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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_111_библиотеки_им_акад_М_И_Перельмана
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diagram. Facing the mirror, touch the side of your
cheek to indicate the approximate intraoral position
for /k/, then open your mouth widely and show the
child the /k, ɡ/ placement; follow this with several
“kuh” (or “guh”) productions as the child observes
intraorally.) Then say, “We want it to be a ‘mouth
sound,’ not a ‘throat sound.’”
• Use any visible or palpable pharyngeal muscle
activity as a cue to pharyngeal stop production. In
therapy, you could tell the child, “I know when you
are using the throat sound because I can see your
throat muscles working down here. Watch in the
mirror and you can see how my muscles work when I
say ‘
’. Put your fingers on my neck, right here, and
you can feel me make the throat sound, too. Now you
make the sound, watch your throat muscles, and put
your fingers here to feel them work. We don't want to
see that; we want to make our tongue muscles work,
like this (look in the mirror and say “kuh”), and make
the sound in our mouth.”
Video 12-6 demonstrates
this visible neck muscle activity associated with the
pharyngeal production.
2. Teach or verify auditory and visual discrimination skills for error
versus desired target before proceeding to production learning and
practice.
3. For teaching production, use VCs with (sustained) high front vowels
to facilitate anterior placement, for example,
, , or even , .
CVs can also be used; however, we have found vowel initiated (VC)
syllables to be more facilitative at first. You can then incorporate CV
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syllables and move into monosyllabic word contexts, and then into
increasingly more connected speech contexts. Don't forget to include
self-monitoring practice.
In phonetic transcription, a colon following the sound indicates
sustained or prolonged production. For this type of placement teaching,
it is helpful initially to sustain the vowel for 2 to 3 seconds before the
off-glide into the consonant.
4. As with the gloal stop, you may need to first establish fricative
manner in the new place (i.e., velar fricative production as in [x] or
)
and then use nasal occlusion to facilitate the velar stop.
5. If both /k/ and /ɡ/ are affected, start with either target, whichever is
easier for the child. Voicing is not a factor here.
For Pharyngeal Fricative Substitution and
Coproduction
Substitution
1. As with the pharyngeal stop, you want to emphasize moving the place of
production up and forward. (Remember that the pharyngeal fricative is
most often substituted for the sibilant fricatives, the blade-alveolars /s, z/
and blade-palatals
, and less frequently, palatal affricates / , /).
Therefore, oral placement targets will be alveolar, palatal, or both.) You
will use similar procedures as for pharyngeal stop to establish oral
place. Use the lateral diagram and mirror to illustrate oral target
placement. Your description and instructions could be similar to the
following:
• “You are making the ‘ssss’ (and/or ‘shhhh,’ ‘chh’)
sound in your throat, here in this place.” (Point to
mid-neck to lower neck place on the lateral diagram,
on yourself, and then on the child). “We want to
move it up into your mouth and make it here.” (Point
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to alveolar or palatal place on diagram; facing the
mirror, open your mouth and tip your head back.
First touch the target [alveolar or palatal] place with
your finger, then demonstrate the target sound
placement. Follow this with several “ssss” [s:] (or
other target) productions as the child observes
intraorally.) “We want it to be a ‘mouth sound,’ not a
‘throat sound.’ When I make ‘ssss’ in my mouth, I can
feel my tongue touching behind my top teeth.”
2. In pharyngeal fricative production, the tongue sits low in the mouth;
the pharyngeal articulation positions the tongue low and back. As with
the pharyngeal stop, use any visible or palpable pharyngeal muscle
activity as a cue to pharyngeal fricative production. In therapy, you
could tell the child, “I know when you are using the throat sound
because it sounds very different from the (name target sound, e.g.,
“shhh”), the mouth sound.” Facing the mirror, say, “We want to hear
this (demonstrate the target), not this” (demonstrate pharyngeal
fricative as best you can). You can also say, “I know when you are using
the throat sound because I can see your throat muscles working down
here. Watch in the mirror and you can see how my muscles work when I
say ‘
’. Put your fingers on my neck, right here and you can feel where
I make the throat sound, too. Now you make your sound; watch your
throat muscles and put your fingers here to feel the muscles work. We
don't want to feel that; we want to make our tongue muscles work. We
want to make the sound in our mouth.”
3. Teach or verify auditory and visual discrimination skills for error
versus new target before proceeding to production learning and
practice. (Do the best you can to produce the target-error productions
for the child to discriminate; you can perceptually simulate a voiceless
pharyngeal fricative (
) by tightly constricting your throat as you
produce a prolonged “h” ([h:]).
4. Pharyngeal fricatives most often replace sibilant fricatives and
affricates. For teaching production, if the child produces pharyngeal
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fricatives for both /s/-/z/ and / /-/ / or for the group of sibilant fricatives
and affricates, you may want to start by teaching “sh” (/
/) since it is
acquired earlier than /s/. This (mouth) sound can be called the “be quiet
sound” with younger children and modeled with the associated finger
to lips gesture. Once /
/ is established you can apply successive
approximation (moving forward from the palatal /
/) to shape to
alveolar /s/. With either /
/or /s/, use VCs with (sustained) high front and
midcentral vowels to facilitate more forward placement, for example,
,
, and [ , ]. CVs can also be used. As noted previously, however, we
have found vowel initiated (VC) syllables to be more facilitative early in
therapy. For “ch” ([
]), you can teach it as the “sneezing sound,”
following similar procedures as described above, adding voicing to elicit
“j”, soft “g” ([
]).
5. There are some additional techniques for eliciting oral target
placement if the pharyngeal fricative cannot be modified using this
“pharyngeal versus oral production contrast” approach. For example:
• You can have the child produce “long h” ([h:]) and
gently bite the teeth together to elicit an /s/-like
production. You can call this “silly blowing.” The [h:]
initiated, sustained airflow opens the pharynx
(eliminating the linguapharyngeal constriction) and
facilitates oral airflow. The coproduced biting gesture
constricts the interdental airflow to elicit the /s/-like
production. Using phonetic placement teaching, you
can then refine and stabilize the /s/.
• If [t] is in the child's inventory, you can use it to
facilitate [s]. Ask the child to make a “long t” ([t:])
(which becomes the fricative, [s]). Most children learn
this quickly. Once [t:] “tssss” is established, you can
move to syllable and monosyllabic word drills:
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Using “long t” to teach [s] is a reliable technique regardless of the error
affecting /s/. Be sure to call the production “long t” and not “s” because
referring to “s” often triggers the “old” (in this case pharyngeal)
production.
— Practice in imitated target-initial drills (in CCV
contexts or “silly words”) as in [t:o] “tso,” [t:i] “tsee,”
[t:e] “tsay,”
“tsome,” “Sam.”
— Practice in imitated target-final word-final [t:]
contexts (VCC), for example, [it:] “eat
s,” [ot:] “oats,”
“mats,” “puts.” With some children, it may
be easier to establish the oral target in this context
first.
— Use successive approximation to shape to [s] by
gradually shortening the “long t”. Once the /s/ is
stabilized in word-initial context, move on to
establishing and practicing word-final /s/.
— For practice, use VC or CVC words such as “us,”
“ice,” “ace,” “miss,” “kiss,” or /s/ + vowel + /s/
contexts, for example, “sis,” “sauce,” “sass.” You can
then move on to word-medial or intervocalic contexts
as in “sissy,” “saucy” or “saucer,” “sassy,” “missing”
or “missy,” “kissing.”
Some children spontaneously generalize the new production to other
positions and contexts.
— If the pharyngeal fricative production (or
coproduction) continues to “sneak back,” practice
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first with target words beginning with “h,” for
example, “hiss,” “house,” “horse”; “has,” “his,”
“hose” to keep the pharynx open.
— When the oral target has stabilized in this context,
you can then incorporate CV and VCV syllables and
words and move into more demanding word and
phrase/sentence contexts. Remember to incorporate
self-monitoring practice.
— You can also use minimal pairs therapy to contrast
the (final) [t] versus [ts] using pictures of single
versus plural items, (e.g., hat-hats). To elicit initial /s/,
practice in sentences such as, “It's soup,” “It's silly,”
“It's sunny,” and prolong the “t's” to isolate the word
initial target (e.g., “itssssss sunny”). Once [s] is
stabilized, you can add voicing to elicit [z], and shape
from [s] to elicit [
].
6. Some children will spontaneously generalize this learning to other
affected targets. For example, with /s/ as the target, they may generalize
to /z/ and even to /
/ and / /. (Remember, [ ] and [ ] are produced by
slightly retracting /s/ and /z/ productions.) Other children will need to
be taught more on a sound-by-sound basis. For these youngsters, the
same techniques can be applied to elicit and stabilize /z/, /
/ and / /.
The child in Video 12-7
is EC, whose assessment data were
presented in Chapter 8, Appendix 8H. Recall that he consistently
replaced /s, z,
/ with pharyngeal fricatives. The therapy excerpts
illustrate techniques and motor learning principles in eliciting and
practicing [s] and [
]. Both sounds were elicited using the “long t.” Note
that even in this early learning stage, his self-monitoring skills are well
developed.
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Coproduction
1. Coproduced pharyngeal fricatives can be realized for any or all of the
sibilant fricatives /s, z/, /
, / and the coproduction involves
simultaneous placements for oral sibilant fricative + pharyngeal
fricative. To illustrate the two places used for this double articulation,
use the lateral diagram and place map to explain this and to point out
that one of the places the child is using is the place we want to keep, but
we need to work to get rid of the other place. Your description and
instructions, facing the mirror, would be something like this:
• “You are saying this sound by making your tongue
touch in two places at the same time, here in your
mouth (point out the oral target place [alveolar or
palatal] on the lateral diagram) and here in your
throat” (point to the point of pharyngeal constriction
for the fricative on the diagram). “We want it to be
only a mouth sound, not a mouth sound and a throat
sound. We want to keep this place (point to target
place), but we want to get rid of this place” (point to
pharyngeal place and X it out).
2. Teach or verify auditory and visual discrimination skills for error
placement (pharyngeal fricative) versus desired target before
proceeding to production learning and practice.
3. For establishing target production, use the techniques for teaching
pharyngeal fricative.
• To eliminate the pharyngeal place, you can use the
production technique of /h/ + biting the teeth together
to elicit an oral /s/-like production, as discussed
earlier.
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• If / / (or / /) is the affected target and the youngster
has /s/ (or /z/) in the inventory, then work to move
the placement of [s] (or [z]) back to elicit the palatal
fricative. If /s/ (or /z/) is the affected target and the
child has [
] (or [ ]) in the inventory, then work to
move the placement of [
] (or [ ]) forward to elicit [s]
or [z].
— Use central mid-vowels (e.g., /o, ə-ʌ, ɛ/) in syllable
and word practice with /
/ and / /.
— Use high front vowels (e.g., /i, ɪ, eɪ/) in syllable and
word practice with /s/ and /z/.
4. Remember to incorporate self-monitoring practice once the target is
established.
For Pharyngeal Affricate Substitution
1. As with the pharyngeal stop and pharyngeal fricative, you want to
emphasize moving the place of production up and forward.
2. Use the lateral diagram and mirror to teach the place differences
(pharyngeal versus palatal) between error and oral target.
3. Then apply the techniques and procedures described for pharyngeal
fricative to establish (palatal) target place of production. Make sure /
/ is
in the inventory so you can work at that place. To establish the “stop”
component of the target affricate, use the techniques and procedures
described for establishing oral stops (i.e., use the lateral diagram to
illustrate how airflow is stopped and pressure builds up behind the
target place [the stopping point] before it is released). For younger
children, remember that the “ch” [
] can be elicited by naming and
modeling it as the “sneezing” sound. Video 12-8
again illustrates
motor learning principles, especially providing lots of feedback in the
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early learning stages, for a youngster who corrected her use of
pharyngeal fricatives to replace /ʃ/ but then substituted /ʃ/ for the /tʃ/
sound. Her therapy has benefied from using the color-coded place
map to elicit the /tʃ/.
For Mid-Dorsum Palatal Stop Substitution or Oral
Coproduction
1. The mid-dorsum palatal stop (MDPS) is a replacement for /t/, /d/, /k/,
/ɡ/. The emphasis in treatment is on establishing the tip alveolar place,
back velar place, or both if the mid-dorsum palatal stop (MDPS) is
realized for both alveolar stops and velar stops.
2. Use the lateral diagram to explain where or how the child is making
the MDPS and to teach the place contrast between the desired target and
the error placement.
3. Particularly with this error, information from lateral view
videofluoroscopy may be helpful in visualizing the placement error, that
is, to determine whether this is a mid-mid-palatal substitution (middorsum to mid-palate articulation) or whether it is an oral coproduction
or double articulation of [t]-[k] or [d]-[ɡ] (articulating at both places
simultaneously). Despite their different placements, the substitution and
double articulation are perceptually indistinguishable. You may want to
consult with the team SLP to see if (lateral view) videofluoroscopy
studies have been done and whether they have captured this placement
error. Electropalatography usually definitively distinguishes double oral
articulation placements from single substitution placement (Gibbon and
Crampin, 2001, 2002). However, this procedure may not be accessible
because it is not in wide use in the United States. If you do not have
specific placement data, our suggestion is that you assume that it is a
mid-palatal substitution error and teach from that perspective. At
present, we have no data on whether the specific error placement makes
a difference in therapy approach or progress. With older children, you
may be able to define the placement error through explanation,
discussion, and fine-tuning the child's tactile-kinesthetic feedback and
reporting abilities.
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4. Remember, the MDPS is realized as a perceptual mix of either
voiceless [k-t] or voiced [d-ɡ].
5. To the extent possible, teach or verify auditory and visual
discrimination skills for error versus target before proceeding to
production learning and practice.
6. If the MDPS replaces /k/, /ɡ/ or both, we want to move the placement
back and work first to establish back velar place or use a velar
production already in the inventory to facilitate target place learning.
• If the child has /
/ in the inventory (which usually is
the case), then the nasal occlusion technique can be
used to elicit a velar stop, and the child may quickly
learn the production.
• Otherwise, the lateral diagram and a focus on the
visual and tactile aspects of /
/ placement can be used
to demonstrate that the child already can make a
sound using that place. Use the color-coded place
map to show the child that [
], [k] and [ɡ] all are
made in the same place.
— Siing side by side in front of the mirror, your
discussion and instructions to the child might be
something like this: “You already can make a sound
in this place; it's the ‘ing’ /
/ sound. Watch me in the
mirror and watch my tongue when I make the ‘ing’
sound.” (Open your mouth widely so the back velar
placement can be viewed as you make a prolonged /
:/.) “See how the back of my tongue goes up, but the
front of my tongue stays down.” (Model several more
productions so the child can see the alternate raising
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