Syllabic nasals – How do we treat them?

Caroline Hattee Cleft Net East

• Study results

• Therapy ideas

• Diagnostic implications

Aims

• Retrospective case note review

• N= 9 ( 6 non cleft, 2 cleft, 1 SMCP)

• Assessed using the STAP and GOSSPASS

• Consonant and vowel inventory tabulated and nasality and nasal airflow noted

Study

Subject Age at assessmnt (years)

Reason for referral

Vowels replaced by syllabic nasal

Speech and language diagnosis

Hearing History

1 TA 2.2 Sus VPD i u Disordered Phonology/Dyspraxia

None

2 LS 1.10 Sus VPD i u ei Dyspraxia/disordered speech

Min loss reported by mum

3 JJ 2.9 Sus VPD i u ai Disordered Phonology/dyspraxia

Sensitive to loud noises

4 CE 2.8 Sus VPD i u ɜ ɔ ʌ ei ai i o əʊ aʊ

Dyspraxia/disordered speech

Grommets ongoing hearing monitoring

5 AM 3;6 Susp VPD Disordered speech OME

6 MT 3.4 CP+Susp VPD

ɔ ɒ Delayed language and disordered speech

2x grommets

7 HT 3.6 SMCP+VPD

i Dyspraxia Flat tymps

8 BT 4.4 Susp VPD ɪ (weak syllable)

Dyspraxia OME

9 CS 2.10 CP+ Susp VPD

ɪ ə Delayed None

Subject Age at assessmnt (years)

Reason for referral

Vowels replaced by syllabic nasal

Speech and language diagnosis

Hearing History

1 TA 2.2 Sus VPD i u Disordered Phonology/Dyspraxia

None

2 LS 1.10 Sus VPD i u ei Dyspraxia/disordered speech

Min loss reported by mum

3 JJ 2.9 Sus VPD i u ai Disordered Phonology/dyspraxia

Sensitive to loud noises

4 CE 2.8 Sus VPD i u ɜ ɔ ʌ ei ai i o əʊ aʊ

Dyspraxia/disordered speech

Grommets ongoing hearing monitoring

5 AM 3;6 Susp VPD Disordered speech OME

6 MT 3.4 CP+Susp VPD

ɔ ɒ Delayed language and disordered speech

2x grommets

7 HT 3.6 SMCP+VPD

i Dyspraxia Flat tymps

8 BT 4.4 Susp VPD ɪ (weak syllable)

Dyspraxia OME

9 CS 2.10 CP+ Susp VPD

ɪ ə Delayed None

Subjects

• Therapy eliminated syllabic nasals in 8/9 cases.

• 3/9 prolonged therapy• 1/9 persisting syllabic nasals • 1/9 secondary speech surgery during this

treatment period.• Close vowels /i, Ì, u/ (and for the diphthongs

containing these) tended to respond most quickly to therapy.

Outcomes

Therapy

Auditory perceptual approaches• Input modelling/vowel bombardment

therapy (e.g. Hope cochlear implant ideas hope.cochlearamericas.com)

• Audio and Video therapy e.g. lorry reversing iiii ; u for cow

• Headphone use as playback in video therapy – optimal proximity of sound

Vowel Therapy to update input processing

• Input : Extended vowel duration (Rusche et al 2004)

• Increased pitch via Melodic Intonation Therapy (Helfrich-Miller 1984) –counting 1-6 contains u/i/Ì. Hope cochlear website has good resources in pitch unit section.

• Output : immediate verbal feedback for each production as “incorrect” placement information or sensory feedback can hamper potential for subsequent target sound production (Ruscello 2008).

Vowel Therapy to update vowel perception

Video TK orl

Visual feedback• Historical glossometry; speech viewer• EPG• The future - MRI imaging/ultrasound

Computer approaches• PC programmes –; SAILS (Rvachew et al 2004) ;

Earobics (Earobics cognitive Concepts 2000); Phoneme factory (Wren &Roulstone 2006); LiPS(Lindamood & Lindamood 1998); Nessy language programme.

• Apps available - vowel viz and IPA vowels; cued articulation; vowels central

Vowel Therapy

Vowel viz

Apps

Linguistic approaches:• Maximal contrast therapy : contrasting open

front vowels with close back vowels. • Metaphonological – e.g. The vowel

house/Metaphon – visual referent lip rounding vs lip spread

• Core vocabulary (Cosbie,et al 2006).• Semantic/rhyme sets e.g.

baby/mummy/dummy.

Vowel Therapy

Motor approaches• Nuffield production and sequencing

(Williams and Stephens 2010).

• PROMPT

• Cued vowels

Vowel Therapy

• Assess consonants and vowels; notice weak syllables

• Hearing levels and complexity of speech disorder important prognostic factors – maximise visual and auditory input

Implications for future Practice

• Diagnostic therapy may help differentiate between syllabic nasals and nasalised vowels

• Syllabic nasals do respond to therapy

• Detailed notes of therapy aims and methods needed to inform outcome. Ideally video pre and post therapy

• SLT Training at undergraduate level

• Further research opportunities

Implications for future practice

• Geirut 1998 “ direct therapy for vowels can have a positive outcome”

But…..

• Gibbon 2013 “one approach not advocated is non speech oral motor activities as there is no evidence to suggest that these methods are effective”.

Conclusion

Don’t be alarmed – go for it !

Jennie Smith – Specialist SLt Cleft Net East

Anne Harding-Bell Module Co-ordinator, Human Communication Sciences, University of Sheffield

Acknowledgements

• Video data of case examples to be made available via SIG website

• Forthcoming text• Purdy S, Harding-Bell , Differential

diagnosis :signs of conductive hearing loss In Case Studies of Cleft Palate Speech. Ed Harding-Bell, A. J&R Press (Forthcoming)

Additional Resources

Ball,M.J,Gibbon,F.E.(2013).Handbook of Vowels and Vowel Disorders.Psychology Press Hope Cochlear Implant Ideas www.cochlear.com/rehabilitation-resources Cosbie,S,Pine,C,Holm,A and Dodd,B.(2006).Treating Jarrod:A core vocabulary approach.Advances in

Speech-Language Pathology,8(3),316-321. Gierut,J.A(1988)Treatment efficiency:functional phonolgydisorders in children.Journal of Speech,

Language Haring Research 41,85-100 Gibbon, F(2013).Therapy for abnormal vowels in children withspeech disorders in

Ball,M.J,Gibbon,F.E.(2013).Handbook of Vowels and Vowel Disorders.Psychology Press Hayden,D,A,Eigen,J,Walker,A,Olsen,L.(2010)PROMPT:A Tactually grounded model. In

Williams,Smcleaod, and R Mcauley(eds)Interventions for speech sound disorders in children.Brookes:Baltimore.

Helfrich-Miller,KR.(1984).Melodic Intonation therapy with developmentally apraxic children.In Perkins WH,Northern JL.Editors:Seminars in speech and Language .New York.

Passy,J(1990)Cued Vowels.Ponteland:STASS publications. Also available as app Ruscello,D.M. (2008).Treating Articulation and Phonological Disorders in Children.Mosby Reid,J(2003)The Vowel House.A cognitive approach to vowels for literacy and speech.Child

Language Teaching and Therapy,19,152-180. Rusche, N., Markovitz, S., & Kwiatkowski, J. (2004, November). Treating vowel errors in speech-

delay: A case study. Poster presented at the Annual Convention of the American Speech-Language-Hearing Association, Philadelphia, PA

Shriberg,LD,Friel-Path,S,Flipsen,P.(2000).Otitis media, Fluctuating hearing loss and speech – language outcomes:a preliminary structural equation model.Journal Speech Language Hearing Research 43:100-120.

References

Rvachew,S;Slawinski,E,B;Williams,M.(1996) Formant frequencies of vowels produced by infants with and withot early nset otitis media.Canadian Acoustics24(2),19-28

Ferdos,N;Ashayer,A;Modarresi,Y;Rovshan,B.(2014)The effectiveness of melodic intonation therapy on fundametal frequency and intensity in Persian autistic children’s speech.Audiology23(2):74-82

Williams,P&StephensH.(2010).The Nuffield Centre Dyspraxia Porgramme.

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