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Speech and Resonance Evaluation

Date (e.g. January 1, 20xx)
Client Name: Joe Smith

Date of Birth: January 1, 20xx C.A.: 4 years, 6 months

Address: 10000 Sweetwater Lane,

Pluto, VT 05000



Phone:

Parents:

School:

Referral Source

Clinicians: Student name, graduate clinician

Supervisor: Gayle Belin, M.A., CCC-SLP

Diagnostic Code: Hypernasality: 784.43
Referral Questions:

  1. On which specific sounds does Joe Smith demonstrate nasal emission or is excess nasality pervasive?

  2. What specific treatment strategies can be used to improve resonance and speech sound production?


Background:

Joe Smith is a four and a half year old boy currently enrolled in preschool at The Best Preschool in Rutland, VT. He has received speech and language therapy for a speech delay since September 2008. He was referred to this center for a speech and resonance evaluation by his speech language pathologist, Ms. Terrific SLP, who provides services through the Essential Early Education. Ms. SLP reported that Joe Smith’s speech intelligibility is reduced by hypernasality paired with nasal emission, most often on the phoneme /s/ and sometimes on final /t/. She also reported that tongue movements and lip closure have been difficult for Joe Smith and works on these in therapy.


Joe Smith’s mother also reported that she notices nasal emission, which along with his speech delay impact his ability to be understood by others.
Medical history:

Joe Smith was born at 36 weeks of gestation and development seemed typical in every way. While he passed his newborn hearing screening, he has experienced frequent ear infections, the first at three months of age. He had six ear infections before the age of 12 months and four more ear infections between one and two years of age. Joe Smith was fitted with pressure equalizing tubes and had his adenoids removed at the age of two to decrease the ear infections. He has since had three sets of tubes implanted because they have repeatedly fallen out. On January 25, 2008, Joe Smith saw his otolaryngologist, Dr. Tom Thumb, of Fletcher Allen Health Care in Burlington, who ensured that his pressure equalizing tubes were in place. Today, Joe Smith’s mother reported that he currently has an ear infection for which he has received drops as treatment.


Objectives: Both formal and informal assessments were used in today’s evaluation session. Results are conveyed in the following paragraphs.
Otoscopic Evaluation:

Examination of the external ears and otoscopic examination of the ear canals and tympanic membranes was conducted. The pressure equalizing tubes were viewed bilaterally. This examination was remarkable for the presence of ear wax with surrounding plaque near Joe Smith’s left tympanic membrane. There was also a darker substance present, which may have been blood. This is the ear in which he currently has an ear infection.


Diagnostic Evaluation of Articulation and Phonology:

The Diagnostic Evaluation of Articulation and Phonology (DEAP) is a standardized test used to identify phonological processes employed by children. The single word portion of the phonological processes subtest was completed. Joe Smith received a standardized score of 85, placing him in the 16th percentile of scores for children his age and one standard deviation below the mean. More importantly, the DEAP revealed that Joe Smith exhibited several phonological processes, some of which are remarkable for his age. The results are summarized below.



Diagnostic Evalaution of Articulation and Phonology: Summary of results:

Phonological Process

Example of Process

Percent Occurrence

Error Pattern

Appropriate Age Range

Age Appropriateness

Gliding

/l/  /w/

“helicopter”  “hewicopter”



38%

Yes

3:0 – 5:5

Yes

/r/  /w/

“rabbit”  “wabbit”



Vocalization of liquids

/l/  vowel

“apple”  “apo”



11%

No

3:0 – 4:11

Yes

Cluster reduction

/br/  /b/

“umbrella”  “umbella”



30%

Yes

3:0 – 4:5

No

/kw/  /k/

“queen”  “keen”



Weak syllable deletion

/tΛ/  ø

“tomato”  “mato”



8%

Yes

3:0 – 3:11

No

Stopping

/ʃip/  /tip/

“sheep”  “teep”



6%

No

3:0 – 4:5

No

Phonological processes are considered phonological error patterns if they occur five or more times during the test (two or more times for weak syllable deletion). By these standards, Joe Smith employed the phonological error patterns of gliding, cluster reduction, and weak syllable deletion. He used the phonological process of vocalization of liquids only once and stopping twice, so neither is considered a consistent pattern of error in his speech. Joe Smith exhibited nasal resonance and emissions regularly on several fricative and affricate phonemes (sounds), including /s/, /z/, /tʃ/ (“ch”), and /dƺ/ (“j”). Nasal emissions were evident 100% of the time when he attempted production of /s/ and /ʃ/ (“sh”) during administration of this assessment tool. Nasal emissions were variable for other phonemes such as /f/ and /t/. Facial grimacing was noticed at times, which is probably an indication that he was attempting to prevent air from escaping through his nose.


Oral Mechanism Examination:

A superficial examination of the oral mechanism was conducted. Digital and visual inspection of the lips, dentition, tongue, hard palate, and soft palate were unremarkable. During production of /a/, both prolonged and in short bursts, typical superior movement of the velum (soft palate) was noted, however, movement of the lateral walls was not visible. Some posterior movement of the soft palate was observed but it was unclear whether or not this was adequate for full closure of the velopharyngeal port. Joe Smith appeared reluctant to perform movements of the tongue as modeled by the clinical team members. However, tongue protrusion and retraction were observed later in the session.


Intelligibility:

Intelligibility is the percentage of a person’s speech that is understandable by an unfamiliar listener. Based on the assessment of these samples of connected speech, Joe Smith was judged to be approximately 90% intelligible. It was observed, however, that at times of more excited speech Joe Smith was harder to understand.


Resonance Assessment:

Joe Smith was instructed to repeat consonant-vowel combinations in order to assess his resonance and the presence of nasal emission in various phonemic contexts. He was able to produce the proper oral resonance for the sounds /pa/, /pi/, /ta/, /ka/ and /ki/. He demonstrated nasal resonance with emission on the sounds /ti/, /fa/, /fi/, /sa/, /si/, /ʃa/, /ʃi/, /ʧa/ and /ʧi/. Nasal grimacing was observed on the sounds /fa/ and /fi/.


With the help of the clinicians, Joe Smith recited part of the nursery rhyme, “The Itsy Bitsy Spider”. He demonstrated consistent excess nasal resonance on the phoneme /s/ in “itsy” and “sun”, and /ʃ/ as in “washed”.
Repetition of sentences containing pressure-sensitive words was assessed in order to observe resonance in Joe Smith’s structured connected speech. Joe Smith repeated phrases such as, “Popeye plays baseball”, “Buy baby a bib”, “take teddy”, “cherries and cheese”, “French fries” and “sally snake”. Nasal resonance and emission was noted on the fricative phonemes, /f/, /s/, and /ʃ/ (“sh” as in shirt), and on the affricate phoneme /ʧ/(“ch” as in church)
Stimulability Testing:

Since there was some evidence that Joe Smith’s excessive nasality was on specific sounds only and not pervasive, the use of touch cues to help him identify the correct place of articulation for sounds was tried. He was instructed to repeat the isolated sounds /ʃ/ (“sh”) and /s/ and these sounds in words and short phrases. Following the clinician’s models and cues to direct the airflow forward and to speak slowly, Joe Smith demonstrated the ability to make both sounds without the presences of excess nasal resonance or nasal emission suggesting that at least some of his current hypernasal behaviors are phoneme (sound) specific and are not entirely due to weakness or dysfunction of the velopharyngeal musculature. They may very well be amenable to traditional speech therapy techniques.



Summary and Interpretation:

Joe Smith LastName, age 4;6, is a delightful young boy who was initially very quiet and slightly reticent to participate with the assessment activities. His mother and father joined him in the room, and over time he became more talkative.


Joe Smith’s speech and resonance was notable for the presence of hypernasality, but this resonance characteristic appeared to be more phoneme specific in nature. Hypernasal resonance appeared to increase in connected speech, which is not unusual due to the nature of coarticulation (or the influence of one sound on another). More specifically, excess nasality was present inconsistently on some plosives (/t/) and more consistently on the fricatives (/s/ and /f/) and affricates (/ʃ/ and /ʧ/). Stimulability testing demonstrated that with instruction, modeling and cueing, Joe Smith was able to make these sounds orally and without excess nasality or nasal emission, when encouraged to imitate the targets at a slower rate. This bodes well for improvement with continued speech therapy. However, though his hypernasal resonance appears today to be mostly due to phoneme specific nasality patterns, this does not rule out some underlying weakness and/or dysfunction in the velopharyngeal mechanism. Progress in sound production or lack thereof over the coming months will provide a better picture of this issue.
Joe Smith also demonstrated many sound substitutions and sound deletions during today’s testing, representing a phonologic delay. The combination of hypernasality and phonologic delay create reduced intelligibility in Joe Smith’s speech.
Joe Smith was unable to perform some of the tongue tasks in today’s examination of his oral mechanism. This indicates that he may have impaired motor sequencing abilities, making it difficult for him to coordinate movements of the mouth and adding to reduced intelligibility. If Joe Smith’s motor sequencing abilities are in fact impaired, progress in speech therapy can still be made but most likely at a slower pace.

Recommendations: The following recommendations were made at the conclusion of today’s session and were discussed briefly with Joe Smith’s parents and Ms. SLP.


  1. Joe Smith should continue to receive speech and language services to address his hypernasality and phonologic delay.

  2. It is important that these services be provided consistently for at least six months in order to monitor changes in resonance and phonological development.

  3. If marked decrease in nasal resonance and emissions is not observed after this time, Joe Smith should be referred to an otolaryngologist and/or to the Rutland Craniofacial Team clinic for further investigation of the velopharyngeal mechanism to ensure adequate closure.

Specific therapy techniques to address hypernasality in Joe Smith’s speech were demonstrated today for Joe Smith’s school speech language pathologist. These techniques are described below.




  1. Progression of sounds: Begin with isolated sounds or words with sounds such as /h/ or /w/ which are very clearly oral sounds in order to teach the concept of oral airflow. Other more oral sounds and then words can then be incorporated as long as they remain oral: /p, b, t, d, ∫, θ/. The hierarchy found in the “Hypernasality Modification Program” lists words in an order that tend to be easier for many individuals. When working with Joe Smith directly on hypernasality, therapy should begin with the /ʃ/ because he showed excellent stimulability for that sound, followed by /s/, /ʧ/ and /f/.

  2. Whispered Speech: It might be helpful to begin with whispered speech which does not recruit the musculature of the larynx and confuse the issues. This will also prevent the production of glottal stop substitutions.

  3. Paper Paddle: Place a paper paddle in front of Joe Smith’s mouth and instruct him to produce forceful stop, fricative, and affricate sounds. When he does this, the paper paddle in front of his mouth will wave if he is correctly forcing air of out his mouth. However, if he allows air to escape through his nose, the paper paddle will not move. A variation of this task could use a feather, which Joe Smith will see move when he direct airflow out his mouth. The feather may move even if air escapes through Joe Smith’s nose, so this should be monitored carefully.

  4. See Scape: Use a See Scape to provide Joe Smith with immediate feedback regarding where air is escaping. Place the nasal-olive tip in or near Joe Smith’s mouth (as opposed to his nose) and observe the movement of the Styrofoam ball as the air pressure in the device changes. This will be particularly helpful for more forward bilabial plosives but can be adapted for other sounds.

  5. Imagery: Create a bull’s eye to hang on the wall and instruct Joe Smith to stand one to two feet away from it while producing phonemes such as /s/ and final /t/. The goal will be for Joe Smith to allow air to escape only from his mouth, “shooting” it toward the center of the bull’s eye. If he achieves this, the clinician will place a sticker right on the center of the bull’s eye. If Joe Smith does not achieve oral resonance, the sticker should be placed above the bullseye to indicate that the air was coming out of his nose rather than his mouth.

  6. Tactile Feedback: Teach Joe Smith to feel when air is escaping through his nose. Begin with the clinician’s fingers on Joe Smith’s nose, and ask Joe Smith to produce sounds on which he often has nasal emissions. With his fingers on the sides of his nose, teach Joe Smith to recognize the feel of nasal emissions while making these sounds. Then have Joe Smith make sounds on which he does not demonstrate nasal resonance, such as /b/, while keeping his fingers on the sides of his nose. Teach him to feel the difference, first with his fingers on his nose, and eventually without using his fingers. This task can be approached hierarchically and add words and phrases as Joe Smith has success at each level.

  7. PINCH Technique: Instruct Joe Smith to plug his nose (but ensure that his hand is not covering his mouth in order to avoid interfering with articulation) and to produce a few words on which he does not exhibit nasal emissions. Contrast this with a word that includes a problematic phoneme. When air escapes through his nose, he should feel pressure in his nose. The clinician can explain that air is coming out of his nose instead of his mouth. Instruct Joe Smith to practice word production using this technique to provide biofeedback.


Prognosis:

The likelihood that Joe Smith will improve his resonance and speech intelligibility through speech therapy is somewhat mixed. A positive prognostic indicator is Joe Smith’s ability to correct the nasality in his speech during stimulability testing. However, it is still unclear that excess nasality is due solely to the manner of production and isn’t, in part, due to some velopharyngeal dysfunction). Additionally, progress in therapy will be slower if motor planning and sequencing are demonstrated.


It was a pleasure to work with Joe Smith and his parents during this visit. If there are any questions or concerns regarding this evaluation, please feel free to contact us at the Eleanor M. Luse Center.
Respectfully submitted,


______________________

Graduate Student Clinician


______________________

Graduate Student Clinician


________________________

Gayle Belin, M.A., CCC-SLP

Speech-Language Pathologist
Cc:

Parents




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