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Parents, Teachers, and the Speech
Notebook
In previous chapters, we mention the wisdom of involving the parents
and other caregivers in the therapy process. Especially with very young
children, the role of the parents is critical. Parents or other caregivers
must be “partners” with you, sharing an understanding of how they can
facilitate success in the therapy you are providing. In the school-age
years, although their child is in another seing most of the day, parents
still need to have a clear idea of the current goals of therapy and must
spend some practice time with the child during nonschool hours.
Parents can be great sources of reinforcement when they show pride in
the child's acquisition of new speech production skills. The child's
teachers must also have an understanding of the goals of therapy and
the need for reinforcement (praise!) in the classroom. Time and effort
will be wasted if you are working toward one goal in the speech therapy
seing and the classroom teacher is unwiingly reinforcing error speech
productions or, worse yet, somehow punishing the child for not
demonstrating good speech production skills. Although most
elementary school teachers expect that preschoolers and some early
school-age children will have immature speech, they may not be at all
familiar with what palatal clefts and other VP problems can do to
speech. You will want to spend some time sharing this information with
the teachers, so everyone shares a common goal and a basic understanding of
how you intend to reach that goal.
Because clefts and noncleft VPI or VPD can sabotage speech in so
many ways, therapy is most likely to be effective when the instructive
time is not limited to 20 or 30 minutes two or three times a week
(especially if it is group therapy). The child's parents or other caregivers
will need to “sign on” to a home program and expect to help the child
with speech practice or homework for at least a short period of time
most days of the week. In fact, you will have to make the point to the
parents that therapy will not succeed unless work is done at home. You
can make the analogy to them of a child who takes music lessons or
participates in sports: If the child plays the piano only during lessons
and does not practice, or plays his or her sport only when games are
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scheduled and does not aend team practice, there is lile likelihood of
improvement in performance.
Although the time that working parents have to spend with their
families is always limited and is far too apt to be stressful rather than a
time of enjoyment, parents may become eager participants when you
show them that the speech practice time at home can be fun for both
them and their child. You and the parents should agree on what type of
positive reinforcement is most likely to work with their child, and they
can share with you any concerns about frustrated behavior they see at
home. Of course, at the beginning of therapy, you will also consult with
them (without the child present) about what bothers them most about
the child's speech.
A key tool in speech homework, as well as in the therapy seing, is a
speech notebook (either hard copy or an e-notebook) that helps the
parents, child, and even the classroom teacher track current goals, lets
them review “today's therapy accomplishments,” and provides
homework instructions and activities. It also provides a basis for
reviewing progress with parents and teachers. Properly constructed and
geared to the age and interests of the child, the notebook becomes a
“motivator,” not just a record. The child takes the responsibility (with
some pride, we hope) of showing the parents what he or she did that
day in therapy and what the homework is until the next therapy session.
For toddlers and preschoolers, especially, it is important that a hard
copy speech notebook be used only for speech practice (i.e., not as a
“scribbling resource!”) and that it be kept in a special place, out of
harm's way. School-age children will likely benefit more from electronic
documentation. The notebook will contain the appropriate orthographic
symbols for the child's target sounds and simple diagrams for phonetic
placement and place of production contrasts (see examples later in this
chapter). The parents or other caregivers will indicate the child's
achievements during the home practice sessions and perhaps reward
the child with stars or other colorful stickers, if appropriate to his or her
age level. The notebook can be organized by sections (e.g., target
sounds, homework assignments, sticker [good work] pages, parent or
caregiver comments and questions, and language activities), as
appropriate. A loose leaf, three-ring binder works well for a hard copy
notebook for keeping materials in order; homework “pages” can be
either the hard copy or e-notebook and can be reorganized as sections
are completed and new sections are added.
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Useful Therapy Materials
In Chapter 11, you read about some of the therapy materials that can be
particularly helpful with toddlers. We resume and expand that
discussion here with the emphasis on useful teaching materials that
address the speech deviations that uniquely characterize cleft palate
misarticulations:
1. Nonoral compensatory productions and
2. Backed oral productions (both of which are place of production
errors)
3. Audible nasal air emission (the intentional error in direction of speech
airflow)
Given the nature of cleft-related errors, it follows that cleft palate
speech therapy relies heavily on phonetic placement activities and on
activities that teach oral airflow and eliminate nasal airflow and
therefore will also benefit oral pressures. It is essential that the child
understands his or her mouth and can follow phonetic placement
instructions. If not, the basics about structures used in speech will need
to be an initial teaching activity. You will want to teach the names and
locations of other oral structures, what those structures can do, and how
they move. Box 12-2 provides an example of steps in teaching the child
to locate and identify oral structures important for speech and how they
move. Mirror work is a central activity at all levels of therapy for cleftrelated speech sound errors.
Box 12-2
Steps in Teaching Identity, Location, and
Actions of Oral Structures
1. With the two of you seated side by side in front of a large mirror, let
the child get used to looking in the mirror and encourage him or her
to imitate playful tongue and lip gestures, funny faces, and so forth.
Explain why you want you both to be looking into the mirror.
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2. Teach identity and locative labels by naming and pointing to your
own oral structures, including the following:
• Upper (top) lip versus lower (boom) lip
• Top teeth versus boom teeth
• Behind the top teeth
• Between the teeth
• Front of the tongue versus back of the tongue
• Tongue tip
• Roof of mouth, palate
3. Instruct the child to point to structures in his or her mouth, as you
name them; assist the child (with your gloved hands), as necessary.
4. Teach actions for placement instructions as you model in the mirror;
for example:
• Make the front (back) of your tongue go up.
• Put your tongue between your teeth.
• Put your tongue tip behind your top teeth.
• Bite your teeth together.
• Bite your lower lip.
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5. Assign this as a home practice activity. It is easy and a good way to
encourage parental involvement. If the parent or other caregiver
cannot aend the session to see how this works, you can make a short
video and send it with instructions.
Activities and associated tools for teaching phonetic placement and
oral direction of airflow are summarized in Table 12-1.
TABLE 12-1
Activities and Corresponding Materials for Teaching Phonetic
Placement and Oral (Direction of) Airflow
TEACHING ACTIVITY USEFUL MATERIALS
Phonetic placement
1. Tactile placement cues Stimulation (stim) sticks, flat tooth picks, tongue blades, orthodontic elastics,
buon on a thread
2. Schematic illustrations for
place learning
Lateral diagrams to show place of production of desired target and place
contrasts between targets and errors
Oral airflow Materials for blowing activities: bubbles using wand or pipe; whistles;
blowing against easily moved, small objects (e.g., coon ball, ping pong ball)
Discriminating and monitoring
for oral versus nasal airflow
Flexible listening tubes, See-Scape, mirrors, and paper air paddles
Materials for Teaching Phonetic Placement
Perhaps the most important “material” for teaching phonetic placement
with any treatment population is a single piece of (“low-tech”)
equipment—a large therapy mirror, large enough so clinician and child
can sit side by side and work while looking into the mirror. You want to
be able to use the mirror for visual modeling of target sounds and for
facilitating the child's visual matching and visual monitoring of correct
and error productions and production contrasts (Fig. 12-1).
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FIGURE 12-1 Phonetic placement therapy is facilitated by mirror
work.
The mirror can be placed on a tabletop or on the floor when working
with younger children. A large wall-mounted mirror or a two-way
mirror also will work provided it extends low enough to accommodate
floor work.
Materials that provide tactile information on what points the articulators
should contact for the target sound are key components of phonetic
placement techniques and probably are familiar to you. Stim sticks
(coon swabs), flat tooth picks, and pediatric or standard tongue blades
can be used to cue/identify the place (e.g., anterior alveolus) or
articulator part to be used (e.g., tongue tip for tip alveolar sounds).
Although the more accessible and more visible anterior sounds lend
themselves beer to these techniques, placements for more posterior
sounds such as posterior tongue dorsum-to-velar place (as in [k, ɡ,
]) or
for the affricates [
, ] also can be tactilely cued using a tongue blade
angled up and back from the maxillary incisors. A rubber-gloved index
finger also works. Small colorful orthodontic elastics can be placed on
the tongue tip and the tip raised to contact the anterior maxillary
alveolus. Tip alveolar place as in [t, d] also can be cued using a buon on
a thread with the buon flush to the inner anterior alveolus and the
thread pulled taut and out between the central incisors to hold the
buon in (target) place (Fig. 12-2).
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FIGURE 12-2 Button on a thread technique for phonetic
placement therapy.
For bilabial place cueing, orthodontic elastics also can be placed on
the lower lip, and the upper lip brought to compress against the elastic
or a tongue blade can be placed across the lower lip and the lips
compressed against it. Additionally, of course, the rubber-gloved index
finger and thumb can manually cue bilabial closure.
Phonetic placement teaching and learning is facilitated by schematic
illustrations that can be used to show target sound place of production
and to illustrate the place contrasts or place differences between targets
and error productions. Figure 12-3 provides examples of place contrasts,
showing gloal stop realization ([
] replacement for /b/) and pharyngeal
fricative realization [
] replacement for /s/.
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FIGURE 12-3 Place contrasts for target versus error. A, Glottal
versus bilabial. B, Alveolar versus pharyngeal.
Materials for Teaching Oral Airflow and Learning
Oral Versus Nasal Airflow Direction
Useful materials for teaching oral airflow all incorporate blowing. These
blowing activities focus specifically on redirecting nasal airflow and
establishing the oral airflow pathway. They are not a means of
improving either the strength of the velum or the firmness of VP closure
and are distinguished from nonspeech oral motor “exercises”
(NSOMES). For younger children, blowing activities include blowing
bubbles (using a wand or bubble pipe). Blowing whistles and blowing
against coon balls or small lightweight toys with wheels, or blowing
sideways against a pinwheel also can work with preschoolers and
school-age youngsters. Some children may benefit more by blowing
through a straw onto the coon ball. You want to use blowing toys that
do not present significant resistance to airflow. (In general, party
whistles and balloons offer too much resistance and can interfere with
accomplishing the goal.)
Lof and Ruscello (2013), in their article titled “Don't Blow This Therapy
Session,” trace the history of blowing in the treatment of children with
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cleft palate and VPI. They provide reasons why NSOMES, particularly
blowing “exercises,” should not be used in therapy and they
summarize seminal research articles to show that they do not work.
For children who have strongly habituated (learned) nasal air
emission, or who have some degree of insufficiency, it may be necessary
to occlude the nostrils manually to teach oral airflow and to redirect
intentional nasal airflow. In addition to gently “pinching” the nostrils
closed with your fingers or covering them from below with your
thumbs, “nose clips” or nose clamps or (loosened) swimmer's clips can
be used to prevent nasal escape so that the child can learn the feeling of
adequate oral airflow, but these should not be clips that exert strong
force on the sides of the nose. Most school-age youngsters can easily
learn to do this themselves during therapy and for home practice.
However, beware of what youngsters may be doing with the dorsum of
the tongue, especially if they are exhibiting phoneme-specific nasal
emission. It is not unusual for them to be producing the PSNE by
completely sealing off the oral cavity with the tongue dorsum backed
and raised against the velum, thus preventing all airflow. When you
close off the nasal airway, these youngsters will literally execute a
Valsalva maneuver.
Materials for Discriminating and Monitoring Oral
Versus Nasal Airflow
Flexible “listening tubes” provide both auditory and tactile feedback
and can be used to train auditory discrimination and to teach the child
to monitor production. With one end of the tube held at the base of the
clinician's nose and the other end held at the child's ear, a listening tube
can be used to teach the child to discriminate oral versus nasal airflow,
to ensure that the child understands the difference. Running the tube
from the child's nose to ear cues the child to nasal air escape. The Oral
and Nasal Listener (Super Duper Publications, Greenville, S.C.) and
training stethoscope shown in Figure 12-4 are other options.
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FIGURE 12-4 Oral and nasal listener (top) (Super Duper
Publications, Greenville, S.C.) and teaching/training stethoscope
(bottom). (From Peterson-Falzone SJ, Hardin-Jones MA, Karnell MP: Cleft palate
speech [4th ed]. St. Louis: Mosby, 2010; courtesy Ted Brummond, University of
Wyoming Photo Service.)
Dental mirrors and dental reflectors are also useful for visual
identification of nasal air emission because they cause fogging on the
mirror or reflector and can demonstrate to the child the presence of
nasal air escape. However, we have found these to be more useful for
assessment than as a therapy aid. The low-tech See-Scape (Pro-Ed,
Austin, Tex.) is a very useful tool for visually discriminating and
monitoring oral versus nasal air emission. It is fun and provides
immediate feedback. The nasal olive can be placed into a nostril or held
in front of the speaker's mouth, depending on the therapy goal; for
example, “Let's place this in your nose to see if any air escapes when
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