Transcript Speech sound disorders The basics and beyond

Integral Stimulation and Dynamic
Temporal and
Tactile
“Look
at meCueing DTTC
for help”
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Integral Stimulation is an articulation
therapy involving imitation, auditory
models, and visual models.
Developed by Robert Milisen, 1954
The child IMITATES utterances modelled
by the SLP/SLT with attention focused on
LISTENING while LOOKING.
6 July 2015
Copyright © 2011 Caroline Bowen
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Milisen’s listen + watch  do it
uses a bottom-up approach
works from short, phonetically
simple utterances up to gradually
more phonetically difficult stimuli
TACTILE cues and GESTURE
cues are incorporated into the
approach to encourage accurate
articulatory gestures
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Copyright © 2011 Caroline Bowen
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PROSODIC cueing methods such as MIT
or contrastive stress are also used.
There is an emphasis – particularly early
in therapy – on suprasegmentals
Word stress and the contours of
sentences are emphasised early in
treatment.
Functional communication is emphasised.
‘Don’t breathe on me Lucy’
‘Let me have a turn’
‘I want one’
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Integral Stimulation / DTTC
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For non-verbal children, with very
severe CAS, Edythe Strand uses a
variation of Integral Stimulation that
she developed, called:
Dynamic Temporal & Tactile Cueing
for speech motor learning (DTTC).
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DTTC is based on John Rosenbek
and colleagues’ 1973 “Eight-step
Continuum for Treatment of Acquired
Apraxia of Speech”.
It allows for a continuous shaping of
the movement gesture.
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Integral Stimulation/ DTTC
Steps in DTTC
1.
Imitation
Direct, immediate imitation of
natural speech.
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2. Simultaneous production with
prolonged vowels (most support)
If the child can’t imitate, the
SLP/SLT simplifies the task and
moves to simultaneous production.
 At this level the clinician says the
utterance at normal volume with the
child, very slowly with the addition of
touch cues and/or gesture cues as
required.
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Slowing the utterance by sustaining
the vowel (“sea”  si:::::, not
sssssea) usually helps the child
because the task is easier.
 It also affords the opportunity for the
therapist to run a ‘visual check’,
ensuring jaw and lip postures are
correct.
(no jaw slide / acceptable symmetry)
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3. Reduction of vowel length
As the simultaneous production
phase of therapy advances the
rate of stimuli production is
increased so that the child’s
speech sounds more natural.
 This is achieved by reducing
vowel length.
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Copyright © 2011 Caroline Bowen
4. Gradual increase of rate to normal
Practice continues at this level to the
point where the child synchronises
effortlessly with the therapist:
 at normal rate
 with normal movement gestures,
 without silent posturing (groping).
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5. Reduction of therapist’s vocal loudness,
eventually miming
Using delicate timing the therapist is
then in a position to reduce the vocal
volume eventually reaching a point
where the therapist is producing a
‘mime’, mouthing the utterance as the
child actually says it.
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Careful!
• Because of the intellectual closeness
within the dyad this can be a tricky point
in therapy. Some children will dutifully
follow exactly what the adult is doing so
that the two are miming at each other!
• This is obviously not the goal!
• Children may need explicit instruction
to keep their voice ‘turned on’ even
though the adult’s voice is ‘turned off’.
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The gesture and touch cues may still be
needed at this point,
 They will definitely be necessary in the
next step:
 The Integral stimulation method proper.
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6 July 2015
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The gesture and touch cues may still be
needed at this point.
 They will definitely be necessary in the
next step:
The Integral stimulation method proper.
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Recall that DTTC is a stepping stone
for low verbal or non-verbal children
with severe CAS
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6. Direct imitation
Ensure that the child is secure moving to
this harder level in which he or she:
 watches the adult’s face
 while an
auditory
model is
provided.
“Look at me
for help”
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Copyright © 2011 Caroline Bowen
The child attempts to repeat the model
and if successful does so many times.
(MANY REPEATS!)
 If the child is unsuccessful, the therapist
may backtrack to the simultaneous model
or silent mouthing/miming level.
 Eventually all miming is faded
completely, and the child directly imitates
and ‘repeats’ targets numerous times
before the final step is introduced.
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7. Introduction of a one or two
second S-R delay (least support)
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Once the child is directly imitating the
model with normal rate,
prosody he or she can vary,
and appropriate articulation,
the SLP/SLT inserts a new requirement
in the form of a one or two second
delay between the therapist’s stimulus
and the child’s response.
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8. Spontaneous production
Finally, the therapist elicits spontaneous
utterances, using, for example:
 QUESTIONS: ‘What is this called?
 CLOZE TASKS: ‘Twinkle, twinkle __ __’
 SENTENCE COMPLETION:
‘Mother elephant is big, her baby is ____’
 GAMES: ‘What’s the time Mr Wolf?’ ‘Simon
Says’, ‘I spy with my little eye ___’
 STORY CONTEXTS and ROLE PLAYS
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The key to getting this right is the
therapist’s informed observations of
and sensitivity to what the child is
‘giving’ by way of responses.
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The skill and flexibility involved in
continually fine-tuning the hierarchy
of stimuli and support provided to
the child to enable him or her to
imitate spontaneously are critical.
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This is especially so with the
CAS population who have good
days and bad days with their
speech processing capacities.
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Auditory (including prosodic), visual and
tactile cues and the level of demand on
the child are continually added and
faded, dynamically, in each practice trial
according to the child’s responses.
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Motor Learning Principles
The principles of motor learning are
observed throughout.
Phonotactic Therapy
Because of its focus on syllable structure
and metrical stress, phonotactic therapy
has many ‘uses’ in intervention for CAS.
6 July 2015
Copyright © 2011 Caroline Bowen
6 July 2015
Copyright © 2011 Caroline Bowen