?

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24.

The outer and middle ears comprise the ________________. a. Sensorineural system b. Conductive system c. External auditory system d. None of the above

25.

The cochlea and auditory nerve make up the ________________. a. Sensorineural system b. Conductive system c. External auditory system d. None of the above

26.

_______________________ hearing loss results from deformation, malfunction, or obstruction of the outer or middle ear. a. Sensorineural b. Conductive c. Age-related d. Noise-induced

27.

Describe a conductive hearing loss.

28.

____________________ is a complete closure of the auditory canal that results in significant hearing loss. a. Atresia b. Microtia c. Stenosis d. Impacted cerumen

29.

____________________ is the replacement of healthy bone with spongy bone in the area of the stapes footplate, resulting in reduced mobility of the stapes and hearing loss. a. Otitis media b. Otosclerosis c. Eustachian tube dysfunction d. Myringotomy

30.

_____________________ is an inflammation of the mucous membrane lining of the middle ear cavity. a. Otitis media b. Otosclerosis c. Myringotomy d. None of the above

31.

Negative middle ear pressure can cause the eardrum to retract in the middle ear cavity and can lead to the secretion of fluid, known as a. Otitis media with effusion b. Purulent otosclerosis c. Suppurative Myringotomy d. None of the above

32.

_____________________ are inserted into the eardrum in children with chronic otitis media to serve the same purpose as the Eustachian tube. a. Cochlear implants b. Hearing aids c. Pressure equalization tubes d. Myringotomy tubes

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33.

______________________ hearing loss results from the absence, malformation, or damage to the structures of the inner ear. a. Sensorineural b. Conductive c. Age-related d. Noise-induced

34.

Describe sensorineural hearing loss and factors that influence the effects of the loss on speech, language, and cognition.

35.

____________________ is hearing loss due to absence or malformation of inner ear structures during embryonic development. a. Aplasia/dysplasia b. Usher’s syndrome c. Meniere’s disease d. Meningitis

36.

____________________ is inflammation of the fluids and layers of tissue covering the brain. a. Aplasia/dysplasia b. Usher’s syndrome c. Meniere’s disease d. Meningitis

37.

What is auditory neuropathy spectrum disorder, what are the effects on hearing, and what are effective treatments?

38.

____________________ is a leading cause of acquired sensorineural hearing loss in young and middleaged adults. a. Temporary threshold shift b. Noise-induced hearing loss c. Auditory neuropathy spectrum disorder d. Central auditory processing disorder

39.

Hearing loss that occurs through the aging process is called _________.

40.

____________________ interfere(s) with the ability to efficiently and effectively use and interpret acoustic information. a. Noise-induced hearing loss b. Presbycusis c. Central auditory processing disorders d. Auditory learning disabilities

41.

What are the characteristics of individuals with (central) auditory processing disorder?

42.

____________________________ are designed to identify significant hearing loss in newborn babies and follow up with prompt audiological intervention services. a. Head Start programs b. Pediatrician screenings c. Early hearing detection and intervention programs d. All of the above

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43.

Children who are diagnosed with hearing loss and receive hearing aids and early intervention by _______________ develop significantly better language skills. a. 6 months b. 1 year c. 2 years d. 3 years

44.

School-age, adolescent, and college-age students are at risk for ______________________. a. Meningitis b. Presbycusis c. Noise-induced hearing loss d. Auditory processing disorders

45.

A/an ________________ allows visual inspection of the ear canal and eardrum. a. Tympanometer b. Audiometer c. Otoscope d. Tympanogram

46.

__________________ record neuroelectric responses that are generated by the auditory system in response to sound. a. Electroacoustic measures b. Electrophysiological tests c. Acoustic immittance measures d. Otoscopic examinations

47.

A/an __________________ is a plot representing middle ear compliance based on changes in ear pressure a. Audiometer b. Audiogram c. Otoscope d. Tympanogram

48.

What are otoacoustic emissions and why are they important?

49.

What is the auditory brain stem response and why is it important?

50.

______________________ is used for selection, manipulation, and presentation of stimuli during hearing assessment. a. Tympanometer b. Audiometer c. A & B d. None of the above

51.

In _____________________, the audiologist presents a stimulus through a loudspeaker and observes a child’s reaction. a. Behavioral Observation Audiometry b. Visual Reinforcement Audiometry c. Pure Tone Audiometry d. Conditioned Play Audiometry

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52.

__________________ is one of the fundamental behavioral tests in the standard audiometric assessment; standard practice is to test a range of frequencies from 250 to 8000 Hz. a. Behavioral Observation Audiometry b. Visual Reinforcement Audiometry c. Pure Tone Audiometry d. Conditioned Play Audiometry

53.

__________________ is the lowest intensity at which a person can detect a stimulus 50% of the time. a. Threshold b. Baseline c. Ceiling d. None of the above

54.

Individuals whose degree of hearing loss falls within the slight/mild-severe range are classified as a. Deaf b. Hard of hearing c. Hearing impaired d. B & C e. None of the above

55.

Describe air conduction and bone conduction and what the comparison of the measures can tell us about hearing loss.

56.

Describe the types of speech audiometry (SRT and WRT).

57.

_______________________ is intervention aimed at minimizing and alleviating the communication difficulties associated with hearing loss. a. Hearing aid fitting b. Cochlear implantation c. Aural habilitation/rehabilitation d. None of the above

58.

Describe the processes of informational counseling and personal adjustment counseling.

59.

In most cases, amplification consists of _________.

60.

What are the physical components of hearing aids?

61.

What type of benefit can individuals expect to gain from using hearing aids?

62.

A ___________________ is a neural prosthesis that bypasses the damaged hair cells of the cochlea and directly stimulates the surviving auditory nerve fibers with electrical energy. a. Bone anchored hearing aid b. Digital hearing aid c. Cochlear implant d. None of the above

63.

What is bimodal hearing?

185 .

64.

Children as young as ______________ can undergo cochlear implant surgery. a. 6 months b. 12 months c. 18 months d. 24 months

65.

Children who are implanted at an early age and who receive intensive auditory therapy demonstrate significant gains in: a. Speech perception b. Language acquisition c. Speech production d. Literacy development e. All of the above

66.

__________________ are assistive devices used to overcome problems hearing in various situations. a. Hearing assistive technology b. Augmentative communication devices c. Voice output communication devices d. Unaided symbol systems

67.

In a/an ________________________, the talker speaks into a microphone attached to a transmitter that broadcasts on a designated frequency or channel. a. Sound field amplifier b. FM system c. TTY d. A&B

68.

The goal of auditory training is to a. Restore hearing to normal b. Restore hearing to pre-injury status c. Maximize a person’s use of residual hearing d. Postpone a referral for hearing aids

69.

__________________ are hand shapes used to visually represent each of the 26 letters of the English alphabet. a. Pidgin Signed English b. Manually Coded English c. Fingerspelling d. American Sign Language

70.

Based on available evidence, what is one of the best ways to support a child with (C)APD with listening and learning?

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CHAPTER 12 - Answers AUDIOLOGY AND HEARING LOSS 1. C 2. A

Define the classifications of impairment, disability, and activity limitation. Impairment is a loss of structure or function Disability is a term that includes impairment as well as the environmental factors that interfere with functioning Activity limitation refers to the functional consequences associated with a particular impairment

Describe at least two ways children can be affected by various types of hearing loss. A child with a profound hearing loss would have no access to the speech sounds in a language without amplification. All degrees of hearing loss can interfere with the ability to succeed in school, both academically and socially. Children with mild hearing loss typically have more difficulty in challenging acoustic environments. Children with hearing loss must rely more on memory and attention abilities. They are at risk for delayed morphological development. Children with unilateral hearing loss have difficulty localizing sound and hearing in noise. 5. B 6.

Those who are deaf and do not see their deafness as a disability but as a cultural trait are part of the ____Deaf community_________.

7. C 8. D 9. A 10. B 11.

What are the major components of the auditory system? Outer ear, middle ear, inner ear, vestibulocochlear nerve, auditory brain stem, and the auditory cortex of the brain.

12. E 13. C

14.

What is the external auditory meatus and and what is its function? It is an elliptical tube lined with skin that extends from the concha to the tympanic membrane. The outer external auditory meatus has hair follicles and glands that produce cerumen. The external auditory meatus can enhance certain high frequency sounds.

15. B 16.

The ___malleus__________, ____incus____________, and ____stapes__________ are the bones of the ossicular chain.

17. A 18. D

19.

The outer labyrinth of the cochlea is filled with a fluid called __perilymph______, whereas the inner labyrinth is filled with a fluid called _____endolymph______.

20. B

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21.

Describe the anatomy of the basilar membrane and how it responds to sound. The basilar membrane is narrower, thinner, and stiffer at the base and wider, thicker, and more flaccid at the apex, enabling it to respond differently to sounds that vary in frequency.

22.

How does information get from the cochlea to the vestibulocochlear nerve? As the stereocilia are bent through movement of the tectorial and basilar membranes, chemical transmitters are released at the base of the hair cells, and neuroelectric energy is generated and transmitted to auditory nerve fibers that form the acoustic branch of the vestibulocochlear/VIIIth cranial nerve.

23.

What anatomical structures make up the central auditory system and what is its job? Consists of nuclei, nerve fibers, and nerve tracts; includes pathways that carry auditory information to the brain (ascending) and pathways that receive information from the brain (descending). Anatomical structures leading to the brain ensure that information about the frequency, intensity, and duration of the auditory stimuli remains intact until it reaches the auditory cortex for interpretation.

24. B 25. A 26. B 27.

Describe a conductive hearing loss. Usually prevents low- to moderate-intensity sounds from being heard at all and higher-intensity sounds from being perceived as much softer than normal. Impacts audibility, but does not result in a total loss of hearing. Most are not permanent.

28. A 29. B 30. A 31. A 32. C 33. A

34.

Describe sensorineural hearing loss and factors that influence the effects of the loss on speech, language, and cognition. May be present at birth or develop over time, and is usually permanent. Hearing loss is predominately in the higher frequency range. Sounds that are audible are often perceived as being distorted. Factors that influence the effects of the loss on speech, language, and cognition include the degree of the loss, the age of onset, the age of the person when the loss was identified, and the age of the person when appropriate intervention was done. Age of onset is congenital or acquired, or prelingual or postlingual.

35. A 36. D 37.

What is auditory neuropathy spectrum disorder, what are the effects on hearing, and what are effective treatments? Normal outer hair cell function and abnormal responses from the inner hair cells or auditory nerve fibers. Characterized by a lack of synchrony in the firing of auditory nerve fibers with normal outer hair cell function. May exhibit pure tone hearing within normal limits to profoundly impaired, and usually have considerable difficulty understanding speech even when the pure tone loss is not significant. Hearing aids are helpful to some, but cochlear implants may be more effective.

38. B 39.

Hearing loss that occurs through the aging process is called ____presbycusis_____.

40. C

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41.

What are the characteristics of individuals with central auditory processing disorder? May be easily distracted, have difficulty comprehending rapid speech or speech in poor acoustic environments, difficulty following complex auditory directions, difficulty paying attention, slow or inconsistent responses to verbal messages, or increased dependency on visual cues.

42. C 43. A 44. C 45. C 46. B 47. D 48.

What are otoacoustic emissions and why are they important? OAEs are low intensity sounds (echoes) generated within the cochlea as a result of outer hair cell movement; they can be measured with a microphone. When OAEs are present, hearing sensitivity is presumed to be normal or no worse than a mild loss. Important in newborn screening programs.

49.

What is the auditory brain stem response and why is it important? ABR is a type of AEP that measures neuroelectric activity of the auditory nerve and structures of the lower brain stem. ABR can be used to identify neurological issues, such as a tumor on CN VIII or auditory neuropathy/dyssynchrony disorder. Can be used to estimate the auditory thresholds in individuals who are unable or unwilling to be evaluated using behavioral techniques.

50. B 51. A 52. C 53. A 54. D 55.

Describe air conduction and bone conduction and what the comparison of the measures can tell us about hearing loss. Air conduction testing is administered while a client wears headphones. Bone conduction testing is administered with a bone oscillator, directly stimulating the cochlea. By comparing the results of air conduction testing to bone conduction testing, the type of hearing loss can be identified.

56.

Describe the types of speech audiometry (SRT and WRT). Speech Recognition Threshold is the lowest intensity where a person can recognize approximately 50% of two-syllable words presented. Word Recognition Test assesses how well the client is able to identify one-syllable words presented at some level above threshold.

57. C

58.

Describe the processes of informational counseling and personal adjustment counseling. Informational counseling is the process of giving a client information. Personal adjustment counseling is providing assistance to the client and family in dealing with the emotional consequences of hearing loss.

59.

In most cases, amplification consists of ____personal hearing aids_____.

60.

What are the physical components of hearing aids? Microphone, amplifier, receiver, and some type of computer processor.

61.

What type of benefit can individuals expect to gain from using hearing aids? The primary goal is to make speech audible to improve intelligibility. A hearing aid will not return hearing to normal. The client must be counseled so that his/her expectations for improvement are realistic.

62. C

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63.

What is bimodal hearing? Bimodal hearing is when a cochlear implant is used for one ear and a hearing aid is used for the other ear.

64. B 65.

66. A 67. B 68. C 69. C 70.

Based on available evidence, what is one of the best ways to support a child with (C)APD with listening and learning? Increasing language competence.

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CHAPTER 13 AUGMENTATIVE AND ALTERNATIVE COMMUNICATION 1.

Approximately _______________ people in the U.S. are not able to use natural speech to express their wants and needs and may benefit from AAC. a. 100,000 b. 500,000 c. 2 million d. 4 million

Briefly define alternative and augmentative communication (AAC).

_________________ do not involve external equipment. a. Unaided systems b. Aided systems c. Tangible symbols d. Pictorial symbols

_________________ are things that stand for or represent something else and are central to the process of classifying AAC systems. a. Signs b. Symbols c. Levels of technology d. Levels of support

Manual sign systems include a. Signed English b. American Sign Language c. Amer-Ind d. All of the above

_____________ signs are easily guessable, explainable, and memorable. a. Iconic b. Transparent c. Opaque d. Equivalent

Why are unaided systems not appropriate for every individual who needs to enhance or replace their current communication method?

Aided AAC systems are grouped as a. No-tech, low-tech, mid-tech, or high-tech b. Manual or automatic c. Digital or synthetic d. None of the above

9. 10.

What is a benefit of using pictorial symbols for communication? _____________________ is an access method in which individuals may select an item by pointing with a finger, hand, head pointer, optical head pointer, activating a joystick, or using eye gaze. a. Direct selection b. Indirect selection c. Scanning d. Auditory scanning

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11.

___________________ is an access method that involves the client assembling a message through a series of switch activations in which choices are presented sequentially. a. Direct selection b. Indirect selection c. Scanning d. Auditory scanning

12.

How can efficiency be enhanced for scanning techniques?

13.

Voice output communication can be a. Digitized b. Synthesized c. Both of the above d. None of the above

14.

Partners tend to respond more slowly to a. Recorded speech b. Synthesized speech c. Female digitized speech d. Male digitized speech

15.

__________________ is an individual’s language ability across all dimensions of language. a. Operational competence b. Strategic competence c. Linguistic competence d. Device competence

16.

What is social competence?

17.

Discuss factors related to AAC system selection (feature matching).

18.

Discuss considerations related to AAC symbol selection.

19.

The order of teaching signs or symbols must be guided by a. They way the device is organized b. The school’s recommendations c. Research recommendations that suggest biographical information should be taught first d. None of the above

20.

Abandonment of AAC is usually related to a. Loss of facilitator/partner support b. Equipment malfunction c. The expense of associated therapies d. All of the above

21.

Intervention is most effective if caregivers also use AAC with speech, which is called a. Augmented input b. Parallel use c. Dialogic output d. None of the above

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22.

____________________ is a technique that is promising for children with ASD; it consists of engaging children in interactive play and providing models of AAC symbol use during play. a. Everyday routines b. Aided language modeling c. Dialogic output d. Floor time

23.

Research shows that although AAC users can comprehend a wide range of grammatical structures, they tend to produce a. Only single word utterances b. Structures similar to those around them c. Shorter utterances when using graphic symbol-based systems d. Only responses to questions

193 .

CHAPTER 13 - Answers AUGMENTATIVE AND ALTERNATIVE COMMUNICATION 1. D 2. Briefly define alternative and augmentative communication (AAC). AAC is anything that supplements an existing communication system. 3. A 4. B 5. D 6. B 7.

Why are unaided systems not appropriate for every individual who needs to enhance or replace their current communication method? Motor impairments make it difficult to use manual sign systems. Not all communication partners will understand manual sign systems.

8. A 9. What is a benefit of using pictorial symbols for communication? Symbolic systems are relatively rule governed and generative, allowing for symbol combination and the creation of new symbols. 10. A 11. C

12.

How can efficiency be enhanced for scanning techniques? By placing symbols so that those that are most frequently used are scanned most frequently or by using different scanning methods (linear scanning vs. row/column scanning, etc.).

13. C 14. B 15. C 16.

What is social competence? Relates to how well a person manages the social aspects of communication, such as turn taking, topic maintenance, and using balanced and reciprocal interactions.

17.

Discuss factors related to AAC system selection (feature matching). Consider the client’s motor and cognitive abilities, the potential size of the client’s vocabulary, the ease in learning and using the system, the acceptability of the system to the user and potential communication partners, and the flexibility and intelligibility of the system. In addition, consider the aesthetics of the system, overall size, arrangement and size of the symbols, placement and organization of the symbols, and the output of the system.

18.

Discuss considerations related to AAC symbol selection. May be guided by the potential user’s cognitive abilities, the ease of learning different graphic AAC systems, and the willingness of potential communication partners.

19. D 20. A 21. A 22. B 23. C

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