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2017 EHDI Annual Meeting Topical Session 6 Hanover F BEYOND AUDITORY SKILLS: WHAT ABOUT SPEECH? 1:45 p.m. February 28, 2017

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* * * * * This is being provided in a rough-draft format. Communication Access Realtime Translation (CART) is provided in order to facilitate communication accessibility and may not be a totally verbatim record of the proceedings. * * * * *

>> Welcome, everyone. I want to introduce our speaker, MaryKay Therres. She is talking to us about Beyond Auditory Skills: What About Speech? >> MARYKAY THERRES: Okay. Well, thank you, everybody, for coming this afternoon. I want to talk about a topic that doesn't always get addressed when we come to conferences like this. I know we do a lot of emphasis on listening skills or language skills but I'd like to talk about speech production skills too because I think that's important for communication. Is we're going to do beyond auditory skills, what about speech? My name is MaryKay Therres, I'm a speechlanguage pathologist and auditoryverbal therapist. I currently work for MEDEL Corporation one of the companies that makes cochlear implants and prior to that I spent about 20 years of my career being a speechlanguage pathologist on a cochlear implant team at two different Children's Hospitals. What I would like to focus on today is speech development a quick overview of early vocal production and really talking about how do we talk about facilitating or remediating speech production and then a little bit about assessment so in 30 minutes we're going to cover quite a bit. It's more of the whole overview so speech development. There's different individuals who have organized early vocal production and I'm just going to go through all our stages of vocal development because I think it kind of summarized to me pretty nicely all the different stages that go on. So the first one we have from about 0 to 2 months of age is reflexive crying and vegetative sounds. This is where the child is crying, burping, grunting, sneezing, these are those involuntary sounds that the child makes. And then at about 2 to 4 months we start to get a little more cooing and gooing and laughter that happens to come in, these are more primitive movements of the articulators, although they're not fully formed yet, but a little bit more than the reflexive sounds that we hear, so we might hear some approximate what we would call back viewers but they're not really a CA or GA sound. It's an approximation or some of those lax vowels, some approximates of that. From there at 4 to 6 months of age we start to get a little bit more vocal play and expansion and exploration of the vocal mechanism. So now they're really starting to bring in some of the suprasegmentals and I'm going to ask the people out there, suprasegmentals, when I say DIPS, can anybody tell me what DIPS stands for? You can talk loud. Duration, intensity, pitch, and stress, thank you. So those are our suprasegmental aspects, so they start to play with that more along with improving some of the articulatory control, so even the segmentals, which is vowels and consonants, we start to hear more well formed like those bilabials: PA, BA, UM kinds of sounds, and then they're practicing suprasegmentals, and we get better oral resonance happening because they tend to be more oral resonance when they're very young infants and then 6 to 10 months we get into a very important stage, the canonical babbling and canonical babbling is I'll let the interpreter sign that one is a reduplicated babbling, ba, ba, ba ma. There's not suprasegmental pitch that happens with that. They're producing sounds that are recognized as true phonemes so we're getting better control of the articulators of resonance and of course. They produce early sounds in the language. If you think about universal babble, all babies can babble all the sounds in the different languages and they start to listen and hear the sounds in their language so if a child is being exposed to English, or English and Spanish they're hearing those sounds more and more and those are the sounds that they're going to start to try to produce and other sounds such as a very German guttural sound they could have produced before dies away and then at a certain point no matter how hard you try you can't produce some of those other sounds, like I was not exposed to a trilled R when I was very young. And to this day and being a speechlanguage pathologist I have practiced and I cannot do a trilled R to save my life. So when I was probably 6 months old I could, maybe, not quite a trilled R but I could try to play with the sound but it's too late now. So that's universal babble, so the foreign speech sounds are going to disappear and the child is really just going to start babbling and producing the sounds that they're being exposed to in their home languages. They're also increasing the vowel repertoire so we're getting more of the lax vowels and we're getting a few more velars. They're going to start to disappear and you get the alveolars, but they'll be more precise because they have more control. This is an important stage. If you remember back to training, children who are typical hearing children who are late to canonical babbling are at risk for speech and language development so it's a milestone marker for us to really look at children and their speech production skills, and in working with children who received cochlear implants, one of my milestone markers was that if by 6 months postimplant so they've now had access to listening to sound for 6 months, if by 6 months postimplant they were not starting to produce at least two different consonants in babble, that was a red flag for me that they were not on track for producing speech and language development. If they were still using the earlier stages more reflexive or just the cooing and gooing and very primitive vowel production sounds then I was concerned. So I kind of also use that as a marker not only for children with typical hearing but for children who had access to sound either with cochlear implants or if they received hearing aids, and we know that they are now having access to sounds within the speech range. So canonical babbling is something we can use as a marker as to speech production for children. From there at about 10 months onwards we get into the variegated babbling and then the jargon. So the variegated babbling is where it's nonreduplicated sounds and then we add in the jargon where they're getting that intonation, that suprasegmental patterns into that. So I see one of the markers on the sheet is that there should be audience participation so to do that I would like each of you to turn to your neighbor and show them an example of jargon. Fantastic. You're good at jargoning. That's when children are talking to you and you have no idea what they're saying but boy are they going to town with it. So awesome. At this stage children are also starting to do some imitation of nonspeech sounds, or imitating some simple consonantvowel productions, ma, ma, no, no, da, da, and they're doing long jargoning to people, and then about 12 months the first words appear and after that we get a mixture of jargon with simple words thrown in like "I got 'go' out of that, and the rest I have no idea," until eventually the words kind of take over. So those are the early stages of what we'd call vocal development that we're looking for in children, and hopefully we're all kind of familiar with this here chart that just kind of talks about when the different speech sounds come in and we know those early bilabials come in. I remember memorizing this: Put my house near water, please, I think was one of the those are the first sounds that come in and we have our later developing sounds like the affricates, the CHA and the JA, and the TH kind of sounds, so being aware of how speech develops and then when sounds start to come in is very important when we're working with our children. We want to make sure that any child with a hearing loss we're never expecting them to produce a sound earlier than a typically hearing developing child would produce a sound, so sometimes parents or audiologists get excited, a child has access to sound and the child's 2.5 years old and they come in and they say, he's not producing the S sound very correctly. Could you fix that, please? Well, but typical hearing 2.5yearolds aren't necessarily producing the S sound accurately, so we can't change expectations. We need to be aware of what normal development is in terms of speech production. So after I've reviewed it let's talk about how do we go about facilitating or remediating speech production? Child has access to sound. They're starting to show responses to sound. They're starting to attach meaning to sound. They're vocalizing, we need to monitor that vocalization. Is it going through those stages that we want to see? And are we starting to hear consonants and vowels and so now word production happening? I'm going to talk about speech hierarchy that comes out of the book, the AuSpLan. So I talk about a hierarchy of speech intelligibility. As a speechlanguage pathologist, I love hierarchies or steps. You move here and you move yourself up the hierarchy. What's the next step, the next step. So in terms of speech intelligibility, we start with the child has to turn their voices on. They have to have vocal control. We start at prespeech and play with sounds, and then we get into intelligibility at words, phrases, and sentences. So the first stage we had was speech 1, prespeech, where they learned to turn their voices on and off. For younger children who get access to sound, it's a bit easier. It comes more naturally. However, if we have a child who's a little bit older coming to getting access to sound, I've had many children where I'll go, AH, and the child goes They're imitating the oral motor movement, but there's no sound coming out, so they don't have vocal control yet. They haven't learned to turn their voices on so we want to do that through listening and even if we need to use visual cues and getting them to do a little length imitation so you're hearing me repeat back what you hear and even if it's not an exact vowel or consonant sound if I do AH, and you go UM, you heard something and repeated it back. That's a good thing. And then we get to stage 2 where we want to make sure we're building that speech sound repertoire so we start adding in vowels and consonants. So some toys that I used is you can see my flower's been a bit beat up but if they don't do it through listening I might add in a visual cue, AH, and then the flower moves and they go and the flower doesn't move. They realize I have to do something else to get the flower to move, so that's always a nice little toy that can be used if a child is struggling to learn to find their voice, because the minute you take the flower away, they go AH, but they don't realize that was their voice. It needs to be volitional imitation. I also have the bugs. Can anybody tell me what sound a caterpillar makes? Yeah, I don't know, so it's great. I can make any sound that I want to be and so I'll have one and I'll have the child have one. This is auditory bombardment where I really want the child to hear the sounds we want them to start producing back so I can take the caterpillar and go MMMM and hand a little bug to the child and they'll go like this and eventually they'll start making some noises with it and coming back with what they're hearing so we want to do auditory bombardment and focus in on specific sounds we want them to start to develop. So I kind of went through that. We just do a long versus intermittent and the B might be EEEE, and maybe they go UUUU, but they're listening and hearing that sound difference and we're starting to help facilitate some vocal development with them. When we get to the third stage this is where I really break it down to those children who are implanted younger, and aren't having difficulties accessing sound or producing it. We just want to facilitate more speech sound production so we're going to bombard and we're going to give them stimulation and many, many opportunities to hear these sounds, or even words with these simple sounds in it to get into canonical babbling, variegated and words. However there are a group of children that are either implanted older or maybe even implanted younger, getting access to sound, but still struggle with speech sound production for a variety of different reasons. I don't want that to go on too long. I already told you by 6 months post, if you're not producing a couple consonants in babble I'm going to start going towards a remediation path rather than a facilitated path with you to focus on getting more speech production, because I really want to get to speech intelligibility. So if I'm going to do remediation I go more the apraxia approach with that, so we're doing minimal sound differences, so we're going to go from a consonant to a vowel. BA, to then we're going to stimulate it to BABA, consonant reduplicated, to then changing the vowel, BABE, so you can see how that minimal shift is happening to then eventually changing the consonant, bunny, because if I start off with the word bunny and the child is having difficulty with sound production, they're going to just do BA. And we need to go through those steps and give them that practice so what an apraxia approach can do is give a child a chance to practice coarticulation. It gives them kinesthetic pattern, going from one sound to the next sound, make it with a smooth easy transition and they do it with automaticity. And not think about it. We've seen those children BAAH, we want them to be able to do BA and not have to think about it. And for some of these children, we have to help them with motor planning, and make it become easy for me. Learn that kinesthetic pattern so lots of things I like to use, games with many pieces. So that we can practice the don't break the ice which I've probably played a thousand times at least but they enjoy it. So it's doing some speech drills which isn't always the most fun thing on the planet to do, but if you have a child who's having difficulty with speech, we need to go back a step and we need to not work at word level. We need to take it back to the more syllable sequencing level. It isn't just about producing the sound, but can you also produce it in sequences? Because you need both of those to have intelligibility. Like a word like computer, there's a lot of sound switches that happen in there so you have to be able to sequence that easily. So using, like, PopUp Pirate, Don't Break the Ice, I'll produce the sound, then having them imitate and just working on getting accurate productions and after we've done so many we get to play the game and then we make the game a language activity and if we were working on N, maybe I use the word "no," or "no more," or "not" or something, trying to add in some of those sounds. I always want to do a speech activity, but right after it, a language activity that uses the sounds that I was working on, so it becomes meaningful, and that there's a reason for them to learn that sound and have it motivating so that they can learn to say "no" when they don't want something, or "more" and being able to say it intelligibly. And then the next steps, we follow Van Riper's you want speech intelligibility at words, phrases, and sentences. The goals become: Can they imitate the sound? Because if they can, that's a good indicator or probe we conveniently will be able to produce it spontaneously and can they produce it spontaneously? Not only sounds, but we also have to make sure we're looking at phonological processes, so you know this is the immature form of a child's production for the adult form, and there's typical phonological processes that happen till about 4, 4.5. Final consonant deletion where a child drops off the final sound is up to about age 3 is typical to happen, so again, knowing those milestone markers are what's appropriate as to when it's appropriate for the child to do it, to when that child is outside that range and we really need to be focusing on getting rid of it. So then can they imitate a word or a phrase or a sentence without using the phonological process? Because it's a little strange, you don't want them to use the phonological process to then can they do it spontaneously. We know children who do words they might be able to say boat, but when they put it into language and they say I want bo, it drops out. We have to be looking at phonological processes, just because a child can say a sound or say it in a word eligibly doesn't mean they're done. We need to go a step further and check intelligibility at the phrase level and at connected sentence level so make sure they maintain articulation so they maintain intelligibility. Some examples I would use at the word level if we have the Uno game we can go ahead and work on words and do simple words they might even be producing the animal name or no or mine or mama if mama is playing with that, or animal sounds with that, or different colors. And one other thing you have to be careful with when you're working at words, phrases, and sentences is remember, speech production is coming in at different stages, so P, B, and M might be sounds we expect at words at phrases, but F might be a new sound that they're getting, so we're not going to expect that at, say, the word level we might be working at that, and the simple sequencing level, so then when we get to words like, horse, they haven't I'm not going to do horse. I'm going to go back and I'm going to do let's just say pig. So that we know that they should have the P sound but maybe the final G sound isn't in yet and if they do pid, they do the D for the G and they're doing fronting that might be appropriate for that child at that time so we have to be again knowing our developmental acquisition as to what sounds are appropriate, what substitutions are appropriate, and what phonological processes are appropriate. So what you're doing is making sure they're doing the age appropriate ones, and if it's an age appropriate substitution that they do, that's okay. What only concerns me is if they're not doing an age appropriate substitution, and they say pif or something, then I would be much more concerned because that's not a typical error to make so we're always marking and looking at all of that, being the detective, if they make an error, what type of error is it? Is it an appropriate error or is it an inappropriate error with that? Okay. For phrases, doing lots of little games, and we have the weebles with the tree so we might mark we worked on the B and the M and the W and the N and D kind of sounds. I have to be creative and think: All right, what kind of phrases not single words, I want the child to be putting some words together. What kind of phrases can we be targeting that I would model and try to get the child to imitate or spontaneously produce that have these target sounds in? So when I'm picking games I'm always keeping in mind what sounds am I working on and what games can I find? What words and phrases can I target that will be heavily loaded with those phonemes that we're practicing so weeble up. We get the W and the Bs. Weebles go down. It might be weebles do down, but if they say weeble go DOW it might not be appropriate because I want them to get the final N in there. Then in sentences like I said we don't want to say just because you have intelligible speech at a phrase level, we want to make sure you have it at the sentence level and you're not dropping sounds out. So like the silly sandwich, examples would be my silly sandwich is tastier than yours. There's a lot of hard articulation in there. So we really want to make sure that the children are getting all those sounds in there and being intelligible with their speech. Okay? So just to give you an idea for a child who gets access to sound, after about one year of having appropriate access to sound to the speech banana we would expect the child would be doing vocal play, developing a speech sound repertoire and an ability to do some simple sequencing, those are some examples you might see. Then after two years of having access to appropriate sound, we would expect that speech sound repertoire to be increasing and that they would be developing intelligibility in some words, phrases and some simple sentences. And I threw in the example butterfly. Again if it's a child who's maybe 3.5 years of age, or 4 years of age, they may not have the R sound. They may be doing the W for R which is appropriate for that age. So it might be buttlefly. Get the F in there, and that would not be to me considered an error. But if they say buttafly Or bufly, then they've dropped a syllable or glided through the T, then that's not appropriate, so that's something we would go back and correct. And then by the end of third year, of having access to sound, so they've been listening a good three years, they should have developed all the age appropriate sounds, and having eligible running speech that would be appropriate for a child that age with that so there's examples again with some of them having age appropriate articulation errors in there. Okay, so the last thing I wanted to talk about is assessment for speech production. So when I work with interns, clinical fellows, or interns at came to the centers that I worked at, I couldn't extol the virtues of language samples enough. I know I despised having to do language samples because they're a lot of work but there's so much valuable information that I would say any assessment that you do on a child is not complete unless you've done a language sample and for me the language sample should incorporate two things: Language and articulation. So for the language sample you should have 50 to 100 utterances, not questions like what's your name. That's not really a spontaneous sample back so having them tell a story or talking about pictures in a book and then you're getting your MLI, your comprehension, your grammar, vocabulary, complexity, so forth so you're getting the language. By then I always say, once you've got about, you're halfway through and you've got your sample and your utterances, put your head down, don't look at the child, and start listening for the articulation and write out an articulation sample, because you'll be surprised when you're watching the child and you're looking at the pictures and you know the context, and you can follow along, but the minute you turn away and start listening and you don't know the context you might see there's a change in intelligibility so I think that's a very important thing to keep in mind so when you're doing articulation tests it isn't just going the Goldman Fristoe, it's doing it as part of the language sample and do 15 utterances of just listening to the child and I'm writing it out phonetically and I'm not worrying about what they're saying for the language at that point. I'm really listening to the articulation in connected discourse with that. So informally, you should be doing an artic sample that way and formally, we have different tests. However, when we're looking at these tests, most of them aren't normed until children are at least 2 years of age or at little bit older and if you think of some of the vocabulary on these tests, clowns on the Goldman Fristoe. If you have a child who had their cochlear implant for 8 months, I kind of doubt that's going to be a word that's in that child's vocabulary. So there's a gap in between before we can get to the formal assessment, and Dr. David Ertmer has developed a test that covers that gap which I'm really excited about. And it's called the Open and Closedset Task, and what this does, it's an objective and developmentally appropriate within child criteria so there's not norms for it yet but you get a baseline and compare the child's score to him or herself, and it's for toddlers, and it's looking at their ability to imitate and understand spoken words during the first two years of either implant use or I would say access to sound. So you can really use it as early as like 6 months postimplant and you can give it three times so you can really look to see at the child's development. And what he's done is really used it for young children, so he's got some action to it, and involving familiar delts, so it's working with a young child, and he's using words off the MacArthur. So clown is not on there, but mama, dada, eyes, boat, bubbles, those words are on there, so those are definitely words they will be more familiar with. And this is not an expressive where they spontaneously say it because they may not have a vocabulary of even ten words but hopefully they can imitate, so it's made for toddlers, very young, 12 to 36 months of age. It's also appropriate for children who are a little older and receive a cochlear implant later on, and they have, they don't have good intelligibility or they're just learning to produce sounds. We could get information on that or for children with additional disabilities, I could also be good for those children so it's got the manual, the photo book and three score sheets. So the openset task is the adult says the word and the child imitates it. And then you transcribe it so you're getting a transcription of the sounds the child is producing. And then after the child's imitated you flip, because they have a blank page in front of them. Then you flip it, they see the three pictures and you say now show it to me so now you're getting the word comprehension. This is the beginning vocabulary and you get three scores: Phoneme accuracy, how accurate was the child's production to the adult model? You get word acceptability. It's based on his standard, you get a word acceptability score based on the number of phonemes they use and if they use the right number of syllables and then you get a word comprehension score with that. That's the receptive vocabulary, to see how they're doing and understanding. So I'm going to leave a couple minutes for questions here but hopefully, within this 30 minutes I've kind of reviewed some speech development, the beginning early vocal stages. Some facilitation remediation activities that you can do and steps you'd want to go through to get to intelligibility and then some assessment for speech. So thank you, and does anybody have any questions? I think we have about 2 minutes. Yes? [ Off Microphone ] So Xi was asking, I don't know if y'all heard, so a child who is a child of oral deaf parents who have speech that is more oral deaf and the child is imitating that speech, because that's what we said, they're going to imitate what they hear, would we consider the child behind? I wouldn't say behind, but what I would want to do is to make sure that we provide many models of appropriate or accurate I should say accurate speech production for the child. So that they hear the sounds accurately. And that's doing things where they're in therapy or if they have neighbors or other family members who can spend time and do what I would say even auditory bombardment, reading to the child with a lot of these finding paragraphs or stories and there are story books that are all devoted to P sounds or B sounds or whatever. And giving the child to really hear opportunities to hear it produced accurately. I forgot to say one thing: With the David Ertmer Open and Closedset Task, he's going to be doing a fullday workshop in Georgia for anybody that's in the Georgia area. It's a free workshop that we're doing, and he's doing it on vocal development, so I have some cards up here. If you're interested in finding more information about that workshop, please come up and I'll give that to you. Okay? Yes? [ Off Microphone ] So you're asking, are there some sign tests that is his sign language appropriate for his age, versus oral. In our company, because we're cochlear implant, we're providing services to work on the listening skills. So I would have to refer you to programs or organizations that work with sign language, because I would hope that there would be, and I think there should be, tests out there to make sure a child, whatever their communication, that if they're using manual, that they are developing their language appropriately. I just I don't know any off the top of my head. If anybody else would know where to refer to on that, but I think there are different organizations that might be able to help you with that. But, yes, you would definitely want to know that. You'd want to know how his sign language skills are, and then look at the oral skills, too. And at this point, I have another speaker after me, so if you have questions, I can talk to you later and if you're interested in the workshop, please go ahead and come and get the card later. Thank you very much. [ Applause ] [ End of Session ] * * * * * This is being provided in a rough-draft format. Communication Access Realtime Translation (CART) is provided in order to facilitate communication accessibility and may not be a totally verbatim record of the proceedings. * * * * *