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Welcome to Allied Health Telehealth Virtual Education

“Persistent Sound Disorder” –the inpatient management of adolescent eating disorders

Bronwyn Carrigg Speech Pathologist Sydney Children’s Hospitals Network, Randwick

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Persistent :

Bronwyn Carrigg Speech Pathology Department Sydney Children’s Hospital Network, Randwick [email protected]

Please complete your online evaluation at ttps://www.surveymonkey.com/r/PersistentSpeechSD 1 If you experience connection problems 10 minutes prior to or during the session, please 27/06/2016 phone the HNE Telehealth Help Desk on 02 4985 5400 and select option 1

Speech Sound Disorder (SSD)

• Speech errors due to: ‐ structural or motor constraints ‐ cognitive‐linguistic constraints (Stein et al., 2011)

• Maybe of known or unknown origin: ‐ broad definition = known & unknown origin (Shriberg, 2010; ASHA) ‐ narrow definition = unknown origin (DSM‐5, 2013)

• Persistent SSD has no universally agreed cut‐off. Most agree speech errors > 8‐9 years of age (Shriberg, 2010; Wren..2012)

Prevalence of SSD unknown origin:

• 15.6% of 3‐year‐olds (Campbell et al., 2003) • 3.8% of 6‐year‐olds (Shriberg et al., 1999) • 3.4% of 4‐year‐olds (Eadie et al., 2015)

Prevalence of Persistent SSD: known & unknown

• 3.6% of 8‐year‐olds (‐1.2SD < mean) (Wren et al., 2012) • 3.0% of 8‐year‐olds (‐2SD < mean) (Wren et al., 2009)

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Speech Sound Disorder Classification

• SSD is heterogeneous • Heterogeneity led to subtyping • No universally accepted classification framework.

(e.g., Broomfield & Dodd, 2004; Stackhouse & Wells, 1997; Shriberg et al., 2010)

Speech Disorders Classification System (SDCS)

• Most comprehensively researched classification system • Work of Shriberg and colleagues (e.g., Shriberg et al., 2010) • Relates to SSD of unknown origin (currently unknown) • Persistent SSD is explicitly addressed.

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Speech Disorders Classification System – Typology

(1) (2) (3) Motor Speech Errors multiple multiple errors limited to substitutions &/ substitutions common clinical omissions omissions & distortions (r, ) distortions applies from 6 yrs includes CAS & minus frank neurological abnormality (Shriberg et al., 2010)

Speech Disorders Classification System – Typology

Persistent Speech Disorder (PSD) –errors > 9 years

(1) (2) (3) PSD‐Speech Delay PSD‐Motor Speech Disorder PSD‐Speech Errors

*based on current and/or prior patterns *suffix denotes the historical SSD subtype (Shriberg et al., 2010)

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Speech Disorders Classification System (Shriberg et al., 2010)

Persistent SSD Research: Challenges

• Focus is on early childhood SSD • More on persistent SSD of known than unknown origin • Persistent SSD of unknown origin: ‐ focus on residual common distortions ‐ failure to classify SSD → group heterogeneity ‐ range of study types → Ax, Rx, specific focus ‐ lack of comprehensive assessment

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Persistent SSD: Sources of information

• Early childhood SSD follow up studies; SSD usually resolved (e.g., Lewis.. 2015) • Single cases with persistent SSD (e.g., Stackhouse et al., 1992; Zaretsky et al., 2010) • Small group studies of persistent SSD (Lewis et al., 2004; Kenny et al., 2006; Redle 2015) • One large, prospective population study (Wren et al., 2012) • Genetics cases ‐ typically syndromal ‐ some primarily speech

Persistent SSD: Speech Characteristics

Most published cases of PSD with multiple‐sound errors describe:

• current/historical SSD in severe to profound range (e.g., Speake et al., 2012) • CAS/CAS‐like symptoms frequent (e.g., Lewis et al., 2004b; Zaretsky et al., 2010). • Lack of subtyping & diagnostic reliability • Comorbid dysarthria mod frequent in genetic cases (e.g., Fedorenko et al., 2015) • Comorbid dysarthria rare in cases w/out genetic studies (e.g., Zaretsky et al., 2010) • Orofacial praxis identified in some cases (where Ax’d) (Vargha‐Khadem.. 1995)

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Persistent SSD: Speech Characteristics

n Age Diagnosis Study 28 ‐10 years CAS Snowling et al., 1983 210 years CAS Stackhouse et al., 1992* 111 years CAS Zaretsky et al., 2010 210 years ‘PSD’ Speake et al., 2012* 122 years CAS Carrigg et al., 2015* 10 8 – 11 years CAS Lewis et al., 2004

CAS = Childhood Apraxia of Speech (aka dyspraxia); * = contains speech data

Persistent SSD Case: BJ aged 22 years

“My speech is severely affected by my disorder. I am unable to communicate verbally with most people because my speech contains many sounds errors and is severely unintelligible.

I am only able to talk to my family, but even that is difficult because I cannot say many words and I often struggle to get my message across. I don’t think most people understand the amount of effort I have to put in just to say a few words”.

Email to SP aged 22.6 years (Carrigg et al., 2015., p.41)

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Persistent SSD: Speech Characteristics

• Vowel distortions (Ballard et al., 2010; Carrigg et al.,, 2015; Speake et al., 2012; Zaretsky et al., 2010; McCormack et al., 2012; :Lewis et al., 2004) • Consonant distortions (Ballard et al., 2010; Carrigg et al., 2015; Zaretsky et al., 2010; Speake et al., 2012; McCormack et al., 2012) • Consonant substitutions: fronting, voicing (Lewis et al., 2004; Kenny et al., 2006; Carrigg et al., 2015) • Consonant deletions: initial consonant deletion, cluster reduction (Lewis et al., 2004; Kenny et al., 2006; Carrigg et al., 2015) • Multisyllabic words (Carrigg et al., 2015; Stackhouse et al., 1992; Lewis et al., 2004) • Prosody (Ballard et al., 2010; Carrigg et al., 2015)

Persistent SSD: & Characteristics

• Not always assessed (or partially assessed)

• Impaired expressive language, literacy, &/phonological processing (e.g., Lewis et al., 2004b; Speake et al., 2012; Zaretsky et al., 2010)

• Receptive language variable (e.g., Lewis et al., 2004; Stackhouse, 1992)

• Receptive language > expressive language often reported

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Persistent SSD: Fine & Gross Limb Motor

• Systematic assessment is rare • Limb motor difficulties frequently been noted/queried (e.g., Lewis et al., 2004b; Stackhouse & Snowling, 1992b; Zaretsky et al., 2010).

Persistent SSD: Educational/Vocational Outcomes

• Little research for persistent SSD • All single cases had formal learning support throughout school • Longitudinal studies of early childhood speech & language impairment: ‐ more learning support ‐ fewer years formal education ‐ less skilled occupations ‐ rate of employment did not differ (Felsenfeld et al., 1994; Johnson et al., 2010)

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Persistent SSD: Socio‐emotional Outcomes

• Little on persistent SSD • Single cases: ‐ bullying, struggle to communicate (Carrigg et al., 2015; McCormack… 2012) ‐ crippling social anxiety disorder, depression (Carrigg et al., 2015) • Longitudinal studies: early childhood speech and language impairment ‐ significantly higher rates of anxiety disorder (Beitchman et al., 2001) ‐ no differences on subjective quality of life ratings (Felsenfeld et al., 1994) ‐ no differences on rates of marriage/living with partner (Johnson et 2010)

Persistent SSD Case: BJ aged 22 years

“My has had a significant and profound impact on my life. It has affected my ability to interact with the people around me, my education, and my mental health. I am unable to do many things because of my communication. Growing up I often felt left out because I wasn’t able to talk with other people, I wasn’t able to tell other people my thoughts or if I needed something. It was heartbreaking because I knew what I wanted to say, but I couldn’t say it. I still feel deeply sad about not talking to others”.

Email to SP aged 22.6 years (Carrigg et al., 2015., p.46)

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Risk factors for persistent SSD at 8 years

• not combining words 24 months • low intelligibility to strangers at 38 months • limited use of word morphology at 38 months • weak sucking at 4 weeks • socio‐economic status

*known and unknown origin included in study (Wren, 2015; Schussler, Wren, 2012)

Conclusions: Persistent SSD • More research needed • Children with persistent SSD affecting speech intelligibility into school years and beyond are highly likely to present with a multiple verbal trait disorder (e.g., speech, language, literacy). • Phonological skills are also typically impaired, even if some have a diagnosis of Childhood Apraxia of Speech which is a motor speech disorder. Both phonology and motor planning may need consideration in treatment selection and evaluation. • Comprehensive assessment and monitoring of all verbal traits is necessary for both goal setting and treatment evaluation. • Non‐linguistic skills can be affected, particularly socio‐emotional health and motor skills, for example higher rates of social anxiety. Early referrals to support services required.

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Conclusions: Persistent SSD

• Individuals with persistently poor speech intelligibility require much greater input of therapist time than less complex cases (e.g., need complex, regular analyses; long term training of school/family; implementation of alternative and augmentative communication systems [AAC] ‐ both low and high tech; language and literacy prevention; socio‐emotional concerns such as anxiety, frustration, withdrawal etc). • Where AAC is required, a two therapist allocation is ideal, so that speech targets are not dropped due to the time consuming nature of effectively implementing AAC systems across environments. • Flexible service limits are needed for such children where access to evidence based private services is limited. • Therapists need support. • Work on strengths of children as well as weaknesses

References: American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM‐5®): American Psychiatric Pub. Ballard, K. J., Robin, D. A., McCabe, P. , & McDonald, J. (2010). A treatment for dysprosody in childhood apraxia of speech. Journal of Speech, Language, and Hearing Research, 53(5), 1227. Beitchman, J. H., Wilson, B., Johnson, C. J., Atkinson, L., Young, A., Adlaf, E., . . . Douglas, L. (2001). Fourteen‐year follow‐up of speech/language‐impaired and control children: Psychiatric outcome. Journal of the American Academy of Child & Adolescent Psychiatry, 40(1), 75‐82. Broomfield, J., & Dodd, B. (2004). The nature of referred subtypes of primary speech disability. Child Language Teaching and Therapy, 20(2), 135‐151. Campbell, T. F., Dollaghan, C. A., Rockette, H. E., Paradise, J. L., Feldman, H. M., Shriberg, L. D., . . . Kurs‐Lasky, M. (2003). Risk factors for speech delay of unknown origin in 3‐year‐old children. , 74(2), 346‐357. Carrigg, B., Baker, E., Parry, L., & Ballard, K. J. (2015). Persistent Speech Sound Disorder in a 22‐Year‐Old Male: Communication, Educational, Socio‐Emotional, and Vocational Outcomes. SIG 16 Perspectives on School‐Based Issues, 16(2), 37‐49. Eadie, P. , Morgan, A., Ukoumunne, O. C., Ttofari Eecen, K., Wake, M., & Reilly, S. (2015). Speech sound disorder at 4 years: prevalence, comorbidities, and predictors in a community cohort of children. Developmental Medicine & Child Neurology, 57(6), 578‐584. Fedorenko, E., Morgan, A., Murray, E., Cardinaux, A., Mei, C., Tager‐Flusberg, H., . . . Kanwisher, N. (2015). A highly penetrant form of childhood apraxia of speech due to deletion of 16p11. 2. European Journal of Human Genetics.

Please complete your online evaluation at ttps://www.surveymonkey.com/r/PersistentSpeechSD 12 If you experience connection problems 10 minutes prior to or during the session, please 27/06/2016 phone the HNE Telehealth Help Desk on 02 4985 5400 and select option 1

Kenney, M. K., Barac‐Cikoja, D., Finnegan, K., Jeffries, N., & Ludlow, C. L. (2006). Speech perception and short‐term memory deficits in persistent developmental speech disorder. Brain and Language, 96(2), 178‐190. Lewis, B. A., Freebairn, L., Tag, J., Ciesla, A. A., Iyengar, S. K., Stein, C. M., & Taylor, H. G. (2015). Adolescent Outcomes of Children With Early Speech Sound Disorders With and Without Language Impairment. American Journal of Speech‐ Language Pathology, 24(2), 150‐163. doi:10.1044/2014_AJSLP‐14‐0075 McCormack, J., McAllister, L., McLeod, S., & Harrison, L. J. (2012). Knowing, having, doing: The battles of childhood speech impairment. Child Language Teaching and Therapy, 28(2), 1‐17. doi:DOI: 10.1177/0265659011417313 Shriberg, L. D. (2010). A neurodevelopmental framework for research in childhood apraxia of speech Speech Motor Control: New Developments in Basic and Applied Research (pp. 259‐270). New York: Oxford University Press Inc. Schussler, K. F., Wren, Y. (2012). Opportunities for change in children with persistent speech sound disorders. Paper presented at the American Speech‐Language and Hearing Association Annual Convention, Atlanta, GA. Snowling, M., Stackhouse, J., & Rack, J. (1986). Phonological and —a developmental analysis. Cognitive Neuropsychology, 3(3), 309‐339. Speake, J., Stackhouse, J., & Pascoe, M. (2012). Vowel targeted intervention for children with persisting speech difficulties: Impact on intelligibility. Child Language Teaching and Therapy, 28(3), 277‐295. Stackhouse, J., & Snowling, M. (1992a). Barriers to literacy development in two cases of developmental verbal dyspraxia. Cognitive Neuropsychology, 9(4), 273‐299. Stackhouse, J., & Snowling, M. (1992b). Developmental verbal dyspraxia II: A developmental perspective on two case studies. International Journal of Language & Communication Disorders, 27(1), 35‐54.

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