Transcript Josie - Speech-Language Therapy

Children’s Speech Sound Disorders
Case Study: Josie and PACT Therapy
Josie - Background
Bowen 2009, p.315
Two normal audiograms
5;2 - 5;5 SLP1 - Language Group (6 x)
5;11 SLP2 - Artic Survey – DVD - W/L for tx
6;5 – 7;6 SLP3 (Caroline Bowen)
Initial consult with Bowen at the end of her
Kinder year - request for language testing teacher’s concerns about her language,
pre-reading / PA, unhappiness at school.
History: Josie was a late talker, always poorly
intelligible. Family history of speech and
literacy difficulties (Maureen, Emma and
Ruby).
Copyright © 2010 Caroline Bowen
History & Language Assessment
Josie 6;5, Maureen, David attended Appt 1
Appointment
1
Close, supportive, cheerful family
 Emma 15 had a diagnosed learning
disability and was homeschooled.
 Emma described as Josie’s 2nd mum.
 CELF-P RLS 103 ELS 100 TLS 101
 Finances and travel to tx were problems.
 Family motivated to be involved in tx
(to expedite therapy and save time/money)

Copyright © 2010 Caroline Bowen
Speech Assessment
Josie, David, Maureen
Josie 6;6
Appointment
2
p. 316
The CS and SW data for independent
and relational analyses were gathered
in the second session (4 weeks after
the first) with her parents observing.
Permissions to use Josie’s data for
teaching purposes obtained and
release forms signed.
Copyright © 2010 Caroline Bowen
Diagnosis
Severe Phonological Disorder with
phonemic and phonetic issues.
 CAS (or “DVD”) ruled out.
 The family were extremely relieved.
They had read about “DVD” on the
Internet and were worried and
confused.

Copyright © 2010 Caroline Bowen
p. 321
Intervention Planning
CONSONANT INVENTORY CONSTRAINTS
Marked /ʃ/ appeared occasionally in Josie’s
CS output, but she was not stimulable for it
in the true sense.
The (marked) affricates /ʧ/, /ʤ/ and the
(marked) fricatives /s/, /z/ were never
present and were also non-stimulable.
Consonant inventory expansion top priority.
Copyright © 2010 Caroline Bowen
Intervention Planning
MARKED CONSONANTS
/ʧ/ was selected for stimulability training because there is evidence to suggest that
targeting the marked voiceless affricate
consonant might evoke:
1. the emergence of UNMARKED
consonants with the same features, and
2. generalization to the voiced affricate /ʤ/.
Copyright © 2010 Caroline Bowen
Intervention Planning
NON-STIMULABLE CONSONANTS
A second marked consonant /s/
was selected for stimulability
training on the basis that it might
help promote cluster development
and generalise to /z/ and,
hopefully, other fricatives, and
unmarked features.
Copyright © 2010 Caroline Bowen
Intervention Planning
LATER DEVELOPING CONSONANTS
Consideration given to targeting late
developing, marked /ð/, and rejected…
… because Josie already had the voiceless
cognate /θ/ in her repertoire it was felt that
working on /ð/ might not have much impact
on her overall system as /s/.
‘Was it your birthday?’
(Chronological Mismatch)
Copyright © 2010 Caroline Bowen
Intervention Planning
LEAST PHONOLOGICAL KNOWLEDGE

On the other hand, late developing, nonstimulable, unmarked /l/ looked like a good
candidate for therapy, especially since the
Locke Task revealed that Josie could not
reliably discriminate the liquid /l/ from the
glide /r/.

In hindsight, it might have been more
fruitful to target /r/ (instead of /l/) early on.
Copyright © 2010 Caroline Bowen
Intervention Planning
PHONOLOGICAL PROCESSES
Thinking about /l/ led naturally to
deciding what to do about her clusters.
With 100% Cluster Reduction in her
SW Sample, and only /bw/ SIWI in
conversational speech, clusters were a
high priority.
Copyright © 2010 Caroline Bowen
Intervention Planning
PHONOLOGICAL PROCESSES



Targeting /l/ clusters not the best option.
Rather, targeting the adjuncts /st/, /sp/ and
/sk/ would probably NOT stimulate
generalisation to other clusters, but it
might encourage the idea of ‘2-steps’.
Targeting the s-clusters might also help
in adding /s/ and /z/ as singletons, via
generalization, and possibly /ð/.
Copyright © 2010 Caroline Bowen
INTERVENTION
November – December
p. 327
Age 6;6 – 6;7
4 sessions over 4 weeks
Summer!
Copyright © 2010 Caroline Bowen
Session 1
Josie, Maureen and Emma 40 minutes
Appointment
3
1.
Stimulability Training /ʧ/ and /s/
2.
Sound-Pic-Symbol associations frics & affricates.
Auditory Discrimination Training for /l/ vs. /j/.
3.
4.
5.
6.
7.
Auditory Discrim. for fricatives and affricates.
AB: /ʧ/ words SIWI (hat shop chop, etc).
Near Minimal Pairs Games for /st/, /sp/ and /sk/ SIWI
vs /t/, /p/ and /k/ SIWI.
Homework: 2 to 6 above,
and Auditory Input Therapy
for /ʧ/ SIWI.
Chinese
cooking
Copyright © 2010 Caroline Bowen
Session 2
Josie, Maureen and Emma 40 minutes
Appointment
4
Now stimulable for /ʧ/ SIWI.
2. Imitating /s/ (just).
3. Imagery introduced for /ʧ/, /ʤ/, /s/ and glides.
Imagery used in glides vs. affricates game.
4. JOC game /ʧ/ vs. /s/ CVs.
JOC = judgment
of correctness
5. JOC game /ʤ/ vs. /j/ CVs.
6. Auditory Discrimination between all
fricatives, affricates, and glides SIWI.
While she could soon do this, it was still
difficult for Josie to discriminate between
liquids and glides in words.
1.
Copyright © 2010 Caroline Bowen
7.
AB: /ʧ/ words SIWI; /s/ words SIWI
8.
Production practice:
10 /ʧ/ SIWI CV and CVC words.
9.
Near minimal pairs games for FCD.
– 4, 5, 6 and 7
and to practise /s/ in isolation.
10.Homework
Copyright © 2010 Caroline Bowen
Session 3
Josie and David 40 minutes
1.
2.
3.
4.
5.
Appointment
5
Minimal Triplets: chew, shoe, Sue
Cloze shoe rhymes with ch…, …
Cloze ewe rhymes with ch…, woo rhymes with
ch…
/ʃ/ being used in conversation more.
Stimulability for /ʃ/ SI established. To practice
8 words /ʃ/ SFWF.
To practice 8 words for /ʧ/ SIWI.
Copyright © 2010 Caroline Bowen
6.
7.
8.
9.
“Itchy Archie” was elicited. Josie was
promised a special sticker if she could
still say it after the school holidays.
Games 4 and 5 from Session 2 were
continued, using different words /
syllables.
Near minimal pairs games for FCD
(bee beach…)
Homework – 1, 2 and 3 above
“Itchy Archie”
Copyright © 2010 Caroline Bowen
Session 4
David, Maureen and Emma – 1 hr 50 min





Appointment
6
“Parent education” without Josie.
PPT: modelling, recasting, revisions/repairs.
“Instructions” for working in 5 - 7 minute
“bursts”, 1-3 x daily in the holidays given.
David kept in email contact
Family to model and reinforce /st/, /sp/ and /sk/
clusters, final consonant inclusion, and do to
AIT around /ʧ/, /ʤ/ and /s/, talking about the
imagery and sound-letter-symbol associations,
and to maintain stimulability.
Copyright © 2010 Caroline Bowen
February – April
Age 6;9 – 6;11
5 sessions over 8 weeks
1 cancellation
Copyright © 2010 Caroline Bowen
Session 5
1.
2.
Josie, Maureen, David 1 hr 10 min
Appointment
7
QS - parents observing. Stimulable for all
consonants except /l/ and /f/. SW PCC 65%
CS PCC 50% in the clinic. Reduction in FCD.
Glottals almost gone. Vowels improving.
Attempting longer words, but with WSD.
The /s/ + voiceless stop clusters needed more
work to encourage further generalisation to
other clusters. Multiple Oppositions approach,
using imagery cues, and the Fixed-up-One Routine for
ALL s-clusters (not just s + p, t, k).
3.
Production practice of polysyllables.
Copyright © 2010 Caroline Bowen
4.
5.
/s/ vs /ʃ/ minimal pairs activities
were done in the session and
given for homework, along with /st/,
/sp/ and /sk/ clusters for production
practice. The family were
instructed to model /s/ hard in all
contexts including polysyllables.
Homework: 3 and 4 above, with
Josie being rewarded strongly for
self-corrections.
Copyright © 2010 Caroline Bowen
Materials for Session 5




Fixed-up-one Routine for clusters
Fixed-up-one Routine for polysyllables
Polysyllable production practice
Multiple Oppositions Targets
Copyright © 2010 Caroline Bowen
Multiple oppositions (1)
 spit
 bit
 skit
 Vit
(the alien)
 fit
Copyright © 2010 Caroline Bowen
Multiple oppositions (2)
 spin
 bin
 skin
 Vin
(Vit’s dog)
 fin
Copyright © 2010 Caroline Bowen
Multiple oppositions
(untrained)
 spawn
 born
 scorn
 Vaughan
 faun
Note that this is Australian English (non-rhotic) so
faun and born, for example, are minimal pairs.
Copyright © 2010 Caroline Bowen
Session 6
Josie, Maureen, Emma and Maureen’s sister
Josie was not well and they only
stayed briefly. No homework. Josie
was unable to attend the following
week because she was still unwell.
Appointment
8
Copyright © 2010 Caroline Bowen
Session 7
Josie and David 60 minutes
Appointment
9
Session was devoted to clusters “two step
words”, “three-part words” and “four part
words” (polysyllables) with “finger walking”
and silent tapping of syllables.
2.
Using pictures from her “speech book”
Josie made up her own Fixed-up-One
Routine for clusters. “If I said…”
3.
Homework: Reinforcement of selfcorrections at home. Speech book to school
to “impress” her teacher. (Guess!)
Teacher said, “I’m impressed, Josie!”
1.
Copyright © 2010 Caroline Bowen
Session 8
Josie and David 40 minutes
1.
2.
Appointment
10
Velar nasal introduced in minimal pairs
(win wing, pin ping, bun bung, etc), with
multiple exemplar games and AIT. At
home they modelled the velar nasal,
modelled polysyllables (for WSD) and did
daily production practice for polysyllables.
Josie was still unable to produce /f/ in
CVs, but she could in VCs (not words).
She was given –iff, –off, –aff, –uff to
“perfect” over the next week.
Copyright © 2010 Caroline Bowen
Session 9
Josie and David 40 minutes
1.
2.
3.
4.
Appointment
11
The velar nasal generalised within a week!
Nasal clusters SF were emphasised for a
week, particularly /ŋk/ but also /nt/ and /nd/.
iffy, offy, affy and uffy were established in the
session and sent home to “perfect”.
Homework: She had a judgement of
correctness task and a Fixed-up-One routine
for homework for SFWF /ŋk/, /nt/ and /nd/
words; and production of iffy, offy, affy, uffy
nonsense words.
Copyright © 2010 Caroline Bowen
Session 10
Josie, Maureen and David 40 minutes
1.
2.
3.
Appointment
12
QS again. David did most of the scoring!
The final cluster strategy worked and by the
next session Josie was using them
inconsistently in careful CS … Introduced
Stopping of Fricatives in the session and
for the break.
Using backward chaining she managed /f/
SIWI (iffy-fee, offee-fee, affy-fee).
Copyright © 2010 Caroline Bowen
4.
Homework: Family to maintain /f/
SIWI and model in general. No
specific homework was given, and
Josie was asked to put her speech
book and other materials away in a
safe place and have a break. This
was presented as a reward for a
terrific effort on her part.
Copyright © 2010 Caroline Bowen
June
Age 7;1
3 sessions over 4 weeks
Copyright © 2010 Caroline Bowen
Session 11
Josie, Maureen, David 1 hr 10 min
1.
2.
Aspiration
trick
3.
Appointment
13
At 7;1 SW and CS PCCs about the same.
Barely stimulable for /f/ SIWI and SFWF,
No functional generalisation. Not stimulable
for /l/, but now generally replacing /l/ with
liquid /r/ and not a glide /j/ (i.e., progress).
Decided to focus on /f/ and /v/ concurrently
using a combination of traditional phonetic
production training and multiple exemplar
activities and the f-hat-fat strategy.
Homework: /f/, /f/ and more /f/! And /v/!
Copyright © 2010 Caroline Bowen
The aspiration trick
Strategy for “stop insertion”
f-hat-fat, etc
s-heel-seal, etc
sh-who-shoe, etc
Copyright © 2010 Caroline Bowen
Session 12
Josie, Maureen and David 40 minutes
1.
2.
3.
Appointment
14
Traditional artic (phonetic) therapy for /f/
and the clusters /fr-/ and /-ft/ using lexical
innovation (laugh / laughed, cough /
coughed, etc). AB using /f/ vs. /v/ minimal
pairs (fat-vat, fine-vine, fail-veil, etc).
Auditory Discrimination games for /r/ and /l/
(lung-rung, lead-read, list-wrist, etc).
Homework Modelling and AB for /f/ and /v/.
Copyright © 2010 Caroline Bowen
Session 13
Josie, David, Maureen and Emma
FAMILY SESSION 40 minutes
1.
2.
Appointment
15
Josie’s name had come up on the
CHC waiting list. Had been seen by
SLP4 at school once. Decided to
proceed with our two appointments in
September and one in November.
Therapy and homework were the
same as for Session 12, with
different vocabulary and games, plus
AB for /l/ SIWI.
Copyright © 2010 Caroline Bowen
September
Age 7;3 – 7;4
2 sessions over 4 weeks
Copyright © 2010 Caroline Bowen
Session 14
Josie and David 40 minutes
1.
2.
Appointment
16
More work on /f/ and /v/ in story retelling
and narrative tasks. Both targets were
beginning to show functional
generalisation. This was SO exciting
for Josie.
Homework: none – other than praising
Josie who was self-monitoring and
self-correcting constantly.
Copyright © 2010 Caroline Bowen
Session 15
Appointment
17
Josie, Maureen and David 40 minutes
1.
2.
In the session /l/ was elicited in “la”
for the first time!
Homework: production practice: la-lalaugh, la-la-laugh, la-la-last, etc and
AB for /l/ SIWI and SIWW.
Copyright © 2010 Caroline Bowen
November
Age 7;6
1 session
Copyright © 2010 Caroline Bowen
Session 16
Appointment
18
Josie, David, Maureen and Emma 40 minutes



QS - family observing.
PCC in SW and CS about 93%
Producing laugh, last, llama, etc, perfectly.
Unable to produce /l/ with other vowels.

Fully intelligible and the only outstanding
difficulties were with /l/ and a tendency to
replace /ɪə/ with /e/.

Josie was looking forward to seeing SLP4 in
the new year.
Copyright © 2010 Caroline Bowen
May
Age 8;0

Copyright © 2010 Caroline Bowen
May: Josie 8;0

Conversation with Maureen
SLP4 did CELF-4 Au (2 sessions). CLS = 100
Grouped with 2 boys for weekly 30-min
sessions for /l/ in the lunch period at school.
Reading Recovery teacher who was seeing
her twice a week did “l-homework” with
Josie. No homework.
8 group tx sessions with SLP4 and 12
“homework” sessions with the RR teacher
Dismissed from therapy having reached the
maximum allocation.
Copyright © 2010 Caroline Bowen
May: Josie 8;0

Conversation with Maureen
Maureen was unsure, but she thought the /l/
had not improved. She had not spoken to
SLP4 since the CELF assessment. Maureen
happily reported that Josie had maintained
her other progress and was doing quite well
academically in Year 2. Plans to homeschool her the following year had been
suspended for the time being because Josie
was now enjoying school. Maureen said she
and David might re-contact “if the ells don’t
come good”.
Copyright © 2010 Caroline Bowen
How much intervention?

On caseload 6;5 – 7;6
Language Assessment 1 session
Initial Speech Assessment 1 session
Therapy 6;6 – 7;6
Therapy 16 sessions
Copyright © 2010 Caroline Bowen
12.5 hours face to face
3 - 4 hours analysis / preparation
1.
2.
3.
4.
5.
6.
7.
8.
40 minutes
40 minutes
40 minutes
110 minutes
70 minutes
60 minutes
40 minutes
9.
10.
11.
12.
13.
14.
15.
16.
40 minutes
40 minutes
70 minutes
40 minutes
40 minutes
40 minutes
40 minutes
40 minutes
Copyright © 2010 Caroline Bowen
12.5 hours face to face
3 - 4 hours analysis / preparation
1.
2.
3.
4.
5.
6.
7.
8.
40 minutes
40 minutes
40 minutes
110 minutes
70 minutes
60 minutes
40 minutes
40 minutes
10. 40 minutes
Plus
the
11.
70 minutes
clinician’s
12. 40 minutes
13. 40 minutes
thinking
time
14. 40 minutes
15. 40 minutes
16. 40 minutes
9.
Copyright © 2010 Caroline Bowen
Copyright © 2010 Caroline Bowen
Reference
Bowen, C. (2009b). Working with
PACT. In C. Bowen, Children's speech
sound disorders. Oxford: WileyBlackwell, pp. 296-340.
Copyright © 2010 Caroline Bowen