ࡱ>  ;bjbj?? %]]1- 8< |XxxxaWcWcWcWcWcWcWZ\cW-xxxx|cW W8 aW xaW IXMIOBFJ(M WHXKV] V]PM MMxxx I:   UNIVERSITY OF WASHINGTON Speech and Hearing Clinic Articulation and Language Unit Final Case Summary December 4, 2008 File #:September 30th December 4thName:individual sessions of 50 minutes each DOB:Clinician:Parents:Supervisor:Julie A. Dunlap, MS, CCC-SLPAddress:Disposition:Phone:( ) HISTORY H, age 8, was seen for his first quarter of treatment at the University of Washington Speech and Hearing Clinic (UWSHC). His mother, XX, brought him to the Clinic for assessment and treatment of persisting speech sound difficulties. His mother said she was first alerted to his speech difficulties by his first grade teacher at the beginning of the 2007-2008 school year, and he was seen by the school speech pathologist for an informal speech assessment. Since his articulation errors were developmentally within normal limits, she recommended that he be observed for another year to see if his speech improved with maturation. However, his mother continued to have concerns about his speech since both she and others had problems understanding him. His mother did not have concerns about his receptive or expressive language. He is in a general education second grade classroom at John Hay Elementary School in the Seattle School District (SD). He lives with his mother and older brother. His medical history is unremarkable and he has not previously received speech treatment. WINTER QUARTER 200X ASSESSMENT Speech/Articulation Formal Measures The Goldman Fristoe Test of Articulation (GFTA) was administered to assess articulation. He received a standard score of 70 (mean = 100, SD = 15) placing him 2 standard deviations below the mean and in the 5th percentile for his age. Item analysis of the GFTA revealed deletion of /r/ in medial and final word positions, and substitution of /w/ for /r/ in word initial position and in clusters. Inconsistent substitution of /(/ for /s/ was also noted. Please see the summary report from the September 30, 2008 initial evaluation for additional information. Error Patterns Observed on the Goldman Fristoe ErrorExampleAge Sound Typically Mastered or Age Phonological Pattern Extinguished/r/ deletionca for car7 years/w/ for /r/ substitutionwabbit for rabbit and fwog for frog7 years/ (/ for /s/ substitution housh for house8 years Connected Speech/Intelligibility During a 10-minute speech sample, Hs speech was 100% intelligible to this clinician, however, his r deletion and substitution were distinctly noticeable and called attention to his speech. His speech intelligibility was impacted the most by his low speaking volume necessitating frequent requests for repetition of information and/or requests for him to speak up. In addition to his low volume, H had a somewhat lower pitch during conversational speech. Voice specialist Marty Nevdahl, MS, CCC-SLP was consulted and he informally judged Hs pitch to be within the range of normal. Statement of Treatment Focus Based on the above results, treatment during Autumn Quarter 2008 focuses on improved articulation of /r/ and /s/. Treatment Targets and Baseline Measures Baseline measures (percent accuracy) were taken for the following targets at the syllable level: /r/ Word levelBLPrevocalic (e.g., rat, ring)0%Postvocalic (e.g., car, army)0%Cluster (e.g., train, print)0% /s/ Word positionBL Initial (e.g., sun)0%Medial (e.g., essay)75%Final (e.g., race)50%Clusters (e.g., spot, fist)85%Sentence LevelBL Initial 0%Medial100%Final100% Stimulability Stimulability testing revealed that H was able to produce Post-vocalic /r/ at the syllable level with maximum cueing (e.g., to maintain appropriate tongue, jaw and lip position) and direct modeling from the clinician. Pre-vocalic /r/ at the word level with direct model and cued to use the high , back vowel // (as in cat) preceding the /r/. /s/ at the word and sentence level with a verbal reminder from clinician to attend to tongue position. MANAGEMENT The following program was established for therapy based on the above information. Specific targets were chosen based on stimulability results and appropriateness for age level. Long Term Functional Goal: H will use correct articulation and be 100% intelligible in conversation with a variety of communication partners. Quarterly Behavioral Objective 1: Client will produce prevocalic /r/ at the word level when given a direct model from the clinician in the clinic room during treatment sessions. Criterion for change is 90% correct average over 10 trials of 10 words using trained targets. Procedures: Treatment to elicit /r/ began on October 7, 2008. Because H was not able to produce /r/ in isolation, /r/ was shaped from other vowels and consonants, or other articulation positions. The contexts tried included /a/, /i/, /u/, /ae/, /j/ pronounced like the sound  y in yogurt, /k/, /g/,  sh, /tr/, /dr/, /K/, and /l/. As mentioned above, he was somewhat stimulable for /r/ when shaping from /ae/. He was also intermittently stimulable for /r/ when holding a small piece of candy in his mouth to form a bowl with his tongue or when pressing the piece of candy against the roof of his mouth. Shaping /r/ from the other sounds was unsuccessful. On XXX (date), a Sequential Teaching Program was created using the following resource: D.B. Pittner (2002), An R Therapy Technique that Works. ADVANCE for Speech-Language Pathologist & Audiologists, 12(36). Rather than focusing solely on eliciting a strong /r/ at the syllable level, this method recommends treating /r/ at the word level in the prevocalic position, for which H was stimulable. He was not stimulable for post-vocalic /r/ at the word level; however, he did produce post-vocalic /r/ in syllables. Treatment began by calling Hs attention to tongue position during production of the // vowel. Once good tongue position was established, the high, back /ae/ tongue position was shaped to other vowels as a prerequisite to eliciting /r/. The following vowel contexts were established and treated: uh as in run, // as in rat, eye as in rice, eh as in bet, and eeas in reach Once he maintained good vowel position, treatment progressed to producing prevocalic /r/ in words preceeded by four /ae/ prompts following a direct model (DM) from the clinician. (Definition of // prompt: producing // with tongue up and back before saying the pre-vocalic /r/ word. For example, run would be produced /ae/- /ae/- /ae/ -run with the tongue held up and back through the /ae/s and r sound.) Direct treatment of /r/ was interspersed with games to provide a respite from focusing on his speech and for motivation. Progress: Goal in progress. Treatment data taken on November 18, 2008 showed that H produced a strong pre-vocalic /r/ with the 4 // prompts correctly 47% of the time in 10 words over 10 trials. Item analysis, however, revealed he did the best (75% accuracy) with the words reach and recess, possibly because the ee vowel (mid, back vowel) helped him keep his tongue up in the back. Final probe data (no teaching and/or minimal clinician support given) taken on November 20, 2008 revealed only slight progress with prevocalic /r/ production in treated words when he was given a DM and no // prompts. Word Level Beginning Fall Independent productionWord Level End of Fall Independent productionWord Level End of Fall DM and no // prompts, familiar words0%4%10% Generalization: Word Level End of Fall DM and no // prompts, unfamiliar wordsWord Level End of Fall DM and no // prompts, unfamiliar vowel contexts (oh as in road and ah as in rock)38%45% The higher accuracy with unfamiliar words and unfamiliar vowel contexts may suggest that H has grown dependent on the // prompts in order to produce /r/ in the treated words. Quarterly Behavioral Objective 2: H will independently produce /s/ in all word positions at the sentence level in the clinic during treatment sessions. Criteria for change is an average of 90% accuracy over three trials of ten untrained words Procedures: H produces his /s/ (as in sun) with his tongue tip directly on the alveolar ridge resulting in distortion of the sound to a /(/ as in shoe. When given instructions to place the tongue tip behind but not touching the upper front teeth, his /s/ improves. Treatment began with having H produce /s/ at the word level when given a verbal reminder about tongue placement from the clinician. As his accuracy improved, verbal reminders were faded. Treatment then progressed to the carrier phrase level (e.g., I see a.) when given a verbal reminder about tongue placement from the clinician. Verbal reminders were again faded as his accuracy improved and work at the sentence-level began with verbal reminders for correct tongue placement. Progress: Goal in progress. Final probe data taken on November 20, 2008 revealed no change from baseline in word level accuracy for medial and final /s/. Initial /s/ and /s/ clusters improved to 100% accuracy, however. At the sentence level H improved to 80% for initial /s/, medial /s/ dropped to 50% and final /s/ remained at 100%. Word position% Initial100%Medial75%Final50%Clusters100%Sentence Level% Initial80%Medial50%Final100% ADDITIONAL INFORMATION Although increasing Hs loudness was not formally addressed in treatment, articulation activities were structured so that using a loud or strong voice was a requirement for getting points or moving on to the next item in a game. Reinforcement for using a loud voice without a reminder from the clinician included earning stickers to exchange for a prize from the prize box once he had collected 20 stickers. By the end of the quarter, Hs volume had increased to a more consistently acceptable level in conversation. SUMMARY AND IMPRESSIONS H is a cooperative and motivated 8-year-old boy. Although he was shy initially, he gradually became more comfortable and worked hard in therapy. This quarter focused on improving his production of /r/ and /s/. Although he was marginally stimulable for /r/ at the beginning of the quarter he has slowly progressed to producing prevocalic /r/ at the word level when given a high level of support by the clinician. He has made progress towards his goal for /s/ production and correctly produces /s/ at the sentence level either independently or with only a verbal cue from the clinician. His loudness also improved over the course of treatment. With continued treatment, H should continue to make excellent progress with his articulation skills. A parent conference was held with XXX and H on December 02, 2008. His mother was pleased with the progressed he has made and requested that there be communication concerning treatment between Hs school SLP and his SLP here at the UW clinic. The following recommendations were offered: RECOMMENDATIONS H should continue to receive individual speech and language services twice a week at UWSHC. Communicate with the school SLP as appropriate to coordinate services. Continue to treat /s/ at the sentence level for medial position, begin treating medial position and /s/ clusters in sentences and initial /s/ in conversation. Continue to treat pre-vocalic /r/ at the word level with a focus on reducing the amount of clinician support. Continue to informally address Hs volume in conversation. ________________________ _____________________________ Julie A. Dunlap, M.S., CCC-SLP Graduate Clinician Clinical Supervisor cc: Parent School SLP Whomever Appendix A. 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