Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4578_Библиотеки_им_академика_М_И_Перельмана
.pdf
Record the Speech Sample
Ideally, a video recording should be made, but if this is not possible
audio will also capture many cleft-related speech characteristics. A
remote microphone is recommended for video recording because it
provides a higher-quality recording. It is important to record the
speech sample for several reasons or uses. The recording is a
permanent record that can be used for later transcription and detailed
analysis. Obtaining consecutive recordings at specified intervals (e.g.,
annually) serves to document progress and change for quality
improvement assessments. The recording can be used to educate the
parents and explain the rationale for the therapy activities and goals. It
also can be used to further educate medical, dental, and other
professional colleagues on cleft palate and craniofacial teams regarding
cleft-related speech errors and what speech therapy can treat and what
it cannot (see Chapter 12).
Here are some tips for obtaining a quality video recording that will be
adequate for narrow phonetic transcription:
• Make sure you have good lighting.
• Use an external remote microphone, if possible (a microphone on a
stand is preferable to a lavalier microphone because of noise
generated when the child moves around; children also like to finger
the microphone).
• Zoom the camera so that the child's face is framed, and periodically
monitor to make sure the child's face stays within the frame.
• For both single words and sentences, try to leave a 2-second interval
between stimuli; this makes it easier for later analysis.
A Note on Phonetic Transcription
Perceptual assessment using phonetic transcription remains the “gold
standard” for clinical assessment of speech resonance and articulation.
Do your best to transcribe phonetically any error productions observed
in special sampling contexts, articulation testing, and stimulability
293
t.me/Dr_Mouayyad_AlbtousH
https://t.me/medicina_free
testing. Although broad transcription is clearly preferable to
dichotomous correct/incorrect scoring, more narrow transcription
using special symbols and diacritics is recommended for documenting
the deviant articulations observed in cleft palate speech. Several
different conventions are used for narrow transcription. Chapter 5
provides symbols for transcribing compensatory articulations,
including coproductions and backed oral productions, and also
provides diacritics for hypernasality, hyponasality, audible nasal
emission, and nasal turbulence. Samples of diacritics useful in cleft
palate speech transcription are provided in Table 8-4.
Your transcription can be based on the single word and sentence
stimuli. You need to transcribe only the target sound or sounds in the
different stimulus items. We are not talking about whole word
transcription, and it is not necessary to transcribe the conversational
speech sample or other connected speech items. However, listening for
frequency of occurrence of a specific error type (e.g., nasal fricative or
gloal stop), and for the sound or sounds that an error affects, will
expand your pool of noted errors and will help to identify error
paerns.
294
t.me/Dr_Mouayyad_AlbtousH
https://t.me/medicina_free
TABLE 8-4
Diacritics Useful in Transcription of Cleft Lip and Palate Speech
DESCRIPTION DIACRITIC EXAMPLE
Hypernasal
Vowels, sonorant consonant
Consonants* (less common)
Audible nasal emission
Nasal turbulence
Hyponasal, denasal
Dentalized
Interdental
Lateralized
Fronted
Backed
Inverted, reversed labiodental
†
Ingressive airflow C↓ “see” /si/ → [s↓i]
Clicks
‡
*
When observed this usually occurs on the voiced plosives /b, d, g/; the target
consonant is still identifiable, and the neighboring is vowel typically hypernasal.
†
Describes the labiodental inversion (lower teeth to upper lip) of labiodentals /f, v/.
‡
There are several symbols for clicks and they vary by place of production. See the
ExtIPA Charts.
Modified from Peterson-Falzone SJ, Trost-Cardamone JE, Karnell MP, Hardin-Jones
MA: The clinician's guide to treating cleft palate speech. St. Louis: Mosby, 2006.
Applying narrow transcription to complex speech disorders can be
daunting. Think of this as a learning process in which you gradually
increase your skills. To begin with, you want to learn the symbols for
the more frequently occurring cleft-related errors (gloal stop,
pharyngeal fricative, nasal fricatives, palatal fricatives) and the
diacritics for nasal emission, hypernasality, hyponasality, and backed
or retracted oral placements.
295
t.me/Dr_Mouayyad_AlbtousH
https://t.me/medicina_free
https://t.me/medicina_free
Analyze the Speech Sample
The analysis of the sample (see Table 8-1, section II) should provide
more than a gross notation regarding the presence or absence of
hypernasality, nasal air emission, and articulation errors. For example,
the following diagnostic statements fall short of the goal: “speech was
hypernasal with multiple articulation errors,” “hypernasal speech with
a severe articulation disorder and nasal emission,” “gloal stops, nasal
emission, and developmental errors.” Rather, a useful analysis will
produce the following information:
• A brief description of the phonetic inventory (size, sound types
including vowels, constraints) and, for younger children, whether the
inventory is developmentally on schedule.
• Severity ratings for overall speech understandability and speech
acceptability and for hypernasality. For clinical assessment of these
parameters, a 4-point scale with clear descriptors is recommended.
Rating scales for judging hypernasality range from three-point to nine-
point equal-appearing interval (EAI) scales. These scales have been
criticized for their validity because the difference between adjacent
scale values may not be equal to the perceptual difference (e.g., the
difference between 0 and 1 may be less than the difference between 2
and 3). (See Peterson-Falzone et al., 2010, Chapter 9, for further
discussion and examples.) Other procedures such as direct magnitude
estimation and visual analog scaling have been recommended, but to
date their application has been primarily in research (Baylis et al., 2015;
Whitehall et al., 2002).
• A binary judgment of present or absent for audible nasal emission and
nasal turbulence (because their very presence is abnormal), with
notation of their relative frequency of occurrence.
• A simple binary judgment of present or absent for hyponasality.
• A simple binary judgment of present or absent for voice deviation.
• Documentation of cleft-related misarticulations. The primary focus here
is on documentation of any nonoral compensatory articulations and
296
t.me/Dr_Mouayyad_AlbtousH
https://t.me/medicina_free
backed or retracted oral productions. Secondarily, other oral
misarticulations should be noted, chiefly distortions related to dental
and occlusal status. The special and controlled sampling contexts offer
a rich source of perceptual speech data, and the target error
transcriptions from the single-word and sentence tasks will help to
document the types of misarticulations. As recommended by
Henningsson et al. (2008), an error production must occur more than
once somewhere in the controlled speech sample (i.e., considering all
tasks) to be considered a “reliable” or stable speech error. The
transcription data also provide a database for computing percent
consonants correct (PCC) on the word or sentence stimuli, or both,
that can be used as a severity index and measure of change or
progress over time.
We realize that this type of detailed analysis cannot be accomplished
during busy school days, in busy clinics, and on team conference days.
In most cases, clinicians experienced in cleft palate speech assessment
are able to make perceptual judgments regarding a patient's resonance,
airflow, and types of cleft-related (placement) misarticulations rather
quickly and to determine whether the patient has or does not have VPI
or VPD. However, even the experienced team SLP needs to do a more
detailed analysis of articulation errors and error paerns to provide
appropriate and informative treatment recommendations and engage
in collaborative speech care with school-based SLPs or other
community-based providers. This is an especially important reason to
record the speech sample.
Articulation data can also be viewed in some type of matrix for error
classification that provides a framework for analysis (Bernthal and
Bankson, 2013; Grunwell, 1993; Stoel-Gammon, 1985). The standard
place-manner-voicing classification works well for cleft palate speech
analysis. Once the errors have been classified, error types—
substitutions (oral and nonoral), coproductions, omissions, distortions
—can be summarized, and error paerns involving hypernasality,
nasal emission, nonoral compensatory articulations, backed oral
productions, and adaptive oral misarticulations can be summarized. A
sample blank matrix is provided in Appendix 8-F.
297
t.me/Dr_Mouayyad_AlbtousH
https://t.me/medicina_free
Correlate the Perceptual Speech Data
With Orofacial Examination Findings
At this point, the speech data can be examined to determine any
relationships or correlations between oral structural or physical
findings and speech articulation errors.
For example, is the nasal air emission heard in a given patient's
speech the result of an oronasal fistula (and therefore
obligatory/passive rather than learned)? If so, the “fix” is closure of the
fistula, not speech therapy. Nasal air emission secondary to persisting
physical insufficiency of the VP system is similarly best approached
surgically or with an appliance. In contrast, nasal emission that persists
even in the absence of a fistula or physically based VPI or VPD points
to a learned paern and is an appropriate target for speech therapy, not
physical management. These correlations between perceptual speech
findings and oral structural findings, including dental and occlusal
deviations, are key components in the differential diagnosis and affect
treatment recommendations.
298
t.me/Dr_Mouayyad_AlbtousH
https://t.me/medicina_free
Interpret and Summarize the Clinical
Data
More often than not, experienced clinicians are able to diagnose or rule
out a true cleft-related or noncleft VP insufficiency based on the clinical
findings alone and can present a definitive speech diagnosis. In some
cases, however, the clinical evaluation does not yield a definitive
diagnosis. Instead, the SLP may develop a “diagnostic hunch” or a
more tentative diagnosis that usually warrants instrumental
assessment. Typically, this is an imaging study, to rule out or confirm a
true, physically based, VP dysfunction. For some youngsters, a period
of diagnostic therapy may be warranted before a successful or
informative imaging study can be obtained.
A speech assessment reporting form that provides a checklist for
rating and documenting salient cleft-related speech characteristics, and
making treatment recommendations, may be found in Appendix 8-G.
The form also provides a clear assessment summary that can be shared
with the treating school-based or other community-based SLP. As with
any form, you will likely want to modify it as you use it and, for those
of you in medical seings, to make it compatible with your facility's
electronic medical records system.
To help tie the pieces of this assessment process and its outcome
together, sample case data for EC, the almost 5-year-old boy you saw in
Videos 5-4 and 8-1, are provided in Appendix 8-H. The video excerpts
from the speech assessment on which this case data is based are
provided in Video 8-5
.
299
t.me/Dr_Mouayyad_AlbtousH
https://t.me/medicina_free
Identifying and Documenting Cleft
Palate Speech Errors
Identifying cleft-related speech errors calls on our ability to
perceptually identify unusual and atypical productions—nonoral
compensatory articulations (CAs) and backed oral productions—and to
understand their unique underlying articulatory gestures, as presented
in Chapter 5. Detecting the presence of nasal air emission and
resonance deviations, specifically hypernasality, is relatively easy.
Identifying paerns of audible nasal emission and judging or rating
severity of resonance deviations is more difficult. Likewise, gloal stops
are more frequently observed in cleft palate speech and are easier for
most clinicians to identify. By contrast, detecting pharyngeal stops,
distinguishing between nasal fricatives and coproduced nasal emission,
and distinguishing between pharyngeal and velar fricatives, are all
more difficult tasks. In this last section of the chapter, we present a
systematic step-by-step approach to diagnosis of cleft palate speech
deviations and errors. As you study this material, you may wish to
refer to Table 8-3 for the tasks used to collect the speech sample data.
Diagnostic Questions and Answers
Resonance Assessment
Hypernasal Resonance (Most Common Resonance Deviation)
1. Is hypernasality heard in connected speech?
• At this first level of analysis, this is a binary
judgment: present or absent.
2. If present, is the hypernasality intermient or continuous/pervasive?
• Intermient suggests:
300
t.me/Dr_Mouayyad_AlbtousH
https://t.me/medicina_free
— Marginal closure ability (the velopharyngeal
mechanism can achieve closure but does so
sporadically)
— Assimilation nasality associated with targets
affected by phoneme-specific nasal emission or
affected by “nearby” nasal consonants
• Continuous/pervasive suggests a physically based
velopharyngeal closure problem.
• Hypernasality can also be associated with rampant
gloal stop productions (and less so with pharyngeal
fricatives) that bypass the VP port and cause it to
stay open.
3. Can you feel nasal vibration (just above the nasal alae) on sustained
vowel productions?
• This tactile cue indicates excessive nasal cavity
resonance, but it may take a lot of practice to
“calibrate” your finger sensitivity to the cue. This is
not a sure-fire method of diagnosis.
4. Is there a resonance shift (a resonance difference) heard between
nares-closed and nares-open vowel productions, especially phonation
of /u/ and /i/? (Hint: For the “nares-closed” (cul-de-sac) condition, do
not forcibly pinch the child's nose. Doing so may result in artificial
hyponasality because you are reducing the size of the nasal resonating
cavity. To “plug” the nasal openings, simply place your thumbs
beneath them (thumbs up!) as shown earlier in Video 8-1, and make
sure the child cannot inhale except through his mouth.
301
t.me/Dr_Mouayyad_AlbtousH
https://t.me/medicina_free
Соседние файлы в папке Библиотека им академика М.И. Перельмана