Aphasia Resources

Client/Family:

http://www.aphasia.org/content/communication-tips

• This webpage has a long list of dos and don’ts for caregivers about how to communicate with their loved one with aphasia. It provides useful tips to help communication partners re-establish their interactions, especially after their typically communication patterns have been abruptly altered. Many of these strategies are also beneficial for communication in general.

http://strokesupport.com/info/aphasia/aphasia_resources.htm

• This is another great resource for caregivers for those who have aphasia. It emphasizes self-care for the caregiver and provides coping mechanisms for dealing with the stresses and frustrations of communicating with someone who has aphasia. It gives suggestions for getting involved in their loved one’s therapy in the hospital and at home.

https://www.aphasia.com/about-aphasia/resources/

• This website provides a comprehensive list of website links which give tons of general information about what aphasia is, how it is assessed, how it can be treated, what the prognosis might look like, where to find help, and much more. The information found within the links on this page is endless and extremely useful for a person who has recently suffered a stroke and who has been diagnosed with aphasia.

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SLP:

http://www.asha.org/Practice-Portal/Clinical-Topics/Aphasia/

• This website from ASHA has lots of information about aphasia for a speech-language pathologist who may not be familiar with what it is or how it is assessed or treated. This page has general information about the common practices of speech pathologists regarding aphasia. This could also be used as a way to explain aphasia to clients in terms that are easier to understand by non-speech/language professionals.

http://www.mnsu.edu/comdis/kuster2/sptherapy.html#aphasia

• This webpage has a large list of links for everything aphasia. From assessment tools to treatment techniques, this site has many options for treating all kinds of aphasic symptoms and deficits. This would be a good place to start if an SLP were unsure which approach for therapy to take.

http://www.aphasia.org/content/aphasia-therapy-guide

• This therapy guide for aphasia outlines two different approaches to aphasia therapy: the impairment approach and the communication approach. The impairment approach focuses on remediating deficits while the communication approach focuses on using the client’s strengths to compensate for their weaknesses. It is important to consider your client’s wants and needs when deciding what approach to take in therapy, as you want the approach to fit the client’s lifestyle and level of functioning.

Aphasia Initial Goal Areas

Here are some initial areas to work on for people with aphasia:

1. Decrease jargon
2. Increase verbal output
3. Decrease paraphasias
4. Decrease perseverations
5. Increase word-finding abilities
6. Increase involvement in desired activities
7. Decrease one-sided hemineglect
8. Increase auditory comprehension
9. Increase reading comprehension
10. Increase graphic expression

Aphasia Assessment

***NOTE: Before beginning testing, establish a reliable yes/no communication system with your client. Not doing this will potentially effect validity of test results.***

Formal Tests:

• Boston Diagnostic Aphasia Examination (BDAE)
• Aphasia Diagnostic Profile (ADP)
• Boston Assessment of Severe Aphasia (BASA)
• Western Aphasia Battery (WAB)
• Minnesota Test for Differential Diagnosis of Aphasia (MTDDA)
• Porch Index of Communicative Ability (PICA)
• Communication Abilities of Daily Living (CADL)
• Reading Comprehension Battery for Aphasia (RCBA)
• Cognitive Linguistic Quick Test (CLQT)

Informal Tests:

• Name items around the room (confrontation naming)
• Name animals that start with “m” (generative naming)
• Ask open-ended questions (“wh-” questions)
• Ask emotionally charged questions
• Basic conversation and interview (language sample)
• Cookie Theft Picture (verbal/graphic expression)
• Clock drawing (perseverations?)
• Cancellation activity
• Test attention (how long can they attend to tasks?)

Interview Questions:

1. What happened to you?/What is your story?
2. What is your medical history?
3. What is your occupation?
4. What kinds of activities do you like to be involved in?
5. What is hardest for you to do? Easiest?
6. Do you have trouble finding the names of different items?
7. Which is your dominant hand?
8. Do you have trouble reading or writing?
9. What would you like to do again?
10. What are your hobbies/likes and dislikes?

Aphasia – In General

Aphasia is an acquired communication disorder resulting from damage to the brain, characterized by impairment in the production and/or comprehension of language across spoken, written, and signed modalities. It is NOT the result of sensory or motor deficits, a general intellectual deficit, confusion or psychiatric disorder.

Four key components:

1. Neurogenic
2. Acquired
3. Language issues
4. Not an intellectual/sensory/motor issue

Causes:

• Cerebral Vascular Accident (CVA)
• Traumatic  Brain Injury (TBI)
• Seizures
• Tumors
• Neurogenerative Disorders

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Types of Aphasia:

Fluent (9+ words phrase length)

Types:

• Wernicke’s
• Conduction
• Transcortical-sensory
• Anomic

Nonfluent (0-5 words phrase length)

• Broca’s
• Global
• Transcortical-motor
• Mixed

Borderline (6-8 words phrase length)

• Thalamic
• Anterior capsular-putaminal
• Posterior capsular-putaminal

Areas to look at with aphasia:

1. **Naming abilities**
2. Articulatory agility
3. Prosody
4. Phrase length
5. Paraphasias
6. Auditory comprehension
7. Repetitions
8. Perseverations
9. Use of syntax
10. Substantive vs. Functor word ratio

(Class notes, SPAUD 501)

http://www.ukconnect.org/toptips.aspx

VIDEOS:

Nonfluent aphasia:

• https://www.youtube.com/watch?v=1aplTvEQ6ew

Fluent aphasia:

• https://www.youtube.com/watch?v=aVhYN7NTIKU

Childhood Speech Sound Disorders Initial Goal Areas

Here are some initial goals for childhood speech sound disorders:

– Phonological Processes:

1. Increase fricative production to decrease stopping
2. Increase back sounds like /k/ and /g/ to decrease fronting
3. Increase final sounds in words to decrease final consonant deletion
4. Increase overall production of sounds not currently in child’s repertoire
5. Increase child’s awareness of their misarticulations and encourage self-correction

– Articulation:

1. Increase /r/ production in single words
2. Decrease lateral lisp
3. Increase child’s awareness of their misarticulations and encourage self-correction

– Childhood Apraxia of Speech

1. Lengthen utterances
2. Increase initiation of speech
3. Increase use of polysyllabic words

http://www.tayloredmktg.com/dyspraxia/downloads/iep_sample.pdf – This is a sample IEP for a 3-year-old child who has childhood apraxia of speech. It has a variety of goals to work on for CAS in toddlers and preschool-age children.

Child Speech Sound Disorders Resources

For Client/Family:

http://www.apraxia-kids.org/guides/family-start-guide/

• This “Apraxia Kids” website has a long list of helpful resources for parents of a child who has been diagnosed with CAS. It provides a “start guide” for the family to help them understand what CAS is, how it’s assessed, how treatment might look, and potential prognostic outcomes. Another important component that is included in this resource is methods for coping with a diagnosis like this and explaining feelings and emotions that might be felt by the family of a child with CAS.

http://www.playingwithwords365.com/2011/09/phonological-processes-and-phonological-delay/

• This blog post is written by an SLP for parents, explaining what phonological processes is in layman’s terms so the parents can understand what is happening with their child’s speech production. It also includes a chart of all the different phonological processes with examples so that they can understand what the different terms mean. It also distinguishes phonological processes from a phonological delay, and gives parents some basic information about how to look for these things in their child’s speech.

http://mommyspeechtherapy.com/?p=1935

• This site has two great pdf images which will help parents to understand the development of articulation in children (which sounds typically develop when) and how therapy helps to develop the sounds. This is a great resource for parents to use in determining if their child is meeting articulation milestones as well as helping them to understand how their child with articulation errors compares to a typically developing child.

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 For SLP:

http://mommyspeechtherapy.com/?p=1623

• This blog post provides great information for the SLP working with articulation children. It helps give insight into how to set goals for your child depending on the sounds they can make and which ones give them trouble. It also has a wonderful chart tool for tracking progress in each sound as the child progresses from isolated sound productions to single words to sentences.

Click to access Apraxia.pdf

• This pamphlet is a good resource for SLPs who want to know more about assessment of childhood apraxia of speech. It provides formal and informal test suggestions as well as a brief introduction to what CAS is. It also delineates the different treatment approaches for intervention for a child with CAS.

http://www.home-speech-home.com/phonological-processes.html

• This website is a great source of information for an SLP working with children who have phonological process issues.  It provides an in-depth chart of  all the phonological processes, what is happening when phonological processes are occurring and examples of what those phonological processes look like. It also discusses impacts of phonological process issues on later reading, academic and language skills as well as briefly mentions assessment and treatment methods.

Childhood Speech Sound Disorders Assessment

Interview Questions:

1. How are they doing in school?
2. Are they able to be understood by an unfamiliar listener?
3. Are they able to communicate and interact with their peers?
4. What percentage of your child’s speech would you say you, as parents and familiar listeners, are able to understand?
5. Are there specific sounds/words you notice your child struggles with?

Formal Tests:

• Goldman-Fristoe Test of Articulation (GFTA)
• Hodson Assessment of Phonological Processes (HAPP)
• Clinical Assessment of Articulation and Phonology (CAAP)
• Comprehensive Test of Phonological Processing (CTOPP)
•  The Apraxia Profile
• Screening Test for Developmental Apraxia of Speech (STDAS)
• Kaufman Speech Praxis Test (KSPT) for Children – to determine presence of motor speech problems

*Screen for language as well since there is a high correlation of language problems and phonological deficits*

Informal Assessment Tools:

• Speech sample – reading sample or play
• Speech sound inventory – determine patterns of error
• Probe for different abilities and stimulability of different sounds

http://www.playingwithwords365.com/2011/09/phonological-processes-and-phonological-delay/

http://ilovecharts.tumblr.com/post/3424671278/these-are-the-typical-ages-by-which-children-in

Verbal Apraxia	Phonological Disorder
No weakness, incoordination or paralysis of speech musculature	No weakness, incoordination or paralysis of speech musculature
No difficulty with involuntary motor control for chewing, swallowing, etc. unless there is also an oral apraxia	No difficulty with involuntary motor control for chewing and swallowing
Inconsistencies in articulation performances – the same word may be produced several different ways	Consistent errors that can usually be grouped into categories (fronting, stopping, etc.)
Errors include substitutions, omissions, additions and repetitions, frequently includes simplification of word forms. Tendency for omissions in initial position. Tendency to centralize vowels to /ə/	Errors may include substitutions, omissions, distortions, etc. Omissions in final position more likely than initial position. Vowel distortions not as common.
Number of errors increases as length of word/phrase increases	Errors are generally consistent as length of words/phrases increases
Well-rehearsed, automatic speech is easiest to produced, while volitional speech is most difficult	No differences in how easily speech is produced based on situation
Receptive language skills are usually significantly better than expressive skills	Sometimes differences between receptive and expressive language skills
Rate, rhythm and stress of speech are disrupted, some grouping for placement may be noted	Typically no disruption of rate, rhythm or stress
Generally good control of pitch and loudness, may have limited inflectional range for speaking	Good control of pitch and loudness, not limited in inflectional range for speaking
Age-appropriate voice quality	Age-appropriate voice quality

Adapted from http://www.apraxia-kids.org/site/apps/nl/content3.asp?c=chKMI0PIIsE&b=788447&ct=464135

Child Speech Sound Disorders – In General

What are child speech sound disorders?

Speech sound disorders can be broken into three different areas:

• Articulation: Structural difficulty making one or two sounds with no linguistic component (e.g. a lisp or /r/ misarticulation)
• Phonology: Linguistic-based phonological error patterns, such as phonological processes (e.g. fronting, stopping, devoicing, etc.)
• Childhood Apraxia of Speech (CAS): A neurological childhood speech disorder in which precision and consistency of speech sound movements are impaired in the absence of neuromuscular deficits

Traditional categories of speech sound disorders:

• Substitutions
• Omissions
• Distortions
• Additions

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A bit more about CAS:

– The core impairment is planning, programming and sequencing of speech movements.

– Key Charactaristics:

• Inconsistent errors
• Lengthened and disrupted coarticulation – choppy or stretched speech
• Altered prosody – slower speech or excess stress on words
• Groping/visual searching for articulatory positions
• 2 to 3 feature articulation erros
• Vowel errors
• Sound distortions
• Sound additions – especially schwas
• Slower rate of diadochokinetic rates
• Syllable structure regression with word length or repetition
• Sometime nasality
• Breakdown as words get longer

In a younger child, look for:

1. No cooing or babbbling
2. Late first words
3. Missing sounds
4. Lots of vowels and few consonants
5. Problems combining sounds and syllables
6. Replacing difficult sounds with easier ones
7. Oral apraxia and feeding issues

In an older child, look for:

1. See characteristic list above
2. A gap between expressive and receptive language abilities
3. Imitation may be easier than volitional speech

(Class notes, SPAUD 501)

Dysphagia Initial Goals

DYSPHAGIA GOALS
LONG TERM GOALS – SWALLOWING
• Client will maintain adequate hydration/nutrition with optimum safety and efficiency of
swallowing function on P.O. intake without overt signs and symptoms of aspiration for the
highest appropriate diet level
• Client will utilize compensatory strategies with optimum safety and efficiency of swallowing function on P.O. intake without overt signs and symptoms of aspiration for the highest
appropriate diet level

 

Swallow Study
• Complete a Modified Barium Swallow/Fiberoptic Endoscopic Evaluation of the Swallow to fully assess physiology and anatomy of the swallow and to determine the appropriate diet and/or rehabilitation exercises.
• Complete a Clinical Swallow Evaluation to determine appropriateness of current diet/need for MBS …
Mastication
• Patient will masticate food adequately to safely consume least restrictive diet with
(min/mod/max) verbal, visual and tactile cues
Jaw Coordination/Sensation
• The patient will complete daily oral-motor exercise to increase buccal tension to within
functional limits to eliminate pocketing of food in the anterior and lateral sulci with
(min/mod/max) verbal, visual and tactile cues and ___% effectiveness
• The patient will complete daily oral-motor exercise to increase jaw closure and reduce anterior loss to keep food/liquid in the mouth while eating with (min/mod/max) verbal, visual and tactile cues and ___% effectiveness
Oral Coordination/ Sensation
• Patient will complete daily oral-motor exercise to increase oral sensitivity to a functional level forbolus formation and optimum safety with (min/mod/max) verbal, tactile and visual cues with ___% effectiveness
• The patient will demonstrate a swallow delay of only 1-2 seconds following thermal tactile
stimulation on 10/10 therapeutic trials to reduce the risk of food residue falling into the airway
• Patient will utilize thermal tactile stimulation to increase oral sensation for safe consumption of least restrictive diet with (min/mod/max) verbal, visual and tactile cues
• The patient will move the bolus to the back of the mouth and propel the food and liquid in a timely manner with thermal tactile stimulation to safely consume least restrictive diet with (min/mod/max) verbal, visual and tactile cues
Lip Coordination/Sensation
• The patient will complete daily oral-motor exercise to increase labial function (min/mod/max) verbal, tactile and visual cues with ___% effectiveness to prevent food or liquid spillage from the oral cavity
• The patient will keep food and liquid in the mouth while eating without losing the bolus out of the front of the mouth to safely consume least restrictive diet with (min/mod/max) verbal, visual and tactile cues
Lingual Coordination/Sensation
• The patient will complete daily oral-motor exercise to increase lingual range of motion, strength and coordination with (min/mod/max) verbal, tactile and visual cues with ___% effectiveness for effective bolus formation and to reduce the risk of food residue falling into the airway
• The patient will complete daily oral-motor exercise to increase lingual strength and range of motion for adequate lingual elevation and anterior to posterior movement with(min/mod/max) verbal, tactile and visual cues with ___% effectiveness to reduce the risk of food residue falling into the airway
• The patient will form food and liquid into a cohesive bolus as demonstrated by lack of residue on the tongue and in the lateral and anterior sulci after the swallow to safely consume least restrictive diet with (min/mod/max) verbal, visual and tactile cues
Diet Trials/ Therapeutic feedings
• The patient will tolerate diet upgrade trials without signs and/or symptoms of aspiration with to safely least restrictive diet with (min/mod/max) verbal, visual and tactile cues
• Patient will safely ingest diet trials during therapeutic feedings with the SLP without signs and/or symptoms of aspiration with to safely consume least restrictive diet with (min/mod/max) verbal, visual and tactile cues
Techniques
• The patient will complete _____ swallowing maneuver (supraglottic swallow, Mendelson
maneuver, effortful swallow, etc.)to improve oral motor weakness, tongue base retraction,
hyolaryngeal excursion, airway protection, and/or clearance of the bolus through the pharynx with (min/mod/max) verbal, visual and tactile cues
Compensatory
• Patient will perform compensatory swallow strategies (chin tuck, multiple swallows, head turn, etc.) to eliminate s/s of aspiration of _________ least restrictive diet with (min/mod/max) verbal cues and no more than __# reminders per meal.
• Patient will perform compensatory swallow strategies (chin tuck, multiple swallows, head turn, etc.) to eliminate s/s of aspiration of _________ liquids (min/mod/max) verbal cues and no more than __# reminders per meal.
• The client will demonstrate the ability to adequately self-monitor swallowing skills and perform
appropriate compensatory techniques to reduce s/s of aspiration and to safely consume least restrictive diet with (min/mod/max) verbal, visual and tactile cues
• The patient will alternate liquids-solids bites to clear stasis in buccal cavity with (min/mod/max) visual, verbal and tactile cues

Click to access AdultGoalsandObjectives.pdf

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Food Ideas

Hot Foods	Cold Foods
Puréed meats, poultry, & fish	Puréed cottage cheese
Puréed tuna, ham, & chicken salad	Puréed fruit
Pureed scrambled eggs & cheese	Thickened juices & nectars
Baby cereals	Thickened milk or eggnog
Thinned cooked cereals (no lumps)	Malts
Puréed French toast or pancakes	Thick milkshakes
Mashed potatoes	Ice cream
Puréed parsley, au gratin, scalloped potatoes, candied sweet potatoes	Fruit or Italian ice, sherbet
Puréed buttered or Alfredo noodles	Plain yogurt
Puréed vegetables (no corn or peas)	Smooth & drinkable yogurt
Puréed soups & creamed soups	Smooth pudding, mousse, custard
Puréed scalloped apples	Whipped gelatin
Gravies	Sugar, syrup, honey, jelly
Sauces: cheese, tomato, barbecue, white, creamed	Cream
Decaffeinated coffee or tea	Non-dairy creamer
	Margarine
	Mayonnaise
	Ketchup, mustard

Sample Menu, Level 1
Breakfast	Lunch	Dinner
orange juice 1/2 cup cream of wheat 1/2 cup scrambled eggs with cheese 1/2 cup decaffeinated tea 1 cup whole milk 1 cup non-dairy creamer 2 Tbsp ketchup 1 Tbsp margarine 1 tsp salt 1/4 tsp sugar 2 tsp	pineapple juice 1/2 cup puréed beef 3 oz gravy 2 Tbsp mashed potatoes 1/2 cup puréed fresh broccoli 1/2 cup apple sauce 1/2 cup decaffeinated coffee 1 cup non-dairy creamer 2 Tbsp margarine 1 tsp salt 1/4 tsp sugar 1 tsp	puréed turkey barley soup 3/4 cup puréed Hawaiian chicken3 oz mashed potatoes 1/2 cup puréed spinach 1/2 cup frozen yogurt 1/2 cup decaffeinated tea 1 cup non-dairy creamer 2 Tbsp margarine 1 tsp salt 1/4 tsp sugar 1 tsp

http://gicare.com/diets/dysphagia-diet/

Dysphagia Resources

Client/Family:

http://www.asha.org/public/speech/swallowing/Swallowing-Disorders-in-Adults/

• This website made my ASHA is a great starting place for a client or family member who wants to learn more about swallowing disorders. It begins with an explanation of how normal swallowing works, and then it explains how swallowing can be affected. It also provides information about how dysphagia can be assessed, diagnosed and treated by a speech-language pathologist.

http://www.dysphagiaonline.com/en/pages/08_tips_for_managing_life_with_dysphagia.aspx

• This website provides a plethora of tips for someone who suffers from dysphagia. It outlines what kinds of foods fit into what type of dietary restrictions and even provides an example menu for someone on a restricted diet and liquid intake. These food ideas and tips can make living with a swallowing disorder easier to manage and overcome.

http://swallowingdisorderfoundation.com/the-hungry-games-a-true-short-story-of-life-with-dysphagia/

• This is a blog post written by Julia Shay Tuchman, a writer in New York City who struggles with dysphagia. She gives an honest and real description of what it is like living with chronic dysphagia and the hardships that come along with it. Her emotions in the blog are raw, but definitely felt by those who suffer from a swallowing disorder who simply want to have normality restored to their life through their ability to eat normally.

Professional:

http://www.ucs.louisiana.edu/~ncr3025/roussel/codi531/assessment.html

• This is a thorough description of how a speech pathologist should assess a person who has suspected swallowing problems. It provides detail instructions for pre-swallowing assessment, oral motor and mechanism assessment, bedside swallowing assessment and videofluoroscopy assessment. Following this procedure will give a very comprehensive look at the patient’s swallowing abilities.

http://www.nhs.uk/Conditions/Dysphagia/Pages/Treatment.aspx

• This webpage provides different treatment techniques based on the type of swallowing problem the client is having. Depending on the where the dysphagia is occurring will determine what techniques will make it safer and more effective for the person to swallow. This is a valuable resource for speech pathologists treating different types of dysphagia.

http://jslhr.pubs.asha.org/article.aspx?articleid=1773397&resultClick=3

• This research study presents the idea that neural plasticity impacts the potential rehabilitation of dysphagia. It states that by integrating what is known about neural plasticity in combination with dysphagia therapy, improvements can be made in the client’s swallowing abilities. This would be beneficial for speech pathologists to utilize, as neural plasticity may be a significant strength of the client where many other areas are weak.

Dysphagia Assessment

The Assessment

– Gather information: Review their chart thoroughly, conduct an interview with the client, consider psychological and situational factors (are they refusing to eat? do they have reflux? what is their eating environment like? what is their cognitive status and alertness?)

– Oral Mechanism Exam: Have the client execute a number of speech and non-speech oral movements, such as sticking out their tongue, rapidly saying /pa/ or /ka/ or /ta/, phonating, etc. Look for unilateral or bilateral weakness or incoordination in their movements, if they appear to have sensation of food or saliva in or around their mouth, and listen for frequent throat clearing and coughing which may indicate laryngeal or pharyngeal weakness.

– Presentation of Foods and Liquids: Start with small bites of an easy-to-eat food, such as applesauce or something pureed. Progress to foods that are harder to eat (chewier, crunchier, etc.) Clinically assess their swallowing ability and make decision if they should be place on restricted diet/liquids or if further evaluation is necessary. Do they have anterior or posterior leakage as they eat? Do they have the ability to chew sufficiently? How well do they clean mouth after eating? Is there pocketing of food? Do they have coughing or gurgling or wet vocal quality after swallowing? Do they have sufficient laryngeal elevation to swallow properly?

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Formal Tests:

1. Bedside Evaluation of Dysphagia (BED)
2. Dysphagia Evaluation Protocol
3. Quick Assessment for Dysphagia
4. Swallowing Abilities and Function Assessment (SAFE)

Informal Assessment Tools:

• Observe the patient as they swallow.
  • Does food fall out their mouth as they are chewing/swallowing?
  • Is their food not chewed properly?
  • Does it take them a long time to chew and swallow?
  • Is there excessive residue left in their mouth after they swallow?
  • Is their posterior leakage as they are about to swallow?
  • Are they doing any excessive tongue pumping?
  • Is their laryngeal elevation insufficient?
  • Are they coughing, choking or have a wet vocal quality after they swallow?
  • Do they have watery eyes or sneezing after they swallow?
• Observe the patient’s oral strength, coordination, range of motion, and symmetry.

(Class notes, SPAUD 501)

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Interview Questions:

Do you have difficulty swallowing? In what way?

Is the swallowing difficulty greater for solids or liquids?

Do you have this sensation without swallowing food?

How long has swallowing difficulty been present?

Can you localize the dysphagia?

Has heartburn been associated with the dysphagia?

Is swallowing painful?

Do you get chest pain?

Does food get stuck when you swallow?

Do you choke or cough with swallowing?

Is there temperature sensitivity to dysphagia (especially cold)?

Has there been weight loss?

http://www.ncbi.nlm.nih.gov/books/NBK408/

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Swallowing Studies:

Normal swallow: https://www.youtube.com/watch/?v=PwVreNrTKBw

Abnormal swallow with aspiration: http://www.youtube.com/watch?v=1sFNMk87558

Dysphagia – In General

What is dysphagia?

Swallowing disorders, also called dysphagia, can occur at different stages in the swallowing process:

• Oral phase – sucking, chewing, and moving food or liquid into the throat
• Pharyngeal phase – starting the swallowing reflex, squeezing food down the throat, and closing off the airway to prevent food or liquid from entering the airway (aspiration) or to prevent choking
• Esophageal phase – relaxing and tightening the openings at the top and bottom of the feeding tube in the throat (esophagus) and squeezing food through the esophagus into the stomach

http://www.asha.org/public/speech/swallowing/Swallowing-Disorders-in-Adults/

If a person is not swallowing properly, this can be dangerous to their health. They may aspirate food or liquid and contract pneumonia. Because of this danger, putting patients on a modified diet is crucial:

Liquids:

• Thin – like regular water
• Nectar – like a light syrup
• Honey – like honey
• Pudding – thicker consistency, although this is more rarely used

Diet:

• Pureed – like baby food, applesauce, mashed potatoes
• Blendarized – chunkier and less smooth
• Mech soft – like well-cooked pasta, cooked veggies, etc.
• General – no restrictions

Fluency Resources

For client/family:

http://www.asha.org/public/speech/disorders/stuttering.htm

• This website from ASHA can answer many questions that parents typically have when their child has a stutter. It describes what a stutter is, explains how it can affect the child, delineates how an assessment might look and explains what a speech pathologist might be able to do to help. This is a great resource for people who want initial information about stutters and what next steps they can do do help their child.

http://stutteringtreatment.org/aboutstuttering1.php

• This website provides great information for the client’s family about what stuttering is in a way that is understandable. By clicking on the next links, family members can learn about the other impacts stuttering can have, such as physical impacts and emotional and psychological impacts. There is much more beneath the stutter itself that can influence a child’s communication.

http://www.stutteringhelp.org/resources-parents

• This website gives a long and comprehensive list of books for parents of a child who stutters, providing resources for parent’s of children of all ages. These could be invaluable resources to learning more about their child’s condition and understanding how they can help in their life and their process of overcoming their stutter.

For SLP:

http://www.asha.org/Publications/leader/2003/031118/f031118a/

• This article from the ASHA Leader magazine can help the SLP understand better what cluttering is, how it is different from stuttering and also how it often occurs with stuttering. An explanation of what to look for can assist in the diagnosis of cluttering. The article also provides some ideas for treating a child who has cluttering, as it is a lesser known fluency disorder in comparison with stuttering.

http://www.mnsu.edu/comdis/kuster/schools/SID4page2.html

&

http://www.mnsu.edu/comdis/kuster/schools/SID4page.html

• These webpages provide a wealth of resources for the speech pathologist working with preschoolers or school-age children who stutter. It gives a huge number of links for the assessment of these children and the different treatment methods available. It also provides many resources to give to the teachers interacting with these children so that improvements in stuttering therapy can be made in the classroom too.

http://www.fluencyfriday.org/treatment.html

• This website has a huge list of resources for the speech pathologists working with children who stutter.  It provides links to how to write goals for children who stutter, how to assess them, effective treatment techniques, how to educate parents and teachers, and how to conduct group stuttering therapy. This is an excellent resource for a speech pathologist who is working in the schools, writing IEPs and working with multiple children on their caseload.

Fluency Initial Goal Areas

Initial goal areas for fluency therapy may include:

• decreasing frequency of disfluencies in speech
• increasing client confidence in speaking abilities
• decreasing noticeable accessory behaviors
• finding compensatory strategies to lessen anxiety about disfluencies

Different treatment methods for fluency may be:

• Singing
• Choral reading
• Whispering
• Speaking to younger children
• Speaking under a masking noise
• Delayed auditory feedback
• Altering voice pitch higher or lower

(If one of these strategies is used for an extended period of time, its effectiveness may lessen.)

(Class notes, SPAUD 501)

*** When dealing with a young child, it may be inappropriate to specifically call their fluency problem a “stutter,” as this can have negative ramifications. Instead, calling their speech “bumpy” and helping them “smooth out” their voice may be a better and more effective approach to therapy.

http://www.myeasybee.com/blog/easybee-early-age-fluency-visuals-english-spanish/

http://www.teacherspayteachers.com/

Fluency Assessment

Start with the case history/interview. Here are a few questions to ask:

1. How long has the stutter been present?
2. When is it better or worse?
3. Have you/your child had therapy before?
4. Has there been a recent traumatic or stressful event in your/your child’s life?
5. Can you understand what you child is communicating?
6. How impactful is the stutter on their communication?
7. Does your child have struggle reactions when facing a disfluency, such as foot stomping, eye-blinking, etc?

Descriptions of Normal Disfluencies	Descriptions of Stuttering
–   Less than 10% of speech is disfluent –   Whole-word and phrase repetitions –   Not more than 2 repetitions of a speech unit –   Correct vowel used in speech repetitions	–   More than 10% of speech is disfluent –   Part-word repetitions and prolongations –   More than 3 repetitions of a speech unit – Schwa used instead of actual vowel in target word /ə/

Assessing the Severity of the Stutter

Figure 7.1 from Haynes, W.O. & Pindzola, R.H. (2012). Diagnosis and Evaluation in Speech Pathology. (8th Ed.). Boston, MA: Pearson.

(Class notes, SPAUD 501)

Formal Tests

• Stuttering Severity Index (SSI) – Fourth Edition
• Assessment of Stuttering Behaviors
• Test of Childhood Stuttering (TOCS)

Informal Assessments

• Rating of Stuttering Scale
• Overall Assessment of Speaker’s Experience of Stuttering (OASES)
• CALMS (Cognition, Affective, Linguistic, Motor and Social) Rating Scale

Fluency – In General

Stuttering

Stuttering is a condition that affects the fluency of a person’s speech. Characteristics and core  behaviors associated with stuttering are as follows:

• Part- or whole-word repetitions
• Prolongations
• Hesitations/blocks
• Interjections

Accessory behaviors or secondary characteristics related to the core behaviors are as follows:

• Struggle reactions or a visible struggle to get the word or sound out
• Irrelevant sounds and movements such as tics, foot stomping, eye blinking, hand and arm movements or excess voicing during speech

Covert behaviors relate to the psychological and emotional behaviors that a person who stutters might experience are as follows:

• Negative emotions and self-image
• Fear
• Avoidance
• Frustration
• Anxiety
• Etc.

A Note on Cluttering:

Cluttering is a fluency disorder that often coexists with stuttering but occasionally occurs in pure form. Individuals with cluttering typically manifest rapid or erratic speech rates, reduced intelligibility, and language deviations.

http://lshss.pubs.asha.org/article.aspx?articleid=1780076

Voice Initial Goal Areas

Some initial goals for voice therapy might be:

1. Increasing/decreasing loudness
2. Decreasing hoarseness
3. Decreasing breathiness
4. Educating client about healthy voice practices
5. Reducing glottal fry
6. Relaxation of neck and laryngeal muscles

Voice Resources

Client/Family Resources

http://www.asha.org/public/speech/disorders/voice/

• This website has links to a variety of different causes of voice disorders to help client’s learn more about their specific diagnosis of dysphonia. It also provides a link to another page of the website that has frequently asked questions about voice therapy and dysphonia. This website would be a good resource for first-time clients who have vocal nodules, polyps, paralysis or spasmodic dysphonia.

https://www.dysphonia.org/spasmodic-dysphonia.php

• This is the official National Spasmodic Dysphonia Association website. It provides a wealth of information about what spasmodic dysphonia is, what the causes are, potential treatment ideas and how to get help and support. This is an excellent resource for a patient who has recently been diagnosed with spasmodic dysphonia and would like to know more about their condition.

http://www.pdf.org/en/speech_problems_pd

• This website is a great resource for patients who are receiving voice therapy because of Parkinson’s disease (PD). The information on this page is great for education about the different communication challenges faced by someone with PD, particularly with the troubles that reduced loudness of voice and reduced intonation of voice can cause.

Professional Resources

Click to access schoolbasedtreatment.pdf

• This article is a great resource for SLPs who are working with children who have voice disorders in a school setting. It provides information about working under the IDEA legislation and it helps SLPs to know their role in helping children with voice concerns. Additionally, it helps educate SLPs about how voice disorders can impact education and why this is important.

http://www.asha.org/policy/PP2004-00191/#sec1.3.34

&

http://www.asha.org/policy/PP2004-00191/#sec1.3.35

• This webpage contains ASHA’s recommendations for providing clinical voice therapy to clients. It outlines assessment steps and general voice therapy goals for educating the client and altering voice production practices. Additionally, it gives this information in the context of the World Health Organization’s intervention framework and provides health and safety standards for all procedures listed.

Click to access glaze-tx-hypfxn_voice.pdf

• This research article discusses informative techniques for treating adolescents with vocal hyperfunction. The research suggests that children in the adolescent stage are particularly impacted by voice therapy, so it is suggested that if voice therapy needs to be done, this is a good age to begin. It also claims that direct treatment of respiration, phonation, voice conservation and relaxation are effective therapy areas for these young adults.

Voice Assessment

Formal Tests:

• Boone Voice Program for Children
• Boone Voice Program for Adults
• Voice Assessment Protocol for Adults and Children (VAP)

Informal Assessment Tools:

• Voice Handicap Index (VHI)
• Grade, Roughness, Breathiness, Asthenia, and Strain (GRBAS) Scale
• Listen to their voice in normal conversation
  • Listen and watch for muscle tension in neck and face, paralysis or tremors, inadequate mouth opening, excessive loudness of voicing or not enough loudness of voicing, excessive speaking, frequent throat clearing/coughing, clavicular breathing
• Visipitch software to assess acoustics of voice
• Visually assess structure and function of larynx and pharynx (endoscopy)
• /s/ to /z/ ratio
• Words spoken per breath (upwards of 12 is normal)
• Check maximum phonation time (MPT) – around 20 seconds for women and 25 seconds for men

(Class notes, SPAUD 501)

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Interview Questions to Ask

• What is the problem you’re experiencing with your voice and when did it start?
• Is the problem getting worse? Are there certain situations or environments that make the problem worse?
• How is your voice issue affecting daily life?
• Do you do a lot of yelling?
• Do you smoke? Do you drink?
• What medications are you on currently?
• Do you have allergies?

(Class notes, SPAUD 501)

Voice – In General

What is a voice disorder?

A voice disorder is when a person’s voice loudness, pitch, quality, and resonance are judged to be abnormal, considering their age, gender, and cultural community. A voice disorder is sometimes called “dysphonia.”

Some causes of voice disorders are:

1. Nodules – These are benign lesions on the vocal folds of both adults and children, which are caused by continuous misuse or abuse of the voice. They are often bilateral, causing breathy and hoarse-sounding voice.
2. Polyps – These are often unilateral benign lesions on the vocal folds, slightly deeper lesions than nodules. They are often caused by excessive vocal use or even a single traumatic event to the vocal folds.
3. Webbing – This is a web of tissue across the glottis, which affects the extent of the movements of the vocal folds. This can be congenital or acquired and may affect a person’s breathing if severe enough.
4. Cancer – This is a malignant growth that can occur in a variety of places on or around the vocal folds. Surgical treatment is recommended, which in turn may cause dysphonia from partial or full removal of the vocal folds or inflammation from radiation treatments.
5. Paralysis – This is caused by a neurogenic problem in cranial nerve X (vagus) and can be unilateral or bilateral. It causes breathy and weak voice.
6. Spasmodic dysphonia – This is a neurological condition which causes a strained/strangled voice quality.
7. Reflux disease – This is caused by gastroesophageal reflux disease (GERD), where stomach acid comes up into the larynx, causing edema and potentially dysphonia from inflammation.
8. Laryngitis – This is inflammation of the vocal folds caused by infection or strain of the vocal folds.
9. Parkinson’s disease – This disease can cause a decrease in voice loudness and intonation with the progression of the illness due to neurological degeneration.

Voice Qualities:

• Strained/strangled
• Harsh
• Breathy
• Hoarse
• Glottal fry
• Strident
• Strider
• Diplophonia
• Pitch breaks

(Class notes, SPAUD 501)