Cognitive Communication Initial Goal Areas

Here are some potential goals areas to focus on for a patient with cognitive communication deficits:

• Increase deficit awareness
• Increase executive functioning
• Increase planning and decision making skills
• Decrease impulsivity
• Decrease verbosity and tangential speech
• Increase awareness of nonverbal cues and body language in communication interactions
• Increase attention
• Increase working memory
• Increase short-term/long-term memory
• Increase initiation of tasks/conversations

Cognitive Communication Resources

For the client/family:

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

• This webpage is a great resource for a client or family member who has recently suffered from a traumatic brain injury (TBI). It provides general information in easy-to-understand language about what a TBI is and what symptoms and deficits it might cause. It also helps clients and family members prepare for what assessment and treatment may look like depending on their particular set of strengths and weaknesses.

http://www.biausa.org/living-with-brain-injury.htm

• This website has a lot of information for the client or caregiver who wants to learn more about the brain and what happens when different parts of the brain are damaged due to a stroke, TBI or other neurodegenerative diseases. It gives a brief education about the lobes of the brain and what they are responsible for as well as what kinds of symptoms and deficits are associated with damage in each of these areas. There is even a helpful and informative video at the bottom of the page, which explains the brain anatomy and functioning. All of this would help a client and their family understand what it is like to suffer from a brain injury.

Papa, J. (2013). Patient & family education flash book: Communication after stroke or TBI. Youngsville, NC: Lash & Associates Publishing/Training Inc.

• This book is a wonderful resource for patients and family members who want to improve their communication skills post-TBI or stroke. It has worksheets and information about brain anatomy, the different types of attention and memory, how executive functioning works and tips for better communication, all written in terms that are easy to follow and understand. This book comes on a flashdrive so that materials are easily accessible for clients and family members.

For the SLP:

Kimbarow, M.L. (2011). Cognitive communication disorders. San Diego, CA: Plural Publishing Inc.

• This textbook is a great resource for an SLP who wants to learn more about cognitive communication impairments, assessment of these types of disorders and potential treatments for these types of communication problems. It focuses on education about right hemisphere damage, dementia, traumatic brain injury and the communication difficulties that can accompany these types of conditions. It also provides information about associated attention, executive functioning and planning deficits associated with each of the previously mentioned diagnoses.

http://www.asha.org/Publications/leader/2011/110215/Cognitive-Communication–Research-and-Resources.htm

• This article from the Leader magazine provides a number of links to helpful resources for the SLP working with a cognitive communication client. It has links to different research articles related to the main etiologies responsible for cognitive communication deficits, and it provides links to other websites who focus on research and remediation of these kinds of communication impairments.

Click to access TESCognitiveCommunicationDisordersFromTBI.pdf

&

Click to access TESCognitiveCommunicationDisordersfromRightHemisphereBrainDamage.pdf

•  These two articles have treatment efficacy summaries for remediation of cognitive communication deficits resulting from right hemisphere damage or TBI. Both articles suggest that remediation of problem solving, pragmatics, attention and memory problems can be remediated in 73% and 83% of patients. This gives hope and encouragement to patients and SLPs alike, knowing that the services given and received can effect change in the functioning of the client’s cognitive communication skills.

Cognitive Communication Assessment

Formal Tests:

• Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES)
• California Verbal Learning Test (CVLT)
• Cognitive Linguistic Quick Test (CLQT)
• Mini Inventory of Right Brain Injury (MIRBI)
• Montreal Cognitive Assessment (MoCA)
• Brief Test of Head Injury (BTHI)
• Test of Everyday Attention (TEA) or Test of Everyday Attention for Children (TEA-CH)
• Woodcock Johnson Test of Cognitive Abilities (WJ)
• Detroit Test of Learning Aptitude

---

Informal Assessment Tools:

• Clock drawing – to assess perseverations, attention, planning, etc.
• Assess deficit awareness during conversation and interview

---

Interview Questions:

• What was your injury like?
• Were you unconscious? For how long?
• What do you think you struggle with? What do you think you do well?
• What was your occupation?
• What would you like to be able to do again?
• What are your hobbies and interests?
• What kinds of things are you involved in outside of the home?

---

Deficit Areas	Behaviors to look for
Attention	Not paying attention, disengaged, irrelevant stimuli, incomplete work, careless mistakes, fidgety
Memory	STM loss, forgetting to do assignments,LTM loss
New learning/ strategic learning	Inability to apply new info, unable to remember new names, can’t get “big picture,” inconsistent performance
Processing speed	Difficulty transitioning, can’t keep up, slow test-taker, takes a long time to respond, looks lost
Initiation	Can’t get started on things, a “follower,” needs constant reminders
Planning	Needs to be told step-by-step what to do, gives up quickly, long-term projects are difficult, time management issues
Organization	Tangential speech, messy
Mental flexibility	Can’t think of another way to think about something, can’t take another’s perspective, can’t switch gears
Judgment	Cutting class, can’t take another’s perspective, makes unsafe decisions, sexual promiscuity, recklessness
Social skills/ pragmatics	Can’t keep or make friends, acting younger than their age, says inappropriate things, blurts out, fighting
Word retrieval	Nonspecific language, filler words, writing is sparse
Self-regulation/ impulsivity	Makes poor choices, blurts out, can’t regulate behaviors
Sensory processing	Averse to sounds/noises, slow auditory processing, picky about food texture, unaware of personal space, fidgety

(Class notes, SPAUD 501)

Cognitive Communication – In General

Most Common Etiologies

• Alzheimer’s disease
• Brain tumors
• Stroke
• Traumatic brain injury (TBI)

Potential Consequences/Impact of Cognitive-Communication Impairment Can Include:

• Reduced awareness and ability to initiate and effectively communicate needs

• Reduced awareness of impairment and its degree (i.e., loss of ability to assess one’s own communication effectiveness)

• Reduced memory, judgment, and ability to initiate and effectively exchange routine information

• Difficulty performing personal lifestyle management activities effectively (i.e., pay bills)

• Reduced ability to anticipate potential consequences, with reasonable judgment and problem solving

• Reduced social communication skills and/or ability to manage emotions, often causing loss of relationships

• Disruption of ability to fulfill educational or vocational roles, including potential loss of employment

• At risk for injury due to inability to communicate in an emergency and/or anticipate the consequences of own actions

http://www.asha.org/slp/cognitive-referral/

Leading causes of TBI:

1. Motor vehicle crashes
2. Falls
3. Assault
4. Struck by or against something

At-risk groups:

• Young adults, particularly males
• Under 5
• Over 65

(Class notes, SPAUD 501)

Motor Speech Disorders Initial Goal Areas

Dysarthria

1. Increase labial, velar, and lingual strength
2. Decrease nasality
3. Increase confidence in speech abilities
4. Increase intelligibility

Apraxia

1. Increase intelligibility
2. Increase confidence in speaking abilities
3. Decrease irregularity in prosody
4. Increase regular pacing of speech
5. Increase utterance length

Motor Speech Disorders Resources

For Client/Family:

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

• This website from ASHA provides a lot of general information about apraxia of speech. It outlines what it is, what symptoms often occur with it and how it is assessed and treated. This would be a great resource for a person who has recently been diagnosed with apraxia of speech and/or their family members and caregivers.

http://www.strokeassociation.org/STROKEORG/LifeAfterStroke/RegainingIndependence/CommunicationChallenges/Steps-to-Improve-Communication-for-Survivors-with-Dysarthria_UCM_310083_Article.jsp

• This webpage is a great resource for someone who is living with chronic dysarthria. It provides tips for communication to compensate or go around deficits associated with dysarthria. All of these tips could be applied to all communication interactions but they would be beneficial for those who have dysarthria. Environmental, speaker and listener variables are considered in the suggestions.

http://www.mayoclinic.org/diseases-conditions/dysarthria/basics/causes/con-20035008

• This webpage from the Mayo Clinic provides a comprehensive list of the causes of dysarthria, which can range from a traumatic brain injury to a degenerative disease like ALS. This may help clients to understand why they are having neuromuscular weakness, as it may be caused by a variety of things. It would be beneficial if this list was discussed with an SLP or doctor to help the client understand their specific diagnosis.

---

For SLP:

Haynes, W.O. & Pindzola, R.H. (2012). Motor Speech Disorders, Dysphagia, and the Oral Exam. In Haynes, W.O. & Pindzola, R.H. (8th Ed.), Diagnosis and evaluation in speech pathology. (pp. 239-266). Upper Saddle River, NJ: Pearson Education Inc.

• Table 9.4 in this chapter outlines the differences between dysarthria and apraxia, clearly distinguishing that one is a neuromuscular weakness while the other is a motor planning issue. This would be a beneficial diagnostic tool for an SLP to use when evaluating a patient with potential motor speech problems. It would help to tease apart the motor speech issues that the patient may present with in combination with the language issues that often arise as well.

• Pages 251 and 252 also provide thorough descriptions of the different types of dysarthria. As the different types present with a number of different symptoms, it is important that the SLP understand which type of dysarthria they are presenting with so that treatment can be more effective for their specific needs.

http://ajslp.pubs.asha.org/article.aspx?articleid=1782728&resultClick=3

• This research article centered around the treatment of acquired apraxia of speech.  It suggests that the frequency and intensity of treatment of apraxia of speech does not affect the outcomes of speech therapy; however, avoiding blocks of treatment time or inconsistent therapy will assist the client in maintaining skills learned in therapy and generalizing those skills to conversational speech. This is important for speech pathologists to know, as recommendations for amount of therapy are crucial decisions to make when assessing a new patient.

http://www.asha.org/uploadedFiles/slp/healthcare/AATMotorSpeech.pdf#search=%22motor%22

• This motor speech disorder assessment template form will be beneficial for speech-language pathologists who need a resource when informally assessing patients for potential speech and intelligibility problems. It gives a comprehensive guide for assessing oral mechanisms and structures and oral motor movements. It also assesses respiration, phonation, diadochokinetic rates, and impairment rating scales. At the end of the form, a prognosis checklist, family care plan and treatment plan are provided.

Motor Speech Disorders Assessment

For Dysarthria:

Formal Tests:

1. Oral Speech Mechanism Screening Examination (OSMSE)
2. Quick Assessment for Dysarthria
3. Frenchay Dysarthria Assessment (FDA)
4. Assessment of Intelligibility of Dysarthric Speech (AIDS)

Informal Assessments:

1. Speech sample from conversation or reading
2. Assess physical features of speech, such as lips, tongue, and jaws through informal oral motor test

---

For Apraxia:

Formal Tests:

1. Apraxia Batter for Adults (ABA)
2. Test of Oral and Limb Apraxia
3. Quick Assessment of Apraxia of Speech

*Complete aphasia testing as well if that is an area of concern*

Informal Assessments:

1. Speech sample from conversation or reading
2. Assess physical features of speech, such as lips, tongue, and jaws through informal oral motor test

 

---

Interview Questions:

• When did these concerns start?
• Do you notice more weakness on one side or the other? Both sides?
• Are their words or phrases that are easier/harder for you to say?
• Do other people have a difficult time understanding you?

ONSET & COURSE
1. Do you have any difficulty with your speech? If not, has anyone else commented on a change or problem with your speech?
2. When did the speech problem begin? Did it begin suddenly or gradually? Who noticed it first, you or someone else?
3. Did you develop any other difficulties when your speech problem began? Were other problems present before your speech problem began? Did other problems develop after the sppech problem began?
4. Has the speech problem changed? Better, worse, stable, better-than-stable, fluctuating?
5. Has your speech ever returned to normal? If so, when and for how long?
ASSOCIATED DEFICITS
1. Have you had any difficulty with chewing? drooling?
2. Is it difficult to move food around in your mouth? Why?
3. Does food get stuck in your cheeks or in the roof of your mouth? Do you have to remove it with your finger or a fork?
4. Do you have trouble moving food back in your mouth to get a swallow started?
5. Do you have trouble with swallowing? Food or liquid? Do you have trouble getting a swallow started? Do you lose food or liquid out of your mouth? Does food or liquid ever get into or out of yournose when you swallow? Does food or liquid go down before you swallow and cause coughing or choking? Do you gag or choke when swallowing? Do you cough or choke wheen completing a swallow? Have you had to modify your diet because of these problems? Have you lost weight?
6. Have you had any cahnge in your emotional expression? Do you cry or laugh more easily or less easily than in the past?
7. Are you taking any medications that seem to affect your speech?
PATIENTS PERCEPTION OF THE PROBLEM:
1. What did your speech sound like when the problem began? Did anything feel different when you spoke?
2. Describe your current speech difficulty. How does it sound to you? How does it feel to speak? Is it faster or slower? Louder or slower? Less precise? Is speaking effortful?
3. Have you noticed any change in the appearance or feeling in your face or mouth?
CONSEQUENCES OF THE DISORDER:
1. Do people ever have trouble understanding you? When? What do you do if that happens?
2. Do you ever have to write to make yourself understood? Has your speech problem affected your work? Does it prevent you from doing anything?
MANAGEMENT
1. What have you done to compensate for your speech difficulty? Have you had any help for your speech? When? For how long? What was done? Did it help?
2. Do you think you need help with your speech now?
AWARENESS OF DIAGNOSIS AND PROGNOSIS:
1. What have you been told is the cause of this problem?
2. In view of this diagnosis, what is going to happen?

http://www.appstate.edu/~clarkhm/cd5673/interview.htm

Motor Speech Disorders – In General

Two main categories of motor speech disorders are:

Dysarthria:

Dysarthria is a motor speech disorder. It results from impaired movement of the muscles used for speech production, including the lips, tongue, vocal folds, and/or diaphragm. The type and severity of dysarthria depend on which area of the nervous system is affected.

http://www.asha.org/public/speech/disorders/dysarthria/#what_is_dysarthria

Some symptoms of dysarthria are:

• Slurred or choppy speech
• Unintelligibility
• Mumbly sounding speech
• Slow or rapid rate of speech
• Limited range of oral motion
• Hypernasality of speech

http://www.csuchico.edu/~pmccaffrey//syllabi/SPPA342/342unit14.html – This website has thorough descriptions of the different types of dysarthria.

Handouts from dennis43

Apraxia:

Apraxia is the inability to perform purposeful and learned movements. This can impair a person’s ability to execute communicative motions such as speech movements or gestures.

• Ideomotor apraxia is the impaired ability to program, sequence and execute purposeful movements either on command or in imitation. It is not due to a loss in strength, coordination or cognitive issues such as inattention or confusion. This includes limb and oral apraxia.

• Apraxia of Speech (AOS) is the impaired ability to program, sequence and execute purposeful speech movements. Longer words and utterances are difficult to say, although automatic phrases can be easily said. This type of apraxia often co-occurs with aphasia which makes it difficult to tease out.

Symptoms of AOS include:

1. Perceived substitutions and distortions
2. Perceived omissions and additions
3. Effortful articulation
4. Trial and error groping
5. Slow speech and dysprosody
6. Difficulty imitating
7. Excess and equal stress
8. Part-word repetitions
9. More errors on polysyllabic words
10. Inconsistent errors
11. Islands of error-free speech
12. Severe cases may be nonverbal

(Class notes, SPAUD 501)

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.

---

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

---

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.

---

 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

---

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

---

 

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?

---

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)

---

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/

---

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