Unintelligible Young Children: Assessment and Treatment

1. Unintelligible Young Children: Assessment and Treatment Peter Flipsen Jr., PhD, CCC-SLP, S-LP(C) Idaho State University http://www.isu.edu/~flippete/default.html http://www.SLPinfo.org Flipsen - SC Scottish Rite Centers - Sept 08

2. Part A. Assessment Flipsen - SC Scottish Rite Centers - Sept 08

3. Intelligibility • How well a normal hearing listener is able to recover the intended message from a speaker. • How understandable are they? • Not the same as “severity” though clearly related. • Severity usually relates to particular disorders. Flipsen - SC Scottish Rite Centers - Sept 08

4. Becoming intelligible? • Making yourself understood = the ultimate goal of communication. • We’re not born with the ability to do this. • It takes time to develop. Flipsen - SC Scottish Rite Centers - Sept 08

5. Becoming intelligible? • Normal hearing, typically-developing children develop this ability fairly quickly. • From Flipsen (2006) and Coplan & Gleason (1988): • Age (years) % Understood * • 1 25 • 2 50 • 3 75 • 4 100 ** • * in conversational interaction with unfamiliar listeners. • ** still some speech sound errors likely. Flipsen - SC Scottish Rite Centers - Sept 08

6. Being intelligible? • Getting a message across requires a complex interaction of: • 1. Good listening conditions, and • 2. A listener who • is paying attention, • has normal hearing, and • speaks the same language, and • 3. A speaker who effectively and efficiently integrates their knowledge of how the language works and how speech is produced. Flipsen - SC Scottish Rite Centers - Sept 08

7. Our Focus • For our purposes we will assume: • 1. The problem lies primarily with the speaker. • 2. The speaker has normal hearing. • 3. The speaker has no other obvious or documented reason for having difficulty with speech. • No significant cognitive, structural, or neurological impairment. Flipsen - SC Scottish Rite Centers - Sept 08

8. An intelligible speaker must: • 1. have something to say (cognitive skill). • 2. know the rules of the language (syntax, morphology, phonology) and word meanings (linguistic skill). • 3. know how to convert the message into a motor plan (praxis skill). • 4. be able to carry out the motor plan (articulatory skill). Flipsen - SC Scottish Rite Centers - Sept 08

9. Intelligibility and Speech Sound Accuracy • Intelligibility = % words understood by normal hearing listeners. • Clearly the biggest factor involved is accuracy of speech sound production. • Not the only thing involved. Flipsen - SC Scottish Rite Centers - Sept 08

10. Flipsen - SC Scottish Rite Centers - Sept 08

11. The Role of Context • Intelligibility also varies a lot depending on the message. • In connected speech, if a few details are incorrect the rest of the utterance can help listeners “fill in the blanks”. • Some speakers therefore do better in conversation than they might in single words. • But context may get in the way for speakers who get many details wrong. • May be easier to understand in single words. Flipsen - SC Scottish Rite Centers - Sept 08

12. The Role of Context • For speakers with lots of errors, we should pay most attention to intelligibility in single words. • Change should appear here first. • Won’t immediately transfer to conversation. • As they progress we will also want to monitor how they do in conversation. • WE WILL NEED TO USE MULTIPLE TOOLS. Flipsen - SC Scottish Rite Centers - Sept 08

13. Measuring Intelligibility Flipsen - SC Scottish Rite Centers - Sept 08

14. General Guidelines for Measuring Intelligibility • Clinician working with the child should NOT act as the judge if at all possible. • Record all measurement events and SAVE them! • Best to use unfamiliar, untrained listeners each time. • OK to use parents, older siblings if you use them each time (social validity). Flipsen - SC Scottish Rite Centers - Sept 08

15. General Guidelines for Measuring Intelligibility • Record the same type of material each time. • Use the same tape recorder each time for recording. • Record in the same place each time. • Have judgments done under the same conditions each time. Flipsen - SC Scottish Rite Centers - Sept 08

16. Specific Procedures for Measuring Intelligibility • A widely used approach = informal ratings. • After a diagnostic session, clinician makes a decision about ‘how intelligible’ the child was. • Often a % estimate. • May be a general statement. Flipsen - SC Scottish Rite Centers - Sept 08

17. Exercise #1 Flipsen - SC Scottish Rite Centers - Sept 08

18. Specific Procedures • Labeled rating scales. • Many available. • Usually make judgments based on a connected speech sample (conversation or reading). • May also be done as a ‘general impression’ at the end of an assessment session. Flipsen - SC Scottish Rite Centers - Sept 08

19. Labeled Scales • A typical 3-point scale: • 1 = readily intelligible • 2 = intelligible if topic known • 3 = unintelligible, even with careful listening • Source: Bleile (1996) Flipsen - SC Scottish Rite Centers - Sept 08

20. Labeled Scales • A typical 5-point scale: • 1 = completely intelligible • 2 = mostly intelligible • 3 = somewhat intelligible • 4 = mostly unintelligible • 5 = completely unintelligible • Source: Bleile (1996) Flipsen - SC Scottish Rite Centers - Sept 08

21. Labeled Scales • A typical 7-point scale: • 1 = intelligible • 2 = listener attention needed • 3 = occasional repetition of words needed • 4 = repetitions/rephrasing necessary • 5 = isolated words understood • 6 = occasionally understood by adult • 7 = unintelligible • Source: Shprintzen & Bardach (1995) Flipsen - SC Scottish Rite Centers - Sept 08

22. Concerns with Rating Scales • 1. Different listeners interpret the labels differently. • 2. Listeners don’t treat all points on the scale equally. • E.g., Amount of change needed to move between points is usually unequal. • 3. Often not sensitive enough to use for monitoring change. Flipsen - SC Scottish Rite Centers - Sept 08

23. Specific Procedures • Several more formal procedures are available. • Involve either preset stimuli or transcription of connected speech. • May use “forced-choice” or “write-down” procedures. Flipsen - SC Scottish Rite Centers - Sept 08

24. Specific Procedures • Yorkston-Beukelman test • Assessment of the Intelligibility of Dysarthric Speech • Acronym = A.I.D.S. • Prefer to call it the Y-B test Flipsen - SC Scottish Rite Centers - Sept 08

25. Y-B Test • Has both single word and sentence forms • Sentence form only useful for older children and adults. • Single words = choose 1 randomly from each of 50 sets of 12 words. • Client repeats the words (or reads if older). • Listener’s task = transcription or multiple choice. Flipsen - SC Scottish Rite Centers - Sept 08

26. Figure 10 Flipsen - SC Scottish Rite Centers - Sept 08

27. Exercise #2 • 26 27 28 29 • 30 31 32 33 • 34 35 36 37 • 38 39 40 41 • 42 43 44 45 • 46 47 48 49 • 50 Flipsen - SC Scottish Rite Centers - Sept 08

28. Children’s Speech Intelligibility Measure (CSIM) • Wilcox & Morris (1999). • Modified the single word version of the Y-B test (no sentences). • Changed some of the words that were not appropriate for young children. • Published by the Psychological Corporation. Flipsen - SC Scottish Rite Centers - Sept 08

29. Beginners’ Intelligibility Test (BIT) • Osberger et al (1994). See handout. • Originally designed for children with hearing loss. • OK to use with young, normal hearing children. • Four sets of 10 short sentences. • Randomly choose one list each time. • Child imitates the clinician; ask listeners to transcribe. • Calculate % words understood. Flipsen - SC Scottish Rite Centers - Sept 08

30. Shriberg’s Intelligibility Index (II) • Transcribe a conversational sample of at least 100 words. • Only need regular spelling! • Put X for each word not understood. • Report % words understood. • Probably the best overall way to look at intelligibility since conversational speech is the most socially valid context. Flipsen - SC Scottish Rite Centers - Sept 08

31. So where’s the problem? • Remember that an intelligible speaker must: • 1. have something to say (cognitive skill). • 2. know the rules of the language (syntax, morphology, phonology) and word meanings (linguistic skill). • 3. know how to convert the message into a motor plan (praxis skill). • 4. be able to carry out the motor plan (articulatory skill). • PROVIDES US WITH A MODEL FOR IDENTIFYING THE SOURCE OF THE PROBLEM. Flipsen - SC Scottish Rite Centers - Sept 08

32. Possible sources of Reduced Intelligibility? • 1. Linguistic issues – not being able to correctly translate the intended message into a conventional language form. • Problems with semantics, syntax, morphology, or phonology. • 2. Praxis issues – not being able to translate the form into a motor program. • 3. Articulatory issues – not being able to physical produce the message. Flipsen - SC Scottish Rite Centers - Sept 08

33. Possible sources of Reduced Intelligibility? • For our purposes here, we’ll assume we know how to identify problems with language above the phoneme level. • Problems at the phoneme level could be: • Praxis problems (i.e., CAS)to be dealt with separately later. • Phonological or articulatory – often the most difficult to separate. Flipsen - SC Scottish Rite Centers - Sept 08

34. Artic vs. Phonology: A Quick Historical Review • Up until the mid 1970s we assumed speech sound problems were all about “articulation”. • Applied traditional artic therapy. • Then we learned about “phonology” and we realized children were learning a “sound system”. • Assessment shifted to looking for ‘patterns of errors’ (also called “processes”). • Treatment shifted to ‘contrasts’ and ‘meaning’ and ‘minimal pairs’. Flipsen - SC Scottish Rite Centers - Sept 08

35. Current Status: Some “shaky” assumptions • 1. Perhaps we don’t need to worry about perceptual errors. No. • It’s true, these children don’t have general perceptual problems. • Perceptual problems related to specific errors are not that common but we should check! • 2. We can assume that the child with many errors must have a phonological problem. • No. Child could have a “motor learning” problem. Flipsen - SC Scottish Rite Centers - Sept 08

36. More “shaky” assumptions. • 3. We can assume that the child with few errors must have an articulatory problem. • No. Child may not have figured out where that sound fits in the sound system. • 4. Calling an error a “phonological process” means the problem is phonological. • No. By themselves these labels tell us NOTHING about what is going on inside the child’s head. • E.g., “velar fronting” only says that velar sounds are being replaced by sounds further back in the mouth. Flipsen - SC Scottish Rite Centers - Sept 08

37. Phonological Processes? • Phonological process terms can be useful. • They do help us look for WHAT MIGHT BE systematic patterns of errors. • They can help us focus our intervention efforts if we do eventually determine the nature of the problem. • BUT without further detailed analysis, we can’t know for certain whether the problem is articulatory or phonological. Flipsen - SC Scottish Rite Centers - Sept 08

38. More “shaky” assumptions. • 5. We can assume that if a sound is stimulable, the problem must be phonological. • Not necessarily, though it might be. • Stimulability in isolation or nonsense syllables may only signal the beginnings of motor skill learning. • Stimulability in more than one word position makes it more likely that the problem is phonological. • Also depends on how stimulability is measured. • Should use a verbal imitation model only. Flipsen - SC Scottish Rite Centers - Sept 08

39. How Speech is Learned • Need to be able to hear the differences among the speech sounds of the language. • Perceptual skills. • Need to be able to physically produce the sounds. • Articulatory (motor) skills. • Need to know how the sounds are used to contrast meaning in the language. • Phonological knowledge. • Happens gradually and at different rates for different sounds. Flipsen - SC Scottish Rite Centers - Sept 08

40. Speech Sound Problems • Could be perceptual. • Could be articulatory. • Could be phonological. • And because of different rates of development: • THE PROBLEM MAY BE DIFFERENT FOR DIFFERENT SPEECH SOUNDS – even within the same child. • We need to evaluate each error independently. Flipsen - SC Scottish Rite Centers - Sept 08

41. Identifying Perceptual Problems • At least two ways to do this: • 1. Same/different tasks – present a pair of words (or syllables or sounds) and ask child to judge if they are the same or different. • Child must understand the concepts of ‘same’ and ‘different’ • not always true for very young children. • Only requires the child to hold items in working memory and compare them. • Doesn’t get at ‘underlying representation’ (what is stored in long-term memory). Flipsen - SC Scottish Rite Centers - Sept 08

42. Identifying Perceptual Problems • 2. Judgment tasks – present child with a word (correct production or containing their usual error). Child has to decide if the word was produced correctly. • Requires use of working memory BUT also requires them to compare what they heard to their underlying representation. • Better approach. Flipsen - SC Scottish Rite Centers - Sept 08

43. Identifying Perceptual Problems • Need several examples to control for guessing. • Need a way to ensure that the child understands the task. • Use a sound that is similar to the error sound but which the child has no difficulty with. • Locke (1980) developed his “Speech Production – Perception Task” (SP-PT). • Allows you to create a unique criterion-referenced test for each error sound. Flipsen - SC Scottish Rite Centers - Sept 08

44. Flipsen - SC Scottish Rite Centers - Sept 08

45. Is the error articulatory or phonological? • Relatively few errors are perceptual BUT: • Should still check (may save time later). • Some evidence that for SOME children working on perception alone may solve the problem. • The big problem is usually separating articulatory and phonological errors. • Need to ask a series of questions (none sufficient alone). • 1. Stimulability – across word positions and levels (discussed previously). Flipsen - SC Scottish Rite Centers - Sept 08

46. Articulatory or Phonological? • 2. Is the sound ever correct? • If correct in particular words: • May just be an over-learned word (doesn’t tell us much). • If correct in particular word positions: • May be an articulatory problem. • May not have learned the co-articulatory aspects in particular word positions. • May be a phonological problem. • May not have figured out that the sound can be used in more than one position. Flipsen - SC Scottish Rite Centers - Sept 08

47. Articulatory or Phonological? • 3. Does the sound ever appear accidentally? • Is the sound ever used as a substitute for something else. • E.g., /c/ never correct but used in place of /s/. • Suggests child is capable of producing /c/. • But could just be an over-learned word. • If never used accidentally: • Sound likely not in inventory suggesting a phonological problem. • But may not have learned to physically produce it. Flipsen - SC Scottish Rite Centers - Sept 08

48. Articulatory or Phonological? • 4. Is contrast between target and substitution being “marked” in some other way? • Narrow transcription may reveal subtle differences: • E.g., t/s substitution (stopping error). • Have them produce minimal pairs: nice/night. • Listen for a difference in final /s/. • May produce /ne]t(//ne]t)/ • May be marking the difference using aspiration vs. no aspiration rather than fricative vs. stop. Flipsen - SC Scottish Rite Centers - Sept 08

49. Marking? • With omission errors, look for evidence that the child at least knows that the missing sound is supposed to be there. • Some limitation may be preventing them from actually producing it. • E.g., omits final /n/. • Have them produce minimal pair: can / cat • Listen for differences in nasal quality on the vowel. Flipsen - SC Scottish Rite Centers - Sept 08

50. No One Question Provides all the Answers! • Led to the development of the decision tree. • Can use data from an artic test or transcription of connected speech. • Look at each error separately. • Treat each sound depending on what the problem is for that sound. • With multiple errors of the same type, look for patterns. • May be able to treat some of the errors and see generalization to other related errors. Flipsen - SC Scottish Rite Centers - Sept 08