The Unintelligible Preschooler:

1. The Unintelligible Preschooler: Assessment and Treatment Feb. 11-12, 2000

2. Peter Flipsen Jr., Ph.D. • Assistant Professor of Communication Disorders Minnesota State University, Mankato • ASHA Certified (CCC-SLP) • Minnesota Title Registered (SLP) • Canadian Certified (S-LP(C))

3. Course Objectives: • Identify factors that contribute to the intelligibility of speech • Select appropriate test materials for unintelligible preschoolers • Identify the nature of intelligibility deficits in unintelligible preschoolers • Select appropriate treatment strategies • Incorporate parents into treatment programs

4. Overview • Part 1 - Assessment • Review intelligibility as a concept • Review factors contributing to intelligibility • Review assessment of intelligibility • Discuss possible factors contributing to intelligibility deficits • Review procedures for evaluating each of the factors

5. Overview • Part 2 – Intervention • Dealing with short-term issues • Dealing with structural problems • Dealing with motor problems • Dealing with resonance problems • Dealing with linguistic problems • Incorporating parents

6. Pretest

7. Who Are We Talking About? • Preschool children who are otherwise typically-developing but who present with speech that is unusually difficult to understand • One or both parents may be good “translators” but most unfamiliar listeners have difficulty communicating with these children.

8. Some examples: • Faustin – age 6;0 • Dylan – age 5;1 • Aaron – age 4;1

9. Who these children are not. • Not hearing impaired • No obvious structural problems • No frank neurological impairments • No major cognitive deficits • No problems with receptive language

10. Consequences of Being Unintelligible • Communication is not effective • May reduce attempts to speak • Limits practice time for learning language • Increasing frustration • May lead to behavior problems • Reduced message complexity • Shorter utterances more easily understood

11. Consequences of Being Unintelligible • Limited practice time may account for why many of these children also have expressive language delays (Miller & Leddy, 1998) • Some emerging evidence that significant delays in speech acquisition lead to later problems with reading acquisition

12. Historical Pattern • Up until the early 70s these children were seen as having “functional articulation disorders” • Implied that it was a problem learning how to say the sounds • 1970s -sudden shift to saying they had “phonological impairments” • Implied that it was a problem knowing where to use the sounds

13. The Clinical Puzzle • Difficult to define the specific nature of the problem these children are having • Also difficult to know what the best treatment approach might be

14. The Clinical Solution? • Both of the historical labels assumed that this was a single group • No single approach to treatment seems to work for all of them • Very likely the problems are based in a variety of causes • Need to identify the likely cause for each child if possible

15. Part I - Assessment

16. The Concept of Intelligibility • Understandability • How effectively a person can get their message across • The goal of every communication event • “… the functional common denominator of verbal behavior.” - Kent et al. (1994)

17. Factors Affecting Intelligibility • The listener • The listening environment • The speaking context • (pragmatic and linguistic) • The speaker

18. Listener Factors • Hearing acuity • For most clinical purposes, we select listeners with normal hearing • Receptive language skills • For most clinical purposes, we select listeners with normal skills

19. Listener Factors • Familiarity with speaker personally • Parents (and anyone who spends much time with these children) quickly become “biased” listeners • Learn to ‘translate’ the abnormal patterns

20. Flipsen (1995) • Study of parents as “familiar” listeners • Four children tested longitudinally while in therapy • Made recordings of children speaking single words (Y-B test) • Mothers, fathers and unfamiliar listeners tried to identify words

21. Flipsen (1995) • Mothers understood significantly more of the words than any of the other listeners • Fathers were not significantly better than the unfamiliar listeners • Appeared that mothers were spending much more time with the children (not formally measured)

22. Listener Factors • Familiarity with the material being produced • If you’ve heard the “Rainbow passage” 50 times you come to know what to expect • If you chose the sentences to be read you know what to expect

23. Listener Factors • Familiarity with the speaker’s population • Particular disorder groups do tend to have similar overall speech patterns • The more time you’ve spent with those groups the more easily you are able to understand them

24. Listener Factors • Familiarity with disordered speech in general • Experienced SLPs better at understanding disordered speech than non-SLPs

25. Environmental Factors • Affect both speaker and listener • Noise levels • Presence / absence of visual distractions • Comfort level • THESE CAN USUALLY BE CONTROLLED FOR MOST CLINICAL PURPOSES

26. Contextual Factors • Speaking Task • Conversation • Monologue • Reading • Material being produced • Connected Text • Sentences • Single words

27. Contextual Factors • Usually see an interaction between level of intelligibility and the type of material being produced • Speakers with milder intelligibility deficits tend to do better with connected contexts • Speakers with more severe intelligibility deficits tend to do better with single-word context

28. Fig. 1

29. Fig. 1a

30. Speaker Factors • Cognitive skills • Usually doesn’t impact intelligibility except at very low levels • Poor presuppositional skills – may not provide all the necessary info • May also see speech motor skills deficits in those with more severe cognitive deficits

31. Speaker Factors • Expressive language skills • Vague vocabulary may be a problem • Missing morphological markers may also interfere • Force the listener to have to work harder to process the information

32. Speaker Factors • Phonological skills • Includes knowledge of: • phonemes • allophones • morpheme structure rules and sequential constraints • morphophonemic rules

33. Speaker Factors • Speech Motor Skills • Ability to formulate and transmit the neuromotor instructions • Frank dysarthria and dyspraxia readily reduce intelligibility • Affect both accuracy and timing of segment production

34. Speaker Factors • Hearing Acuity • Clearly if you can’t hear what you’re producing, you will have difficulty producing it accurately • Not a factor in the group we’re discussing

35. Speaker Factors • Auditory Perceptual Skills • Not a major issue for all these children • Some may have problems with perceiving the difference between sounds they have difficulty producing and what substitute

36. Speaker Factors • Status of the physical mechanism • Most minor structural problems are not a problem by themselves • It is possible however for several of these to combine with each other to make the task of producing speech more difficult

37. Speaker Factors • Voice Quality • Harsh or hoarse voice adds noise to the signal making it harder to understand • Higher pitched voices in children are by definition ‘thinner’ (fewer harmonics) making them more susceptible to effects of other factors

38. Speaker Factors • Resonance Status • Hyponasal (denasal) speech can be harder to understand because of the loss of oral-nasal contrasts • Nasal consonants account for about 10% of all speech sounds • Rarely a major factor however

39. Speaker Factors • Hypernasal speech has a more serious impact on intelligibility • Nasal cavity resonances are low intensity (hard to hear) • Nasal cavity has anti-resonances that cancel out some acoustic energy making the output even harder to hear

40. Articulation Skills The ability to produce the individual speech sounds Speakers with few errors may still be unintelligible Speakers with many errors may be quite intelligible Speaker Factors

41. Fig. 2

42. Fig 2a

43. Fig 2b

44. Speaker Factors • Speech sound production skill only accounts for 20-50% of the variance in intelligibility

45. Speaker Factors • Prosodic Skills • Excessively fast or slow rate may reduce intelligibility • Clutterers use extreme rate – hard to process what they are saying • Classic strategy in adult dysarthria is to have them slow down • If speech is too slow, listener may lose track of the whole message

46. Speaker Factors • Atypical stress patterns may also reduce intelligibility • e.g., stress on wrong word in sentence or on the wrong syllable in a word or too little stress • Listeners rely on stress to assist with sorting out the words • e.g., many N-V pairs differ only on stress

47. Speaker Factors • Motivation and effort • We all know people who appear to “mumble” at times but can make themselves understood if they choose to • And when we ask some speakers to repeat, they may change what they do and the result is an improved signal

48. Speaker Factors • Nonverbal communication skills (i.e., gestures) may play a role • Recent study by Garcia & Cobb (1998) showed that gestures also contribute to message understanding in adult dysarthria • (only 2 speakers studied however)

49. Intelligibility and Severity • NOT the same thing though often highly correlated. • A child producing many speech sound distortions may be quite intelligible but may be rated as moderately impaired. • A child with a harsh voice may be quite intelligible but listeners have to work harder to understand him.

50. Intelligibility • Clearly a very complex phenomenon • It is not surprising that it is not well understood by clinicians