Transcript 12603710_currentintervention.ppt (21.46Mb)

發展遲緩介入治療之新趨勢:
語言治療
Current Speech Therapy for Children with
Developmental Delay
Emily Lin, PhD (林永芬)
Department of Communication Disorders
University of Canterbury
Christchurch, New Zealand
Taiwan Academy of Physical Medicine and Rehabilitation Conference:
Current Intervention for Children with Developmental Delay
Taoyuan, Taiwan
December 2, 2006
大綱
• 背景
 發展遲緩兒童
 語言治療的過去和現在﹕以聽障兒童為
例
 語言/言語發展遲緩
 語言/言語發展里程碑
• 發展遲緩兒童的語言/言語障礙分類
• 語言/言語障礙的諮商和評估
• 語言治療
 原則和方法
 未來方向
(E. Lin)
發展遲緩兒童
(Children with Developmental Delay)
• Definition: young children who are below expectations
in one or more areas of development
• Population: children who are at risk for becoming disabled
or who do have a disability present, including those with:
 genetic disorders present at birth
 delays in speech and language development
 visual and/or hearing impairment
 emotional and behavioural problems
 medical and physical problems resulting from a
premature birth
Note: diagnostic assessment vs. functional assessment
(c.f., Down Syndrome, autism)
(Benner, 2003)
(E. Lin)
• 早期介入治療 (early intervention):
more likely to target those with:
 at least 40% delay in one developmental
domain*
 or at least 25% delay in at least 2
developmental domains
*The 4 developmental domains to consider are:
 Cognition
 Language and communication
 Gross and fine motor development
 Social-emotional development
(Benner, 2003)
(E. Lin)
問題的惡化: 骨牌效應
(Domino/cascading Effects Model of Risk)
例如 (Oller et al., 2006):
• 一個輕微的聽力問題, 會擴大成為溝通和學習障礙
• 生理發展問題會影響心理發展, 進而造成認知和行為問題
• 心智和行為障礙, 會降低溝通和社交發展
(E. Lin)
語言治療的過去和現在﹕以聽障兒童為例
過去
•問題發現較晚
•聽到聲音較晚
•老舊的科技
•入學較晚
•期待低
•音聲品質差
•專業協助少
•治療方式和範圍局限
現在
•發現問題的敏感度高
•測試和治療科技先進
-早期聽力測驗
-早期聽力輔助
-早期介入語言治療
-助聽器品質提昇
-人工電子耳
•口語訓練增強
(Gustus et al., 2006)
(E. Lin)
語言遲緩(Speech/Language Delay)
和發展障礙(Developmental disability) 的關係
• 語言發展在出生後前幾年迅速發展
• 語言發展遲緩通常是發展障礙的第一警訊
e.g., auditory expressive language development:
“Rule of 4s” (Coplan, 1985):
The child’s age divided by 4 = the proportion of the child’s
speech that should be understandable to strangers.
1 year-old: 1/4
2 year-old: 2/4
3 year-old: 3/4
4 year-old: 4/4
(E. Lin)
語言的定義
語言
Language
接收
表達
Receptive
Expressive
語音
語意
語法
語用
Phonology
Semantics
Syntax
Pragmatics
•語言(language): 包括口語和非口語的接收和表達
•言語(speech): 儘包括口語表達
(E. Lin)
言語表達的形成
(Bernthal & Bankson, 1988, p. 8)
(E. Lin)
Normal Language Development
• Auditory expressive language development
– Vocalizations
– Vocabulary size
– Speech intelligibility
• Auditory receptive language development
– Alerting to sound (cessation of sucking, eye widening, heart rate changes)
– Orienting to sound (e.g., failure to orient to a bell at 8 months of age despite normal hearing
is associated with increased likelihood of language disability at age 8 years, Winitz &
Darley, 1980)
– Following commands
• Visual language development
– Visual recognition of faces (6-10 weeks) and later objects
– Gesturing (e.g., visual-auditory association by 6 months of age, engaging in gesture games
by 7-9 months, finger pointing by 12 months of age, finger counting around age 3 years)
• Other features of speech and language
– Pragmatics (e.g., by 3 months of age, taking turns in “conversation”; often impaired in
autism)
– Prosody (e.g., often impaired in autism)
– Fluency
– Voice
(Coplan, 1993)
(E. Lin)
Disorders of Speech and Language Development
• Affected: 10-15% of all preschool children
• Language features differ in various developmental
disabilities.
Prevalence & signs:
– Developmental language disorders: 5-10%
– Mental retardation: 3% of children (50% of children with CP are
mentally retarded)
– Hearing loss: 1/1000 children born with severe to profound bilateral
hearing loss; 1% with permanent partial hearing loss (15% of children
with CP have some degree of sensorineural hearing loss).
– Dysarthria: 3 per 1,000; symptoms: excessive drooling for age,
grimacing, involuntary facial movements
– Autism: 2-4 children per 10,000 (60-70 per 10,000 with mild form)
– Stuttering: warning signs include more than 4 years of age, impaired
fluency (the shorter the repeated segment, the greater the likelihood of
stuttering) greater than 6 months, history of stuttering in sibling or parent,
signs of distress
– Voice disorders/anatomic abnormalities
(Coplan, 1993)
(E. Lin)
言語發展與身體構造發展的關係
例如:
兒童的
•聲腔較短
•咽腔較短
•舌頭較前
•口咽道轉折較淺
•聲帶位置較高
•軟顎咽部位和會厭軟骨
較近(所以鼻音較重)
(Bernthal & Bankson, 1988)
(Kent & Murray,
1982; from
Bernthal &
Bankson, 1988,
p. 73)
(E. Lin)
語言/言語發展遲緩
不平常 (uncommon)
異常
(disorder)
無臨床意義
具臨床意義
(Nonclinical)
(Clinical)
正常發展錯誤
(normal
developmental
errors)
遲緩
(delay)
(common)
平常平常
(Common)
(E. Lin)
語言/言語發展里程碑
(Milestones of Speech/Language Development)
• 瞭解的目的:
 及時辨識是否有面臨障礙的風險 (identify risks)
 區分不同障礙所面對的問題 (differential diagnosis)
以便治療(治療目的: 防止惡化, 改善問題)
(Oller et al., 2006)
(E. Lin)
Speech/language Milestones: 1 - 6 months
(E. Lin)
Speech/language Milestones: 7 months - 3 years
(E. Lin)
Speech/language Milestones: 4 - 8 years
(E. Lin)
發展遲緩兒童的語言/言語障礙
溝通障礙的分類可根據:
• 病因 (etiology)
• 症狀 (symptomology):
 認知和心智能力
 感情 ﹑ 情緒 ﹑ 行為
 身體狀況: 感覺 ﹑ 動作 ﹑ 神經生理
• 治療 (therapy):
 醫藥
 飲食
 復健(動作 ﹑ 構音 ﹑ 音聲 ﹑ 輔助溝通 ﹑ 吞嚥)
(Oller et al., 2006)
(E. Lin)
語言/言語障礙的諮商和評估
• 醫師諮商治療師是需要獲得:
 診斷建議
 治療建議
 測驗或程序的執行
(Lee et al., 1983)
• 語言治療師應及時描述:
 語言運作特徵
 運動性言語或音聲症狀
 口腔運動能力
(Guilford et al., 2007)
(E. Lin)
語言/言語障礙的諮商和評估
• 評估方法
 Perceptual
 Descriptive
 Rating
 Standardized vs. criterion-based
 Instrumental
 Acoustic
 Physiological







Nasometer
Airflow (spirometer, pressure transducer)
Electropalatography
Electromagnetic articulography
Strain gauge
Visual tracking device
etc.
(E. Lin)
語言治療: 原則和方法
• 療程三部曲 (Bernthal & Bankson, 1988):
確立
引伸
維持
(establishment)
(facilitation of
generalization)
(maintenance)
Two levels of generalization:
• Linguistic context
• Situational
(E. Lin)
語言治療: 原則和方法
認知
(cognitive)
Therapeutic
Approach
運動
語言
(motor)
(linguistic)
(E. Lin)
語言治療: 原則和方法
Therapy
Structure
(Shriberg & Kwiatkowski, 1982)
Drill
Drill
Play
Structured
Play
Play
Motivation
Instructional
stimulus
Response
Instructional
stimulus
Response
Instructional
play-like
activity
Response
Target
Response
(E. Lin)
語言治療: 原則和方法
• Key teaching strategies:
 Direct modeling
 Indirect modeling
 Shaping by successive approximation
 Prompts
 Fading
 Expansion
 Negative practice
 Target-specific feedback
(Roth & Worthington, 2005)
(E. Lin)
語言治療: 原則和方法
I. Articulation disorders:
• Motor approach:
 Traditional (Perceptual + production training):
Van
Riper (1939, 1978), Powers (1957, 1971), Winitz (1975),
Van Riper & Emerick (1984)






Multiple phonemic: McCabe & Bradley (1975)
Programmed conditioning: Baker & Ryan (1971)
Stimulus shift: McLean et al. (1976)
Sensory-motor: McDonald (1964)
Paired-stimuli: Weston & Irwin (1971)
Auditory-verbal therapy: Estabrooks (1994)
(E. Lin)
語言治療: 原則和方法
• Cognitive-linguistic approach:
 Distinctive features:




McReynolds & Bennett (1972)
Costello & Onstein (1976)
Weiner & Bankson (1978)
Blache (1985)
 Phonological Processes:
 Auditory bombardment (Hodson & Paden, 1983)
 Elimination of instability, elimination of homonyms, &
establishment of new contrasts (Ingram, 1976)
 Minimal contrast therapy (La Riviere et al., 1974;
Elbert et al., 1980; Weiner, 1981)
 Phonological awareness (Gillon & Dodd, 1994; McLeod & Bleile,
2004)
(E. Lin)
語言治療: 原則和方法
II. Voice Abnormality (Andrews, 1999):
For example,
• Hearing impairment:
e.g., activities to improve vocal quality, resonance, vocal variety,
rhythm & rate, pitch, auditory, oral, tactile & visual monitoring
• Cerebral palsy:
 Facilitative strategies
 Compensatory strategies: e.g., phrasing, slow rate of speech,
phonetic approximation
 Early intervention & parent involvement
 Behavioral therapy: e.g., elimination of undesirable habits
 Posture & physical manipulation
 Treatment of velopharyngeal incompetence
(E. Lin)
Use of Appropriate Positioning
(Workinger, 2005)
(E. Lin)
Jaw Control
(Workinger, 2005)
(E. Lin)
語言治療: 原則和方法
III. Others (Autism, Down Syndrome, etc.)
• Modification of environment
• Behavioral therapy:
 Whole language approach: Gibbs & Carswell (1991), Kumin (1998)
 Social stories: Norris and Dattilo (1999)
 Picture Exchange Communication System (PECS):
Frost & Bondy (2002)
 TEACCH (treatment and education of autistic and
communications impaired handicapped children):
Jordan (1999)
(E. Lin)
語言治療: 未來方向
• Early intervention
• Higher expectations
• Holistic approach
– More parent involvement
– Specialized & Interdisciplinary
– Multidimensional assessment/management
• More technological advances
– Instrumental measurement
– Biofeedback device
– Assistive and Augmentative Communication
• Multi-cultural sensitivity
(E. Lin)
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