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As discussed in Chapter 5, the mid-dorsum palatal stop is an exception
because it is an oral placement error.
Also, CAs can occur as substitutions or coproductions. In therapy, our
desired outcome is orally articulated high pressure consonants. Our
general objective is to establish oral place targets—to bring backed articulations
forward and therefore eliminate aberrant, atypical placements.
In this discussion, our sole intent is to provide you with an
operational framework for conducting effective articulation therapy for
cleft-related speech errors, specifically nonoral CAs. Our emphasis is on
providing you with procedures and techniques to accomplish the
following:
1. Teach concepts that underlie place learning.
2. Establish the oral target place, oral pressure buildup in that place, and
release from that place.
3. Ensure adequate speech discrimination and self-monitoring skills.
4. Eliminate the nonoral placements and coproductions.
We do not discuss the “extratherapeutic” elements of therapy
delivery. In other words, we assume that you are familiar with
reinforcement schedules, the use of tokens (as necessary), and the
various components of record keeping that are essential to charting
responses during treatment sessions and documenting progress and
change. We assume that you know how to apply traditional articulation
therapy procedures and how to move through the contextual hierarchy
once the child has learned how to make the target sound. If you believe
that you need further guidance in any of these areas, the text by
Bernthal et al. (2013) is an excellent resource. Our approach is generally
compatible with these authors' traditional approach for motor-based
intervention. This approach incorporates four basic motor learning
principles:
1. Cognitive analysis of the error. This is used for internalization of targets
and facilitating generalization (identification and discrimination
learning).
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2. Practice of the motor skill (new target production) in limited contexts
until correct execution (placement) of the movement is achieved
(practice in isolation and syllabic contexts). This is the most significant
tenet of motor learning.
3. Stages of motor skill development. For the learner, there is a progression
from acquiring the speech gesture to perfecting and stabilizing the
movement through repeated practice, to making it an automatic skilled
movement, which becomes a part of the repertoire of other similar
skilled movements (mastering production at all levels of the hierarchy of
contexts, syllables to spontaneous speech, and generalization to other
related target sounds).
4. Feedback. Intrinsic/internal and extrinsic/external sensory feedback
processes (self-monitoring, error detection and correction) are important
to eliminating the error behavior. (For additional reading on motor
learning theory, see Zwicker and Harris, 2009; for additional
information on application of motor learning principles to treatment of
CAs, see Ruscello and Vallino, 2014.)
Intrinsic feedback is the learner's auditory, visual, tactile-kinesthetic
feedback as a result of the movement. Extrinsic feedback is the
clinician's (or parent's) feedback regarding the learner's performance on
the specific task (verbal feedback, demonstration). Children seem to
perform beer with 100% feedback during motor skill acquisition,
whereas adults do beer with sporadic delayed feedback.
We now turn our aention to what we actually do (and say) in
therapy. We start by providing guidelines that are generally applicable
to treating the group of cleft-related nonoral misarticulations. We then
provide some techniques tailored to treat (1) specific nonoral CAs, (2)
backed oral productions, and (3) learned nasal emission.
Before starting treatment, make sure that both the parent and child
understand the problem and that the child knows his or her articulators
well enough to benefit from phonetic placement instructions.
Mirror work is especially important in teaching phonetic placement.
Make sure you and your patient are siing side by side in front of a speech
mirror that is large enough to reflect you both. The mirror holds a young
child's aention and, for any age, provides for visual modeling and
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matching of speech gestures and visual feedback. For most youngsters,
auditory modeling alone is not adequate for eliminating CAs.
Treating Nonoral Placement Errors and Airflow
Direction Errors: Some General Guidelines
1. Use the lateral diagram and “place map” illustrations to describe the place
of the desired oral target, to point out how it is different from the error
place of production (to contrast target and error placements), to explain
what is happening during coproductions, and so forth.
• These illustrations also can be used for teaching or
review of phonetic placement language and concepts
(e.g., front of the tongue, back of the palate, in the
throat).
It is assumed that a school-aged child understands the mouth and can
follow phonetic placement instructions, as presented earlier in this
chapter. If not, this will need to be an initial teaching activity. Video 124
shows a school-aged youngster who needed this instruction.
2. Aach the orthographic symbol to the target sound. (For younger
children, this will be new learning; for older “readers,” it is a facilitative
visual association with the target sound; oral reading, with the target
sound highlighted or underlined, can be incorporated into speech
homework activities). While working on the sound in therapy, mount it
on a corner of the mirror, and use it as the start page for that sound's
section in the speech notebook.
3. As we all know, it helps to give sounds special names. For the nonoral
placement and airflow errors, and for teaching placement
discrimination and production contrasts, the following name sounds are
useful:
• “Mouth sound” for the desired oral target
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• “Throat sound” for a pharyngeal: stop, fricative, or
affricate
• “Voice box sound” for a gloal stop or /h/
• “Nose sound” for a nasal fricative or intentional
coproduced nasal emission
4. Teach or verify auditory and visual discrimination skills for error
versus desired target.
Perceptual training involving auditory and visual identification of the
target sound and discrimination from the error production and from
other sounds is a standard component of the traditional, motor
phonetic approach.
Using the lateral diagram and [
] (voice box sound) for /p/ (mouth
sound) substitution as an example, your instructions would be similar to
the following:
• “I am going to make some sounds, and I want you to
listen very carefully and to watch my mouth, too.
Sometimes I will bring my lips together and make a
mouth sound, like this, ‘ph’ (clinician makes the
sound), and sometimes I will make a voice box sound
like this, ‘[
]’ (clinician makes the compensatory
sound as best as she or he can). Every time you hear a
mouth sound and see my lips come together, point to
the mouth or lips. Every time I make a voice box
sound, point to the voice box.”
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The lateral diagram can be used to visually represent the place for the
child's “mouth” or “voice box” responses. Hand-drawn pictures or
(personal) photographs of “mouth” and “voice box” also can be used.
You probably also have your own creative ideas.
• “Let's practice first. When I say ‘ph’ you point to the
lips; when I say ‘[
]’ you point to the voice box.
Listen, and watch my face very carefully in the
mirror, because these sounds sound different and they
look different.”
• Similar procedures can be applied to therapy for
other nonoral or postuvular errors, including
pharyngeal errors (“throat sounds”) and
learned/intentional nasal emission errors (“nose
sounds”).
5. Use phonetic placement techniques and imitation to teach and
establish oral place of production and get the sound into the inventory.
• You may need to work first to establish correct place of
production only, in the absence of other production
features. Practice just bringing the target articulators
together. Most children get this quickly and do not
need extended drill to “learn” this. Some children
may require “silent drill” practice before adding
manner and voicing features.
• In teaching the target sounds, be sure to incorporate
auditory, visual, and tactile teaching and learning
strategies.
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Remember to sit side by side with the child so you both are facing the
mirror.
For example, if the error is gloal stop
realization
for /p/, you would first model the (whispered) /p/
(“ph”) with strong aspiration; your instructions and
descriptions be similar to this:
— Visual: “Watch me make the sound: ‘ph’; now watch
again, watch how my lips touch; I'm going to make
some more sounds (slowly): ‘ph ph ph ph ph’; I am
making the sound here, with my lips” (point to lips
on the lateral diagram and on yourself and then on
the child), “not down here (point to vocal folds on the
lateral diagram), not down here with my voice box”
(point to larynx area on the diagram or lower neck
area on yourself and then on the child). “Let's put a
big X on the voice box to remind us not to use the
voice box to make this sound. We don't want to make
it there.”
— Auditory: “I can hear a puff of air come through my
lips. Listen to how it sounds: ‘ph’; listen some more:
‘ph ph ph ph ph’.”
— Tactile: “I can feel my lips touching, and I can feel the
air come out by my lips. Here, let me make some
more sounds, and now you hold your hand in front
of my mouth to feel it.”
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• Use facilitating contexts and shaping procedures. As
applied to cleft palate speech, for example, low
pressure consonants and nasals in the inventory are
facilitating contexts for homorganic high pressure
targets (targets sharing the same place of
articulation):
Facilitating contexts are phonemes in the speaker's inventory that are
used to elicit desired (placement) targets. Shaping uses facilitating
phonemes to reach the target placement successively, also known as
successive approximation.
— Use /m/ or /w/ to facilitate bilabial closure for /p, b/.
— Use /l/ or /n/ to facilitate tongue tip or blade
placement for /t, d/ or /s, z/.
— Use /j/ to facilitate mid-dorsum to mid-palate
placement for /
/.
— Use /
/ to facilitate /k, ɡ/.
Similarly, /
/ shapes to /s/ by advancing the tongue
tip; /θ/ shapes to /s/ by retracting the tongue tip, and
so forth. You can also use the compensatory
pharyngeal stop to shape to /k/ by moving the base of
the tongue up and forward.
6. In general, teach voiceless targets first. For example, if a child substitutes
gloal stop [
] or uses a gloal stop coproduction for /p, b, t, d, k, ɡ/,
start by targeting /p/, /t/ or /k/. For pharyngeal fricative substitutions,
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start by teaching /s/ or / /, and so forth. Some children may
spontaneously generalize the new production learning to other voiceless
stops and their voiced cognates; others need to be taught more on a
sound-by-sound basis. As mentioned earlier with regard to stops, some
children do beer starting with the voiced target.
7. Some children may correctly produce one or two sounds that are in
the same manner class as the affected targets. In other words, /p/ may be
an acceptable bilabial stop, whereas /t/ and /k/ are replaced by gloal
stops. If placement instructions and imitative modeling are not
successful in eliciting the /t/ or /k/, you can make use of the auditory and
intraoral airflow and air pressure buildup sensations associated with the
“good /p/” to teach the same pressure behavior for production of
alveolar /t/ and velar /k/. You can use the lateral diagram to illustrate
how airflow is stopped and pressure builds up behind the target place
(the stopping point). Figure 12-8 illustrates this for /p, t, k/.
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FIGURE 12-8 Points of airflow stop-release for bilabial, alveolar,
and velar stop consonants. A, Stopping place for /p, b/. B,
Stopping place for /t, d/. C, Stopping place for /k, g/.
Your instructions would be like the following:
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• “Your ‘ph’ sound is really good; let's make a ‘ph’ now.
Look in the mirror and watch how you keep your lips
together and puff up your cheeks when you make
‘ph’. Touch your cheeks and feel how much pressure
is inside of your mouth. Your lips are stopping the air
—right here.” (Illustrate where on the illustration; see
Fig. 12-8, A.) “When you open your lips, the air can
get out.” “Now let's try making the ‘ph’ this way:
make a nice ‘long hh’ like this (demonstrate ([h:]).
Now make the ‘hh’ and stop the air with your lips,
puff up your cheeks, and keep the air trapped.
(Phonetically, this would be [h:p].) Now, let the air
out like this to make ‘ph’.” (demonstrate the release of
the /p/). (Phonetically, this would be [h : ph].) “Let's
practice this a few times.”
• For /t/: “Now let's try trapping the air with your
tongue (with the tip of your tongue) instead of your
lips. Look in the mirror and put your tongue in the
‘th’ place, up behind your top teeth, like this (model
the place for the child and illustrate the place on the
lateral diagram); good, that's the right place.
In phonetic placement teaching, it is important to give continuous
feedback because this is where the new motor skill is being taught,
practiced, refined, and automatized in preparation for transfer and
generalization to increasingly complex speech contexts.
Now let your tongue go back down and say ‘hh’. Put
your tongue up there again to stop the ‘hh’ from
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