Children`s Mercy Hospital

Transcript Children`s Mercy Hospital

Cleft Palate &/or Velopharyngeal Inadequacy Assessment or How to Determine Nose vs. Mouth Sounds

KSHA Conference Presentation 10/01/2010

Sally Helton, MS, CCC-SLP Speech/Language Pathologist

Children’s Mercy Hospitals & Clinics Kansas City, Missouri Hearing & Speech Department 913-696-5756

Introduction

• Educational Background • # Years at CMHC • # Years CMHC Cleft Palate/Craniofacial Team • # Years CMHC FFVN Team • # Years Member ACPA • Primary Job Function • Other Job Functions

Intent of Presentation

• To provide information regarding diagnostic assessment for communication disorders due to cleft lip &/or palate &/or velopharyngeal inadequacy • To provide information regarding other issues that impact cleft lip &/or palate &/or velopharyngeal inadequacy • To provide information regarding importance of team approach to treatment • To provide referral criteria for more advanced assessment, perceptual &/or instrumental

Basic Terminology

Cleft Lip

• A cleft of the lip which may be: -complete or incomplete -unilateral or bilateral -extend to the nostril -extend to the alveolus

Cleft Palate

• A cleft of the palate which may be: -complete or incomplete -unilateral or bilateral

-submucous

Cleft Palate cont’d.

-overt: observe one or more of: -bifid uvula -zona pellucida -muscular diastasis -notch in posterior border of hard palate

Cleft Palate cont’d.

• Submucous cont’d.

-occult (hidden)

Cleft Palate cont’d.

• Variations • Incidence • Other Clefts • Classification Systems

ACPA

• American Cleft Palate-Craniofacial Association

22q deletion

• Deletion of genetic material from chromosome 22 • Other names: 22q11.2 deletion Shprintzen’s Syndrome Velo-Cardio-Facial Syndrome

22q deletion cont’d.

• Other manifestations • Organ systems affects • Variable expression • Incidence • Significance in regard to education

Flexible Fiberoptic Video Nasopharyngoscopy (FFVN)

• Invasive procedure used to evaluate the structure & function of the velopharyngeal mechanism during speech.

Velopharyngeal Mechanism

• Velo: velum/soft palate • Pharyngeal: lateral & posterior pharyngeal walls • Pharynx: part of throat between esophagus & nasal cavity

Velopharyngeal Port

• Port or gateway formed by action of the pharynx & velum to control the flow of air and sound through the mouth & nasal passages

Velopharyngeal Valve

• Valve which closes & opens velopharyngeal port between nasopharynx & oropharynx • Formed by velum & aided by posterior & lateral pharyngeal walls • Nasopharynx: part of pharynx above soft palate & just behind nasal cavity • Oropharynx: part of pharynx below soft palate at the level of the oral cavity

Velopharyngeal Valve

Velopharyngeal Closure

• Closing of nasal cavity from the oral cavity • Accomplished by using velum & pharynx & possibly adenoid tissue • Directs airflow through mouth instead of the nose

Velopharyngeal Valve

Velopharyngeal Inadequacy (VPI/A)

• Generic term • Refers to any abnormal velopharyngeal function • Diagnosed perceptually (by listening)

Velopharyngeal Inadequacy cont’d.

• 3 basic subtypes: -velopharyngeal insufficiency (VPI/S) -velopharyngeal incompetency (VPI/C) -velopharyngeal mislearning Subtypes CANNOT be distinguished perceptually.

Subtypes are not mutually exclusive.

Velopharyngeal Insufficiency (VPI/S)

• Structural defect of the palate &/or pharyngeal area

Velopharyngeal Incompetency (VPI/C)

• Neurogenic impairment • Movement disorder/motor planning • Not structural

Velopharyngeal Mislearning

• Functional disorder • Faulty learning of articulation patterns • Sound (phone) specific nasal air emission (s)

Relationship of VPI/A Types

Learning (articulation disorder) VP Mislearning Anatomy (structure) VP Insufficiency (VPI/S) Physiology (movement) VP Incompetency VPI/C

Relationship of VPI/A Types cont’d.

• Significance of relationship: if types are not mutually exclusive, treatment will need to target all types presented by the patient

Relationship of VPI/A Types cont’d.

• Significance of relationship: diagnostic assessment needs to determine types of VPI/A the patient presents diagnostic assessment should include perceptual evaluation & possible instrumental/more invasive evaluation such as FFVN

Relationship of VPI/A Types cont’d.

• Instrumental diagnostic assessment with FFVN needs to be a VALID study • Use or attempted use of high pressure consonants is REQUIRED for a VALID FFVN study • If high pressure consonants are not being used/attempted, speech therapy should occur first.

Areas of Assessment

• History • Articulation • Resonance • Nasal Air Emissions (NAE) • Velopharyngeal Adequacy • Language • Voice • Fluency • Oral Mechanism/Oral Peripheral Examination

Tools Needed for Assessment

• Tissues • Gloves • Flashlight • Mirror • Reinforcers/Toys • Articulation test & score form • Language test & score form • Resonance/NAE protocol form (stimuli) • Tape recorder (optional)

Tools Needed for Assessment cont’d.

• CMHC Protocol • ACPA Universal Parameters for Assessment (The Cleft Palate-Craniofacial Journal, January 2008, Volume 45, Number 1, Henningsson et.al., pg. 1-17)

Assessment-History Areas to Consider

• Cleft: type & surgical &/or prosthetic management of • School History (including learning issues) • Medical • Speech Therapy • Psychological Issues • Feeding/swallowing • Parents’ Concerns/Perspective • Peer Interactions

Assessment-History Type of Cleft/Surgeries/Prosthesis

•

Type of Cleft:

- note type of cleft (i.e., left cleft lip & palate) •

Surgeries Related to Cleft/VPI/A:

- note surgeries regarding primary repair of cleft - note secondary surgeries in regard to VPI/A - note surgeries that may negatively impact VPA (i.e., tonsillectomy &/or adenoidectomy/T&A) •

Prosthetic Management of Cleft/VPI:

- note any prosthesis used in regard to cleft/VPI (i.e., palatal obturator, palatal lift)

Assessment-History

•

Medical:

Pregnancy Birth Newborn period Other conditions: heart congenital anomalies Significant illnesses/diseases Audiological

Assessment-History

•

Speech Therapy:

Enrollment: previous/ current length of enrollment # of sessions per week length per session group/ individual/combination Goals/Progress Treating SLPs name Results of Previous Evaluations

Assessment-History

•

Parents’ Concerns/Perspective:

Start with a general question: “How do you feel (name) is doing with communication/speech?” Follow-up with specific questions regarding: understandability, articulation skills, hypernasality/NAE, voice, language skills

Assessment-History

•

School History:

Name of School Grade Enrolled Regular Education/Special Education (or combination) Therapies Enrolled in Special Classes/Educational Help Receive Any teacher concerns regarding learning Results of recent reports/grades

Assessment-History

•

Psychological Issues:

-Obtain results of any psychological, educational &/or IQ testing, if available.

Assessment-History

•

Feeding/Swallowing:

Inquire as to any history of difficulty with: sucking, chewing, swallowing -This includes both liquids & solids.

- Any history of nasal regurgitation of liquids -Any issues with textures, temperatures, spiciness/blandness - Swallow studies/Oral Pharyngeal Motility (OPM) studies - History should be from birth to current age

Assessment-History

•

Peer Interactions:

- First find out if the child has opportunities for peer interactions -Then find out if they have age-appropriate interactions with their peers or if they have difficulties

Determining Nasal Patency

• Need to determine patency (airflow) of each nostril • Need to determine patency for both breathing & production of nasal sounds • If airflow is restricted or obstructed, it may mask

SEVERITY &/OR INCIDENCE

of resonance/NAEs

Determining Nasal Patency cont’d.

•

Procedure:

1. Tell the patient to blow their nose.

2. Place the mirror under both nostrils (or one at a time).

3. Tell the patient to close their mouth & breath out of their nose.

4. Keep the mirror under the nostrils.

5. Tell the patient to say /m/.

Determining Nasal Patency cont’d.

• Place the mirror under both nostrils (or 1 at a time)

Determining Nasal Patency cont’d.

• Tell the patient to close their mouth and breathe out of their nose.

Determining Nasal Patency cont’d.

• Keep the mirror under the nostrils & tell the patient to say /m/.

Determining Nasal Patency cont’d.

• Variability in Responses

Determining Nasal Patency cont’d.

• Recording responses/information

Recording Nasal Patency Information Nasal Obstruction: Right Nostril Occluded Left Nostril Occluded

Inhalation/exhalation none partial complete none partial complete b.

Sustained /m/ (3 secs.) none partial complete none partial complete (Circle response)

Assessment-Articulation

•

Intent of Articulation Assessment:

1. To obtain as much information as possible regarding articulation abilities.

Assessment Articulation cont’d.

•

Intent of Articulation Assessment cont’d.:

2. Use information not only to diagnose articulation/phonological deficit/disorder BUT: a. Determine possible causes for deficit/ disorder b. Determine if attempt to use &/or use enough high pressure consonants to determine VP adequacy c. Determine if compensatory articulations are being used d. Help determine prognosis for improvement with/without speech therapy

Assessment Articulation cont’d.

•

General Guidelines:

It is very important to

watch the face/nose/mouth!

Allows you to observe: nasal grimace, incorrect placement, facial/neck tension etc.

True for both assessment & therapy.

Assessment Articulation cont’d.

•

General Guidelines cont’d.:

Watch for

lip & tongue mobility

&/or

restrictions

Watch for

dental abnormalities

which might impact correct sound production. This includes

dental appliances

Watch for

respiratory abnormalities

Assessment Articulation cont’d.

•

Guidelines:

1. Transcribe the entire production phonetically including correct productions.

2. Note if response was spontaneous or imitative.

Assessment Articulation cont’d.

•

Guidelines cont’d.:

3. Use “narrow phonetic transcriptions” for errors not transcribable with normal phonetic symbols.

Other Narrow Transcriptions

• Nasal Air Emission / / • Denasal / / • Nasalized Resonance[ ] • Unaspirated [ ] • Unreleased [ ] • Interdental [ ] • Lateralized [ ]

Other Narrow Transcriptions

•

Transcription Symbols for Compensatory Articulation Errors

Assessment Articulation cont’d.

•

Guidelines cont’d.:

4. Note any vowel errors.

5. If more than just a few nasal air emissions (NAE) occur, count as errors when scoring.

Assessment Articulation cont’d.

•

Guidelines cont’d.:

6. Do stimulability testing.

7. Note any differences during conversational speech.

8. Rate the overall intelligibility/understandability of speech.

Assessment Articulation cont’d.

•

Guidelines cont’d.:

9. Note any

weak pressure consonants

&/or

reduced intra-oral air pressure

Assessment Articulation cont’d.

•

Test Selection:

Consider age of patient, language abilities etc.

Want a test that will

keep the patient’s interest

Want to assess sounds in as many positions as possible.

Want to assess as many consonant blends as possible.

Compensatory Misarticulations

• Learned articulation errors • Are mostly errors of PLACEMENT • Are typical to those with “cleft palate speech” • Develop as a means or strategy to overcome structural difficulties due to the cleft • Are used to attempt to obtain valving for high pressure consonants • Become part of child’s phonology • Can be very persistent

Types of Compensatory Misarticulations

• Glottal Stops • Laryngeal Stops • Pharyngeal Stops • Mid-dorsum Palatal Stops • Laryngeal Fricatives • Pharyngeal Fricatives • Velar Fricatives • Mid-dorsum Palatal Fricatives • Posterior Nasal Fricatives • Laryngeal Affricates • Pharyngeal Affricates • Mid-dorsum Palatal Affricates • Posterior Nasal Affricates

Types of Compensatory Misarticulations cont’d.

• Atypical Backing of /l/ • Atypical Backing of /n/ • Atypical Backing of /r/ • Novel or idiosyncratic misarticulations

Glottal Stop / /

• Most common error • Normal sound in many languages – English: vowel initiation • Voiced Stop consonant with glottal placement • Laryngeal / Vocal cord valving – Adduct – Pressure build-up below glottis

GLOTTAL STOP / / • Greater pressure builds up

– Consonant substitution > vowel initiation

• Excessive tension

– Lower vocal tract – > intense opening / closing vocal cords – Ventricular vocal cords adduct / contact

Glottal Stop / /

• Substituted: whole class of stops • Frequently co-articulated – One manner of production – Two places of production • Deviant / nonphonemic place effects manner • Perceptually distinct – Pharyngeal stop / omission

Glottal Stop / /

Laryngeal Stop • Substitution for stop sounds • Base of tongue

– Moves posteriorly toward PPW (posterior pharyngeal wall) – Epiglottis contacts PPW • Momentarily blocking airstream

• Larynx thought to move

– Superiorly – Assist stopping airflow

Pharyngeal Stop

• Lingua-pharyngeal consonant articulation – Contact: tongue base to PPW – Pressure build-up / Sudden release • Manner of production: Stop/Plosive • Contact: high or low • Substitution for /k/ , /g/ • Not used as co-articulation • Voiced / / or unvoiced / /

Pharyngeal Stop

Mid-Dorsum Palatal Stop

• Stop consonant made in approximate place of “y” • Mid-section of tongue (dorsum) contacts mid-section of palate • Typically substituted for /t/ or /k/ (voiceless) & /d/ or /g/ (voiced) • Perceptually is a cross between /t-k/ or /d-g/ • May represent a place compromise between anterior & posterior • May have been learned to use tongue to occlude palatal fistula • Only mid-dorsum compensatory articulations are not behind the uvula for place of articulation • Voiced / / or unvoiced / /

Laryngeal Fricative

• Substitution for fricative sounds • Tongue base – Posterior – Pushes epiglottis toward PPW – Narrows airstream • Constriction – Epiglottis & PPW • Larynx moves up • Variant – Pharyngeal fricative

Pharyngeal Fricative

• Lingua-pharyngeal fricative articulation • Tongue moves posteriorly toward PPW • Dorsum of tongue flattened • Constriction of airstream = frication • Substituted: fricatives & affricates • Co-articulation • Voiced / / or unvoiced / /

Pharyngeal Fricative

Velar Fricative

• Fricative production made at back velar for place of articulation • Similar to /k/ or /g/ but tongue isn’t touching the palate • Common substitution for sibilant fricatives or as distortion of /k/ or /g/ which then lack stop quality due to VP port leak • Seen with dysarthria due to reduced range of movement in back of tongue • Voiced / / or unvoiced / /

Mid-Dorsum Palatal Fricative

• Substitution for fricative sounds • Same positioning as mid-dorsum palatal stop but positioning creates frication • May be place compromise to attempt to achieve valving for airflow • Voiced / / or unvoiced / /

Posterior Nasal Fricative

• May be called velopharyngeal fricative • Turbulent VP fricative articulation occurring with small VP opening • Tongue moves back to help occlude the port (lingual assist), velum approximates PPW but does not touch. Result is constricted airflow through the VP port; velum “flutters” against PPW or adenoid pad • Perceived as frication/”snorting” • May occur as selective substitution for sibilant fricatives & affricates • Can be co-produced with any high pressure consonants • May be obligatory due to VPI/S or learned • Notable occurrence in individuals without clefts as phone specific nasal emission • Symbol: / /

Laryngeal Affricate

•

• Substitution: affricate sounds Tongue base posterior

– Epiglottis • Brief contact PPW • Then constrict airstream – Stopping – Then frication

• Larynx moves superiorly

Pharyngeal Affricate

• Combines pharyngeal fricative & glottal stop • Less frequent in occurrence than glottal & pharyngeal stops as well as pharyngeal fricatives • Mostly substituted for oral affricates “ch” & “j” • Dorsum of tongue moves posteriorly to contact PPW • Tongue contact constricts airstream to create stopping followed by frication • Does not occur as co-articulation • Voiced / / or unvoiced / /

Mid-Dorsum Palatal Affricate

• Substitution for affricate sounds • Same positioning for mid-dorsum palatal stop but positioning creates affrication • May be place compromise to achieve valving for airflow • Voiced / / or unvoiced / /

Posterior Nasal Affricate

• Substitution for affricate sounds • Posterior dorsum of tongue & velum – Create at VP valve • Stopping • Frication • • Audible NAE / Posterior Nasal Fricative

Amenable to speech treatment

– Tongue placement / Oral airflow

Atypical Backing of /l/

• Backed oral production of /l/ • Move place of production back to velar area • Characteristic of cleft palate speech • Less impact on intelligibility than other compensatory misarticulations • Symbol: / /

Atypical Backing of /n/

• Backed production of /n/ • Placement may be anywhere on palate including velum • Characteristic of cleft palate speech • Less impact on intelligibility than other compensatory misarticulations • Symbol: / /

Atypical Backing of /r/

• Backed oral production of /r/ • Placement is farther back, may be on velum • Characteristic of cleft palate speech • Less impact on intelligibility than other compensatory misarticulations • Symbol: / /

Novel or Idiosyncratic Misarticulations

• Individuals will make their own unique misarticulations • Idiosyncratic misarticulations tend to occur more in patients with cleft palate • Novel/idiosyncratic misarticulations may include compensatory error co-articulated with normal placement production with manner error or placement may be also in error

Observations Regarding Compensatory Misarticulations

• Are active errors • Can be changed in therapy • Need to eliminate/reduce as many as possible prior to FFVN for valid study • Are “stubborn”; therefore, really need to apply the “new pathways” techniques/principles

Assessment-Resonance

• Resonance -hypernasality -assimilative hypernasality -hyponasality -cul-de-sac -denasality -mixed resonance

Assessment Resonance cont’d.

Definitions

• Resonance: -vibratory response of a body or air-filled cavity to frequency of sound -quality of voice resulting from sound vibrations in pharyngeal, oral &/or nasal areas -refers to both perceptual & physical aspects

Assessment Resonance cont’d.

Definitions

• Hypernasality: -excess nasal resonance on vowels & vocalic consonants (i.e., “ir” as in “bird”), glides (“w, y”) or liquids (“l, r”) -transcribed as: ~

Assessment Resonance cont’d.

Definitions

• Assimilative Hypernasality: -excess nasal resonance on vowels in presence of nasal consonants (“m, n, ng”) -transcribed as: ~

Assessment Resonance cont’d.

Definitions

• Hyponasality: -reduction in nasal resonance -affects nasal consonants -is NOT opposite of hypernasality/can co-occur

Assessment Resonance cont’d.

Definitions

• Cul-de-sac Resonance: -blind pouch/passage with only one outlet -resonance sounds as if in a cave -created by trapping resonance (or sound) in back of mouth -tongue placed back in mouth toward pharyngeal wall

Assessment Resonance cont’d.

Definitions

• Denasality: -nasal air flow is completely blocked -prevents nasal air flow for nasal consonants -/m/ sounds like /b/ -/n/ sounds like /d/ ”ng” (as in “ring”) sounds like /g/

Assessment Resonance cont’d.

Definitions

• Mixed Resonance: -combination of hypernasality, assimilative hypernasality, hyponasality, &/or cul-de-sac resonance -can have any combination -severity may vary between resonance types

Assessment Resonance cont’d.

Procedure

•

Rating Scale:

Numerous rating scales exist Ratings are usually descriptive & numerical Rating is SUBJECTIVE CMHC currently uses a

7-point scale

CPCF Journal (January 2008) article shows how to convert various scales to a 4-point scale

Assessment Resonance cont’d.

Procedure

•

Rating Scale cont’d.:

CMHC 7-point rating scale: 7 6 5 4 3 2 1 None Slight Mild Mild-Mod Mod Mod-Sev Severe

Assessment Resonance cont’d.

Procedure

•

Hypernasality:

Areas to Assess: Spontaneous Speech Sample Sustained Vowel Sentence Imitation task

Assessment Resonance cont’d.

Procedure

•

Hypernasality cont’d.:

Areas to Assess: Spontaneous Speech Sample

Assessment Resonance cont’d.

Procedure

•

Hypernasality cont’d.:

Areas to Assess: Sustained Vowel /i/

Assessment Resonance cont’d.

Procedure

•

Hypernasality cont’d.:

1. Place glove on your hand. 2. Tell child you’re putting the glove on because

“in a little while I’m going to gently touch your nose”

3. Tell child

“we’re going to practice how long we can say a sound”

4. Tell child

“right now my hand with the glove is going to stay over here by me”

Assessment Resonance cont’d.

Procedure

•

Hypernasality cont’d.:

4. Tell child

“I want you to say /i/ for as long as you can”

5. Tell child

“Let’s do it together”

6. Tell child

“Good! Now this time I want you to say /i/ until my finger is on your side of the table”

Assessment Resonance cont’d.

Procedure

•

Hypernasality cont’d.:

7. Tell child

“Now I want you to say /i/ again for as long as you can (until my finger is on your side of the table). While you say /i/, I’m going to gently open & close your nose”

Assessment Resonance cont’d.

Procedure

•

Hypernasality cont’d.:

Areas to assess: Sentence Imitation Task

Assessment Resonance cont’d.

Procedure

•

Hypernasality cont’d.:

1. Tell child:

“I want you to say what I say”

Say “I see a big black dog”.

“Say it again”. “Good”

4. Do the same with the other 2 sentences:

“Put your feet by the seat.” “He has a beet to eat.”

Assessment Resonance cont’d.

Procedure

•

Hypernasality cont’d.:

Sentence Imitation Task cont’d.

Assessment Resonance cont’d.

Procedure

•

Assimilative Hypernasality:

Area to assess: Sentence Imitation Task

Assessment Resonance cont’d.

Procedure

•

Assimilative Hypernasality cont’d.:

Area to Assess: Sentence Imitation Task cont’d.

Assessment Resonance cont’d.

Procedure

•

Assimilative Hypernasality cont’d.:

1. Tell child:

“I want you to say what I say”

Say “Hand the mean dog some meat”.

Say “The swing is neat and clean”.

Assessment Resonance cont’d.

Procedure

•

Hyponasality:

Areas to Assess: Sustained nasal /m/ Sentence Imitation Task

Assessment Resonance cont’d.

Procedure

•

Hyponasality cont’d.:

1. Tell child:

“I want you to say what I say”.

Say “My mama makes lemon jam”.

Say “Nancy is a nurse”.

Assessment Resonance cont’d.

Procedure

•

Other Resonance Types:

Cul-de-sac, denasality, mixed resonance Specific stimuli not used Rate/make observations regarding while assessing other resonance areas & articulation as well as during conversational speech

Assessment Resonance cont’d.

Procedure

•

Infant-Toddler Assessment:

1. SLP rates

severity of overall hypernasality

spontaneous speech

2. SLP rates

severity of overall hyponasality

spontaneous speech

3. SLP asks

parents to rate severity of hypernasality

4. SLP asks

parents to rate severity of hyponasality

5. SLP asks if

parents perceive any CHANGES in resonance

. If so,

when & how?

Assessment-Nasal Air Emissions (NAE)

• Nasal air emissions (NAE): -audible -inaudible -nasal grimace -nasal turbulence/rustle

Assessment NAE cont’d.

• Audible Nasal Air Emissions: -oral consonants produced (emitted) through the nose -airstream is heard from the nose -transcribed as: ~

Assessment NAE cont’d.

• Inaudible Nasal Air Emissions: -oral consonants produced through the nose -not heard perceptually -detected by mirror exam

Assessment NAE cont’d.

• Nasal Grimace: (NG) -noticeable movement of nose during speech -movement may occur at nares, mid-nose, nasal bridge -movement may be unilateral or bilateral -movement occurs in attempt to achieve velopharyngeal closure -movement is subconsciously used to move oral sound back to oral cavity from nasal cavity

Assessment NAE cont’d.

• Nasal Turbulence/Rustle: (NT) -oral consonant sound occurs during partially opened velopharyngeal valve -air flow is turbulent with noted noise/rustle

Assessment NAE cont’d.

Procedure

•

Nasal Air Emissions-Audible & Inaudible:

Areas to Assess: Isolation CV Syllables Phoneme-Loaded Sentences Stop/Plosive Fricative/Affricate Mixed Nasal/Oral Loaded Words & Sentence(s) Conversational Speech Single High Pressure Consonant Words (IPAT) Stimulability for Correction

Assessment NAE cont’d.

Procedure

• Area to Assess: Isolation

Assessment NAE cont’d.

Procedure

•

Isolation:

1. Tell child

“we’re going to say some sounds”

“First we will do them without my mirror.”

“Then we will do them with my mirror.”

“Say /s/”.

Assessment NAE cont’d.

Procedure

•

Isolation cont’d.:

“Say /p/”.

“Say /t/”.

“Say /k/”.

“Say “sh”.

Assessment NAE cont’d.

Procedure

•

Isolation cont’d.:

“Now let’s do them again with my mirror”.

10. Repeat each sound while holding the mirror under the nostril(s).

Assessment NAE cont’d.

Procedure

• Area to Assess: CV Syllables

Assessment NAE cont’d.

Procedure

•

CV Syllables:

1. Tell child

“we’re going to say some more sounds”.

“First we will do them without my mirror.”

“Then we will do them with my mirror.”

“Say /sa/”.

Assessment NAE cont’d.

Procedure

•

CV Syllables cont’d.:

“Say /pa/”.

“Say /ta/”.

“Say /ka/”.

“Say “sha”.

Assessment NAE cont’d.

Procedure

•

CV Syllables cont’d.:

“Now let’s do them again with my mirror”.

10. Repeat each sound while holding the mirror under the nostril(s).

Assessment NAE cont’d.

Procedure

• Areas to Assess: Phoneme-Loaded Sentences

Assessment NAE cont’d.

Procedure

•

Phoneme-Loaded Sentences:

1. Tell child

“now we’re going to say some sentences”.

“First we will do them without my mirror.”

“Then we will do them with my mirror.”

“Say ‘Peter has a paper puppy”.

Assessment NAE cont’d.

Procedure

•

Phoneme Loaded Sentences cont’d.:

“Say ‘Buy a baby bib’.”

“Say ‘Tell teddy to try’.”

“Say ‘Daddy did the dishes’.”

“Say ‘Katie likes cookies’.”

“Say ‘Go get a bigger egg’.”

Assessment NAE cont’d.

Procedure

•

Phoneme Loaded Sentences cont’d.:

10.

“Now let’s do them again with my mirror”.

11. Repeat each of the plosive-loaded sentences while holding the mirror under the nostril(s).

Assessment NAE cont’d.

Procedure

•

Phoneme Loaded Sentences cont’d.:

12.

“Now we have some more sentences to do”.

13.

“Say ‘Silly Sue eats icicles’.”

14.

“Say ‘Zippers are easy to close’.”

15.

“Say ‘Should I wash the dishes?’.”

16.

“Say ‘The garage hid the treasure’.”

Assessment NAE cont’d.

Procedure

•

Phoneme Loaded Sentences cont’d.:

17.

“Say ‘Chad’s teacher was at church’.”

18.

“Say ‘Jack wore a soldier’s badge’.”

19.

“Say ‘Feed five frogs fish food’.”

20.

“Say ‘Vic veered everywhere’.”

21.

“Say ‘Thank you for the birthday present’.”

Assessment NAE cont’d.

Procedure

•

Phoneme Loaded Sentences cont’d.:

22.

“Now let’s do them again with my mirror”.

23. Repeat each fricative & affricate-loaded sentence while holding the mirror under the nostril(s).

Assessment NAE cont’d.

Procedure

• Area to Assess: Mixed Nasal/Oral Loaded Words & Sentence(s)

Assessment NAE cont’d.

Procedure

•

Mixed Nasal/Oral Loaded Words & Sentence(s):

1. Tell child

“say ‘hamper hamper hamper’.”

“Good! Now do it again as fast & as many times as you can.”

“Now say ‘donna donna donna’.”

“Good! Now do it again as fast & as many times as you can.”

Assessment NAE cont’d.

Procedure

• Area to Assess: Conversational Speech

Assessment NAE cont’d.

Procedure

•

Conversational Speech:

Areas to Rate/Observe in regard to NAEs: Present vs. Absent Pervasive vs. Inconsistent vs. Occasional Nasal Turbulence Nasal Grimacing

Assessment NAE cont’d.

Procedure

• Area to Assess: Single High Pressure Consonant Words

Assessment NAE cont’d.

Procedure

• Area to Assess: Single High Pressure Consonant Words cont’d.

Stimuli:

Iowa Pressure Articulation Test (IPAT)

Assessment NAE cont’d.

Procedure

•

Iowa Pressure Articulation Test (IPAT):

Single Items Two-Item Blends /-k-/ MONKEY _____ / sm/ POSSUM _____ “-ker” CRACKER _____ /-g-/ WAGON _____ / ks/ BOOKS _____ “-ork” FORK _____ /k / CAT _____ “-per” PAPER _____ “-sher” WASHER _____ /g-/ GIRL _____ /sk-/ SKY _____ /gr-/ GRASS _____ /t-/ TABLE _____ /sm / SMOKE _____ “-ger” TIGER _____ /-f-/ TELEPHONE _____ /sn-/ SNAKE _____ /-lf/ WOLF _____ /-f/ LEAF _____ /st-/ STOVE _____ /-z-/ SCISSORS _____ /kr-/ CRAYON _____

3-Item Blends

/-s-/ PENCIL _____ /sp-/ SPOON _____ /s-/ SOAP _____ /tr-/ TREE _____ /-mps/ STAMPS _____ “sh-” SHOE _____ /kl-/ CLOWN _____ /str-/ STRING _____ /-s/ BUS _____ /gl-/ GLASS _____ /-g/ PIG _____ /bl-/ BLOCKS _____ “-sh” FISH _____ /br-/ BROOM _____ “j-” JEEP _____ /dr-/ DRUM _____ /-k/ BOOK _____ /tw-/ TWELVE _____ “-sh-” DISHES _____ /pl-/ PLATE _____

Assessment NAE cont’d.

Procedure

•

IPAT cont’d.:

1. Tell child

“we’re going to same some words without pictures”.

“I want you to say what I say.”

“Say ‘monkey’ , say ‘wagon’ etc.

Assessment NAE cont’d.

Procedure

• Area to Assess: Stimulability for Correction

Assessment NAE cont’d.

Procedure

•

Overall Rating of Nasal Air Emissions:

Present vs. Absent Audible Inaudible Pervasive/Inconsistent/Occasional Nasal Turbulence Nasal Grimace (describe) Severity Rating: none/slight/mild/mild-moderate/moderate/moderate-severe/ severe

Assessment NAE cont’d.

Procedure

•

Infant-Toddler Assessment:

1. SLP performs

overall rating of nasal air emissions

2. Note if

stimulable for correction

3. Note if

could not test (CNT)

did not test (DNT)

Assessment-Velopharyngeal Adequacy (VPA) Procedure

• Intent: To

PERCEPTUALLY

determine VP adequacy

Assessment-Velopharyngeal Adequacy (VPA) cont’d.

Procedure

•

VP Ratings:

Velopharyngeally Adequate (VP/A) or Velopharyngeally Inadequate (VPI/A)

•

Assessment-Velopharyngeal Adequacy (VPA) cont’d.

Procedure VP Ratings cont’d:

Other possibilities: Borderline VPI/A Questionable

•

Assessment-Velopharyngeal Adequacy (VPA) cont’d.

Procedure VP Ratings cont’d.:

Other Possibilities cont’d.: Unable to determine at this time Could not test

Assessment-Language Procedure

• Intent: to determine if language skills are age-appropriate

Assessment Language cont’d.

Procedure

•

Guidelines for Test Selection:

1. Assess receptive & expressive skills 2. Choose an age/developmentally-appropriate test 3. With most patients, want in-depth testing (vs. screening)

Assessment Language cont’d.

Procedure

•

Additional Information:

If there are

time

cooperation restraints:

CMHC

prioritize EXPRESSIVE over receptive

due to the

greater depth of information gained OR

DEFER language testing

to the

treating SLP

Assessment-Voice Procedure

• Intent: to assess voice for abnormalities in pitch, volume, &/or quality

Assessment Voice cont’d.

Procedure

•

Assessment of Pitch:

Make observations regarding

pitch level-high, low, normal

Note if

vocal fry

is present due to talking at bottom of pitch range.

Note if

vocal strain

is heard due to talking at top of pitch range.

Note if able to

vary pitch

or is the

pitch range limited/monotonous.

Observe if using

diplophonia

(talking with 2 simultaneous pitch levels).

If time permits, attempt to

modify level/range etc

BE CAREFUL NOT TO CONFUSE HIGH PITCH WITH HYPERNASALITY!!!

They may

CO-OCCUR,

but are

not synonymous

Assessment Voice cont’d.

Procedure

•

Assessment of Volume:

Note if volume is

too soft/quiet, excessively loud, cannot be maintained over time

(varies).

FREQUENTLY low pressure

(due to VP valve issues)

reduces the volume &/or ability to maintain a consistent volume

If time permits, attempt to

modify volume

Assessment Voice cont’d.

Procedure

•

Assessment of Quality:

Note if: hoarseness breathiness huskiness raspiness harshness aphonic

Assessment-Fluency Procedure

• Intent: to assess if speech is fluent or dysfluent

Assessment-Oral Mechanism/Oral Peripheral Examination Procedure

• Intent: to assess oral mechanism for structure & function deficits