Carrie Eichler

Praxis Study Guide

Session 1: Foundations, research, EBP → Y: 9, 11, 3, 12; B: 2, 3, 4, 24, 25, 26

Session 2: Professional practice → Y: 13, 14; B: 17-23
Session 3: General screening, assessment/evaluation → Y: 11; B: 6-10
Session 4: Etiologies → Y: 12, 13 (pg 624); B: 5
Session 5: Speech sound disorders →Y: 5; B: 6
Session 6: Child language disorders/development → Y: 3, 4; B: 1, 7
Session 7: Fluency → Y: 6; B: 8
Session 8: Voice, resonance, motor speech, AAC → Y: 7, 8; B: 9, 10, 11, 16
Session 9: Language, social communication, cognition → Y: 8; B: 6, 11
Session 10: Hearing, feeding, swallowing → Y: 8, 10; B: 12, 13, 14, 15

Topics covered:
1. Foundations of professional practice
a. Foundations
i. Typical development and performance across the lifespan
ii. Factors that influence communication, feeding, and swallowing
iii. Epidemiology and characteristics of common communication and
swallowing disorders
b. Professional practice
i. Wellness and prevention
ii. Culturally and linguistically appropriate service delivery
iii. Counseling, collaboration, and teaming
iv. Documentation
v. Ethics
vi. Legislation and client advocacy
vii. Research methodology and evidence-based practice
2. Screening, assessment, evaluation, diagnosis
a. Screening
i. Communication disorders
ii. Feeding and swallowing disorders
b. Approaches to assessment and evaluation
i. Developing case histories
ii. Selecting appropriate assessment instruments, procedures, and materials
iii. Assessing factors that influence communication and swallowing disorders
iv. Assessment of anatomy and physiology
c. Assessment procedures and assessment
i. Speech sound production
ii. Fluency
iii. Voice, resonance, and motor speech
iv. Receptive and expressive language
v. Social aspects of communication, including pragmatics
vi. Cognitive aspects of communication
Carrie Eichler

vii. Augmentative and alternative communication

viii. Hearing
ix. Feeding and swallowing
d. Etiology
i. Genetic
ii. Developmental
iii. Disease processes
iv. Auditory problems
v. Neurological
vi. Structural and functional
vii. Psychogenic
3. Planning, implementation, and evaluation of treatment
a. Treatment planning
i. Evaluating factors that can affect treatment
ii. Initiating and prioritizing treatment and developing goals
iii. Determining appropriate treatment details
iv. Generating a prognosis
v. Communicating recommendations
vi. General treatment principles and procedures
b. Treatment evaluation
i. Establishing methods for monitoring treatment progress and outcomes to
evaluate assessment and/or treatment plans
ii. Follow-up on post-treatment referrals and recommendations
c. Treatment
i. Speech sound production
ii. Fluency
iii. Voice, resonance, and motor speech
iv. Receptive and expressive language
v. Social aspects of communication, including pragmatics
vi. Cognitive aspects of communication
vii. Augmentative and alternative communication
viii. Hearing
ix. Feeding and swallowing
Carrie Eichler

According to ASHA, we need to know the following:

● Foundations of professional practice
○ Foundations
i. Typical development and performance across the lifespan
● Birth-3: startle response to loud sound, visually tracks to sound, smiles reflexively,
attends toward voice, cries for assistance, quiets when picked up, produces vowels
● 4-6 months: raises arms to be picked up, moves/looks toward named family members,
makes raspberries, growls, adult-like vowels, marginal babbling, responds to name (5
months)
● 7-9 months: recognizes names of common objects, comprehends “no,” plays peek-a-
boo, uses a wide variety of sound combinations, variegated babbling (9 months)
● 10-12 months: understands 10+ words, first words, obeys some commands, object
permanence, recognizes own name, jabbers loudly
● 1-2 years: holistic single-word phrase, begins putting 2 words together, overextensions
○ Halliday’s 7 functions of communicative intent (1975):
■ Imaginative: use language to create environment
■ Heuristic: explain environment
■ Regulatory: control behaviors of others
■ Personal: express feelings and attitudes
■ Informative: tell someone something
■ Instrumental: attempt to get assistance/material things from others
■ Interactional: initiate interactions with others
○ Dore (1975): children use early words to signal communicative intent
● 2-3 years: word combinations, 3-4 word sentences, express negation, wh- questions,
plurals
○ Acquisition of grammatical morphemes for age 2-3
■ Present progressive -ing
■ Prepositions “in,” “on”
■ Regular plural inflections -s
■ Irregular past-tense verbs
■ Possessive -s
■ Uncontractible copula (Here I am)
● 3-4 years: passive voice, opposites, can answer “what if” questions, modify speech to
age of listener
○ Acquisition of grammatical morphemes for age 3-4
■ Articles (a cookie)
■ Past-tense regular -ed
■ Regular third-person -s
■ Irregular third person (does, has)
■ Uncontractible auxiliary (She was walking)
■ Contractible copula (He is nice)
■ Contractible auxiliary (Mom is coming)
● 5-6 years: uses tenses consistently, begins to tell jokes, uses comparisons, understands
humor, can identify politeness
Carrie Eichler

● 6-7 years: uses “if” and “so,” apt to use profanity and slang
● 7-8 years: anticipates story endings, tells stories, uses superlatives, able to take
listener’s point of view
● Language disorders are typically identified in grades 4-6, because there is a shift
between “learning to read and write” and “reading and writing to learn”
● Cognitive skills most strongly influence the child’s responses in early development
● Intensive phonemic-awareness treatment for children who have difficulty reading might
have no direct relationship to improving reading
● Phonological processes that should be eliminated by age 3
○ Reduplication
○ Weak syllable/final consonant deletion
○ Consonant assimilation
○ Fronting of velars
○ Diminutization
● Phonological processes that may persist past age 3
○ Final consonant devoicing
○ Consonant cluster reduction
○ Stopping
○ Epenthesis
○ Guiding
○ Depalatization
○ Vocalization
Carrie Eichler

ii. Factors that influence communication, feeding, and swallowing

→ General
● ASD (pervasive developmental disorder): Leo Kanner originally described autism (IQ
under 70), Hans Asperger originally described asperger’s syndrome (IQ above 70)
● Cerebral palsy: can be prenatal, perinatal, postnatal; hemiplegia, paraplegia,
monoplegia, diplegia, quadriplegia
○ Ataxic: disturbed balance, awkward gait, uncoordinated movements (cerebellar
damage)
○ Athetoid: slow, writhing, involuntary movements (basal ganglia and indirect motor
pathways)
○ Spastic: increased muscle tone, stiff, abrupt, jerky, slow movements (motor
cortex and direct motor pathways)
● Fetal alcohol syndrome: pre/postnatal growth problems, delayed language, prone to
ADD/ADHD, malformation of organ systems, physical impairments correlate
→ Random anatomy facts
● The anterior cerebral artery supplies blood to the corpus callosum and basal ganglia
● The aryepiglottic folds form a connective tissue ring and separate the laryngeal vestibule
from the pharynx
● Velopharyngeal closure is caused by the contraction of the palatoglossus, tensor veli
palatini and levator veli palatini
● The adduction of the vocal folds is due to the LCA and transverse arytenoid contracting
● Commissural fibers connect the cerebral hemispheres
● Left RLN damage → left UL VF paralysis, left pharyngeal paresis, aspiration
→ Cranial nerves
● 5 = sensory from face and mouth, motor to mastication
● 7 = sensory from anterior ⅔ of tongue, facial expression, lacrimal/salivary glands
● 9 = sensory from pharynx and posterior ⅓ of tongue
● 10 = sensation from internal organs, parasympathetic motor regulation
● 11 = movement of head, neck, shoulders
● 12 = motor to tongue
→ Speech science
● Stridents are produced by forcing air through a small opening (ch)
● Sonorant are produced with uninterrupted air (n, m, l, r, w, j)
● Interrupted sounds are opposites from sonorants
● Obstruents are produced by an air obstruction and include fricatives, affricates and stops
● Sibilants are high frequency sounds and include fricatives and affricates
● Cognate pairs are similar in all ways except voicing
● In vowels, F1 represents tongue height and F2 represents tongue advancement
● Normal conversation takes place between 50 and 70 dB SPL
● Coarticulation is the influence of one phoneme on another in production and perception
wherein two different articulators move simultaneously to produce two different speech
sounds
● Harmonics are whole number multiples of fundamental frequency
● Voiceless fricatives and whispering has significant aperiodicity
Carrie Eichler

iii. Epidemiology and characteristics of common communication and

swallowing disorders
→ Terminology
● Assimilation: children apply new info to an existing cognitive scheme
● Accommodation: children modify an existing cognitive scheme to include new
information
● Mediated learning experience: children learn through interaction with more experienced
adults or peers who interpret the environment for them
● Scaffolding: a clinician models the strategy or task to be learned, then gradually shifts or
removes instructional support for the child
● Stimulus control: stimulus sets the occasion for performing a behavior
● Response generalization: teaching or modifying a behavior results in changes in other
similar behaviors
● Primary reinforcer: food, sex, touch
● Secondary reinforcer: verbal praise with food
● Extinction: withdraw a reinforcer when an undesirable behavior occurs, causes a quick
increase in the undesirable behavior but realization that the behavior is not reinforced
will cause a gradual decrease
● Assumptions for children when learning language
○ Novel-name-nameless assumption = mutual exclusivity: nameless = new word
○ Whole object assumptions: assume pointing to whole thing and not just a part
○ Taxonomic: children group things together
→ People
● Behavioral theory = Skinner (children learn only the language they are exposed to)
○ Mands: involves requests (reinforced by foods)
○ Tacts: involves motivators like physical objects (reinforced socially)
○ Echoics: imitative verbal responses
○ Autoclitics: comment on tacts and mands
○ Intraverbals: continuous, fluent speech
● Nativist theory = Chomsky (humans learn language due to innate biological ability to
learn, hardwired, that’s why syntax is very difficult to teach)
Carrie Eichler

● Cognitive theory = Piaget (language acquisition is made possible by cognition and

general intellectual processes)

● Social interactionism theory = Vygotsky (children increasingly use language internally to

structure their actions and direct their thoughts, cultural tools play a critical role)
○ Zone of proximal development: difference between what a child can do
with/without assistance
● Bandura's social learning: people learn from one another, via observation, imitation, and
modeling (has often been called a bridge between behaviorist and cognitive learning
theories because it encompasses attention, memory, and motivation
→ Behavioral processes: positive reinforcement (consequence presented to person when they
perform the behavior), negative reinforcement (remove stimulus increases positive behavior)
→ Random grammar terms
● Compound sentence: ____ and (conjunction) ___
● Complex sentence: independent clause, dependent clause
● Pragmatics=function of language
○ Perlocutionary (signals without communicative intent)
○ Illocutionary (socially organized action)
○ Locutionary (words)
● Semantics=context of language
Carrie Eichler

→ Brown’s morphemes
Stage Order of Morpheme Example
Acquisition

1 Combining 2 words

2 1 Present progressive - ing Mommy driving.

(no auxiliary verb)

2 2 In Ball in cup.

2 3 On Doggie on sofa.

2 4 Regular plural - s Kitties eat my ice cream.

Forms: /s/, /z/, and /Iz/, e.g.
Cats
Dogs
Classes

3 5 Irregular past Came, fell, broke, sat, went

3 6 Possessive - 's Mommy's balloon broke.

Forms: /s/, /z/, and /Iz/ as in regular plural

3 7 Uncontractible copula Who's sick?

(Verb to be as main verb) Response: He is.

4 8 Articles I see a kitty.

I throw the ball to daddy.

4 9 Regular past - ed Mommy pulled the wagon.

Forms: /d/, /t/, /Id/, e.g.
Pulled
Walked
Glided

4 10 Regular third person -s Kathy hits.

Forms: /s/, /z/, and /Iz/ as in regular plural

5 11 Irregular third person Does, has

5 12 Uncontractible auxiliary Who's wearing your hat?

Response: He is.

5 13 Contractible copula Man is big.

Man's big.

5 14 Contractible auxiliary Daddy is drinking juice.

Daddy's drinking juice.
Carrie Eichler

→ Multicultural issues
● General
○ Demographic data: increasing diversity in the US is due to both increases in birth
rates among CLD (culturally linguistically diverse) groups and immigration trends,
and this affects SLPs from early intervention to end of life care
○ Culture includes beliefs, behaviors, and values of a people group
○ The culturally competent SLP is one who: is actively in the process of becoming
aware of his/her own assumptions, actively attempts to understand the worldview
of his or her culturally diverse clients and families, and is actively developing and
practicing culturally relevant, sensitive, and appropriate service delivery skills and
practices
○ A dialect is a rule-governed variation in a language used by a racial, ethnic,
geographic, or socioeconomic group
○ Remember basics of second language learning and vocabulary differences when
testing CLD kids
○ It is normal for language differences to occur during second language learning,
specifically the process of inference, the silent period, code-switching, and
language loss
○ Basic interpersonal communication skills (BICS) take approximately 2 years to
develop to a native-like level, cognitive-academic language proficiency (CALP)
takes 5-7 years to develop to a native-like level
Carrie Eichler

● AAE
○ To assess children who speak AAE, language sample analysis, contrastive
analysis, and description of children’s functional communication skills should be
used
○ Characteristics of AAE articulation and phonology
■ /l/ lessened or omitted (“too” for “tool”)
■ /r/ lessened or omitted (“doah” for “door”)
■ /f/ substitution for voiceless /th/ at final or medial position (“teef” for
“teeth”)
■ /t/ substitution for voiceless /th/ at initial position (“tink” for “think”)
○ Characteristics of AAE morphology and syntax include:
■ Omission of plurals (“He got two box of apple.”) → ALL CLD
■ Omission of possessives (“That the woman car.”) → Also Spanish
■ Omission of third-person singular present-tense (“She walk to school.”)
■ Omission of copula (“She a nice lady.”) → Also Asian
■ Use of the perfective (distant past) construction “been” (“I been had a
marble collection when I was 7.”)
● Spanish-influenced English
○ Hispanics are the fastest growing racial/ethnic group in the US
○ Characteristics of Spanish-influenced English articulation
■ Dentalized /t/, /d/, /n/
■ Devoiced final consonants
■ /b/ substitution for /v/
■ /ch/ substitution for /sh/
○ Characteristics of Spanish-influenced English language
■ Omission of plurals → ALL CLD
■ Omission of possessives → Also AAE
■ Omitted past tense morpheme → Also Asian
■ Adjectives following nouns (“The house green.”)
■ Auxiliary past tense construction (“Did he bit somebody?”)
■ Double negatives
● Asian-influenced English
○ Characteristics of Asian-influenced English articulation
■ Omission of final consonants
■ Truncate polysyllabic words and make most monosyllabic
■ Devoicing of voiced consonants
■ /r/ and /l/ confusion
○ Characteristics of Asian-influenced English language
■ Omission of plurals → ALL CLD
■ Omission of copula (“He going home now.”) → Also AAE
■ Omission of past-tense morpheme → Also Spanish
■ Past tense double marking
Carrie Eichler

○ Professional practice
i. Wellness and prevention
ii. Culturally and linguistically appropriate service delivery
iii. Counseling, collaboration, and teaming
→ Counseling
● Approaches to counseling
○ Psychodynamic theory: (Freud) behavior is the product of conflictual interaction
between the id, ego, and superego, make clients conscious of repressed
problems
○ Client-centered theory: (Rogers) clients need acceptance and positive
unconditional regard in order to develop congruence between self-concept and
behavior
○ Behavioral theory: (Pavlov) track changes using observable measures, operant
conditioning measures (reinforcement, punishment)
○ Cognitive-behavioral theory: (Ellis) client’s thoughts are key to his/her feeling and
actions, counseling consists of changing the client’s thinking, changing the belief
system, and changing the behavior
○ Eclectic approach: combination of client-centered, behavioral, and cognitive-
behavioral approaches
● Defense mechanisms: include rationalization, reaction formation, displacement,
projection, repression and suppression
iv. Documentation
→ Medical imaging techniques
● Tomography/laminography: taking pictures of different planes, not used often
● Computerized axial tomography (CAT): x-ray beams circle through brain segments and
tissues (frequently used to detect hemorrhages, lesions, tumors, etc)
● Electroencephalography (EEG): records and measures electrical impulses of the brain
through surface electrodes, can show different types of brainwaves associated with
talking, listening, thinking (frequently used to detect seizures)
● Magnetic resonance imaging (MRI): fine detail in brain in magnetic field, provides higher
resolution but is very expensive and difficult to tolerate
● Positron emission tomography (PET): shows measures of radioactivity and can identify
problem-areas, evaluates function of blood flow
● Polysomnography: snoring suggests airway occlusion, presence or absence of sleep
apnea, then figure out more about the pharyngeal flap, determines the severity of
retrognathia (malocclusion)
→ Client records can be reviewed only by the client themselves unless written permission is
provided
Carrie Eichler

v. Ethics
→ Principle of Ethics I: Individuals shall honor their responsibility to hold paramount the welfare
of persons they serve professionally or who are participants in research and scholarly activities,
and they shall treat animals involved in research in a humane manner.
Rules of Ethics
1. Individuals shall provide all services competently.
2. Individuals shall use every resource, including referral when appropriate, to ensure
that high-quality service is provided.
3. Individuals shall not discriminate in the delivery of professional services or the conduct
of research and scholarly activities on the basis of race or ethnicity, gender, gender
identity/gender expression, age, religion, national origin, sexual orientation, or
disability.
4. Individuals shall not misrepresent the credentials of assistants, technicians, support
personnel, students, Clinical Fellows, or any others under their supervision, and they
shall inform those they serve professionally of the name and professional credentials
of persons providing services.
5. Individuals who hold the Certificate of Clinical Competence shall not delegate tasks
that require the unique skills, knowledge, and judgment that are within the scope of
their profession to assistants, technicians, support personnel, or any nonprofessionals
over whom they have supervisory responsibility.
6. Individuals who hold the Certificate of Clinical Competence may delegate tasks related
to provision of clinical services to assistants, technicians, support personnel, or any
other persons only if those services are appropriately supervised, realizing that the
responsibility for client welfare remains with the certified individual.
7. Individuals who hold the Certificate of Clinical Competence may delegate tasks related
to provision of clinical services that require the unique skills, knowledge, and judgment
that are within the scope of practice of their profession to students only if those
services are appropriately supervised. The responsibility for client welfare remains with
the certified individual.
8. Individuals shall fully inform the persons they serve of the nature and possible effects
of services rendered and products dispensed, and they shall inform participants in
research about the possible effects of their participation in research conducted.
9. Individuals shall evaluate the effectiveness of services rendered and of products
dispensed, and they shall provide services or dispense products only when benefit can
reasonably be expected.
10. Individuals shall not guarantee the results of any treatment or procedure, directly or by
implication; however, they may make a reasonable statement of prognosis.
11. Individuals shall not provide clinical services solely by correspondence.
12. Individuals may practice by telecommunication (e.g., telehealth/e-health), where not
prohibited by law.
13. Individuals shall adequately maintain and appropriately secure records of professional
services rendered, research and scholarly activities conducted, and products
dispensed, and they shall allow access to these records only when authorized or when
required by law.
Carrie Eichler

14. Individuals shall not reveal, without authorization, any professional or personal
information about identified persons served professionally or identified participants
involved in research and scholarly activities unless doing so is necessary to protect the
welfare of the person or of the community or is otherwise required by law.
15. Individuals shall not charge for services not rendered, nor shall they misrepresent
services rendered, products dispensed, or research and scholarly activities conducted.
16. Individuals shall enroll and include persons as participants in research or teaching
demonstrations only if their participation is voluntary, without coercion, and with their
informed consent.
17. Individuals whose professional services are adversely affected by substance abuse or
other health-related conditions shall seek professional assistance and, where
appropriate, withdraw from the affected areas of practice.
18. Individuals shall not discontinue service to those they are serving without providing
reasonable notice.
→ Principle of Ethics II
Individuals shall honor their responsibility to achieve and maintain the highest level of
professional competence and performance.
Rules of Ethics
1. [Deleted effective June 1, 2014] Individuals shall engage in the provision of clinical
services only when they hold the appropriate Certificate of Clinical Competence or
when they are in the certification process and are supervised by an individual who
holds the appropriate Certificate of Clinical Competence.
2. Individuals shall engage in only those aspects of the professions that are within the
scope of their professional practice and competence, considering their level of
education, training, and experience.
3. Individuals shall engage in lifelong learning to maintain and enhance professional
competence and performance.
4. Individuals shall not require or permit their professional staff to provide services or
conduct research activities that exceed the staff member's competence, level of
education, training, and experience.
5. Individuals shall ensure that all equipment used to provide services or to conduct
research and scholarly activities is in proper working order and is properly calibrated.
→ Principle of Ethics III: Individuals shall honor their responsibility to the public by promoting
public understanding of the professions, by supporting the development of services designed to
fulfill the unmet needs of the public, and by providing accurate information in all communications
involving any aspect of the professions, including the dissemination of research findings and
scholarly activities, and the promotion, marketing, and advertising of products and services.
Rules of Ethics
1. Individuals shall not misrepresent their credentials, competence, education, training,
experience, or scholarly or research contributions.
2. Individuals shall not participate in professional activities that constitute a conflict of
interest.
3. Individuals shall refer those served professionally solely on the basis of the interest of
those being referred and not on any personal interest, financial or otherwise.
Carrie Eichler

4. Individuals shall not misrepresent research, diagnostic information, services rendered,

results of services rendered, products dispensed, or the effects of products dispensed.
5. Individuals shall not defraud or engage in any scheme to defraud in connection with
obtaining payment, reimbursement, or grants for services rendered, research
conducted, or products dispensed.
6. Individuals' statements to the public shall provide accurate information about the
nature and management of communication disorders, about the professions, about
professional services, about products for sale, and about research and scholarly
activities.
7. Individuals' statements to the public when advertising, announcing, and marketing their
professional services; reporting research results; and promoting products shall adhere
to professional standards and shall not contain misrepresentations.
→ Principle of Ethics IV: Individuals shall honor their responsibilities to the professions and their
relationships with colleagues, students, and members of other professions and disciplines.
Rules of Ethics
1. Individuals shall uphold the dignity and autonomy of the professions, maintain
harmonious interprofessional and intraprofessional relationships, and accept the
professions' self-imposed standards.
2. Individuals shall prohibit anyone under their supervision from engaging in any practice
that violates the Code of Ethics.
3. Individuals shall not engage in dishonesty, fraud, deceit, or misrepresentation.
4. Individuals shall not engage in any form of unlawful harassment, including sexual
harassment or power abuse.
5. Individuals shall not engage in any other form of conduct that adversely reflects on the
professions or on the individual's fitness to serve persons professionally.
6. Individuals shall not engage in sexual activities with clients, students, or research
participants over whom they exercise professional authority or power.
7. Individuals shall assign credit only to those who have contributed to a publication,
presentation, or product. Credit shall be assigned in proportion to the contribution and
only with the contributor's consent.
8. Individuals shall reference the source when using other persons' ideas, research,
presentations, or products in written, oral, or any other media presentation or
summary.
9. Individuals' statements to colleagues about professional services, research results,
and products shall adhere to prevailing professional standards and shall contain no
misrepresentations.
10. Individuals shall not provide professional services without exercising independent
professional judgment, regardless of referral source or prescription.
11. Individuals shall not discriminate in their relationships with colleagues, students, and
members of other professions and disciplines on the basis of race or ethnicity, gender,
gender identity/gender expression, age, religion, national origin, sexual orientation, or
disability.
12. Individuals shall not file or encourage others to file complaints that disregard or ignore
facts that would disprove the allegation, nor should the Code of Ethics be used for
Carrie Eichler

personal reprisal, as a means of addressing personal animosity, or as a vehicle for

retaliation.
13. Individuals who have reason to believe that the Code of Ethics has been violated shall
inform the Board of Ethics.
14. Individuals shall comply fully with the policies of the Board of Ethics in its consideration
and adjudication of complaints of violations of the Code of Ethics.
vi. Legislation and client advocacy
→ Federal legislation affecting school settings
● Public law 94-142/IDEA: children 3-21 guaranteed free and appropriate public education
in the “least restricted environment”
● Public law 99-457: mandated development of IFSPs (individualized family service plan)
● Public law 101-336/ADA: civil rights protection relative to employment, state and local
government services, telecommunications, and public accommodations to all individuals
with disabilities
→ Federal legislation affecting health-care settings
● SSA (social security act): provided foundation for Medicaid and Medicare
● HIPAA (health insurance portability and accountability act): privacy standards to protect
patient’s medical records and other health information
Carrie Eichler

vii. Research methodology and evidence-based practice

→ Basic precepts
● Research is what scientists do as they practice science
● Empiricism is the philosophical position that statements must be supported by
experimental or observational evidence
● Determinism means that events do not happen randomly or haphazardly; they are
caused by other events
● The inductive method is an experiment-first-and-explain-later approach
● The deductive method is an explain-first-and-verify-later approach
● A theory is a systematic body of information concerning a phenomenon, describing an
event, explaining why the event occurs, and specifying how the theory can be verified
● The researcher hopes to either reject the null and alternative hypothesis
● Intermittent reinforcement (random) is the most effective because it decreases client’s
dependence on the reinforcer
→ Group designs
● Within-subject design: dependent variables are measured repeatedly in the same
subjects under different conditions
● Pretest-posttest control group design: includes experimental and control groups
● Multigroup pretest-posttest design: more than one experimental group
→ Single-subject designs: help establish efficacy of treatment procedures, do not involve
comparisons based on group performances
● ABA and ABAB designs: baseline, taught, withdrawn
● Multiple-baseline designs (across subjects, across settings, and across behaviors):
hopefully shows that untreated skills did not change and only the treated skills did
→ Evaluation of research
● Instrumentation: problems with such measuring devices as mechanical and electrical
instruments
● History: the subjects’ life events that may be partially or totally responsible for chances
recorded in the dependent variable after the independent variable is introduced
● Statistical regression: refers to a behavior that goes from an extreme high or low point to
an average level
● Maturation: biological and other kinds of changes within participants themselves
● Attrition/mortality: problem of losing participants
● Testing refers to a change that occurs in a dependent variable simply because it has
been measured more than once
● Subject selection biases: subjective factors that influence the selection of who
participates in a study
● External validity: generalizability
○ Hawthorne effect: extent to which a study’s results are affected by the
participant’s knowledge that they are taking part in an experiment
○ Multiple-treatment interference: positive or negative effect of one treatment over
another
○ Reactive or interactive effects of pretesting: learning good/desired behaviors
Carrie Eichler

● Screening, assessment, evaluation, diagnosis

○ Screening
i. Communication disorders
ii. Feeding and swallowing disorders
○ Approaches to assessment and evaluation
i. Developing case histories
ii. Selecting appropriate assessment instruments, procedures, and
materials
→ Standardized assessments (Y:11)
● Types of scores
○ Raw scores: actual scores earned on a test
○ Standard deviation: the extent to which scores deviate from the mean or average
score
● Validity refers to the degree to which a measuring instrument measures what it purports
to measure
○ Concurrent validity refers to the degree to which a new test correlates with an
established test of known validity
○ Construct validity refers to the degree to which test scores are consistent with
theoretical constructs of concepts
○ Content validity is based on a thorough examination of all test items to determine
if the items are relevant to measuring what the test purports to measure, and
whether the items adequately sample the full range of the skill being measured
○ Predictive validity refers to the accuracy with which a test predicts future
performance on a related task
● Reliability means the consistency or stability with which the same event is repeatedly
measured
○ InTERjudge reliability refers to how similarly a subject’s performance is
independently rated or measured by two or more observers
○ InTRAjudge reliability is the consistency with which the same observer measures
the same phenomenon
○ Alternate-form reliability refers to the consistency of measures when two forms of
the same test are administered to the same person
○ Test-retest reliability refers to the consistency of measures when the same test is
administered to the same person twice
○ Split-half reliability refers to a measure of the internal consistency of the test
→ Rating scales and developmental inventories
● Rating scales are used to document observations
○ Nominal-level: attributes of objects or events categorized (pass/fail, male/female)
○ Ordinal-level: unequal levels, rank order (Ranchos Los Amigos)
○ Interval-level: equal levels, rank ordered, no true zero (Celcius/Farenheit)
○ Ratio-level: mutually exclusive categories, rank ordered, true zero (vowel
duration)
● Developmental inventories help track children’s physical and behavioral changes over
time and include some degree of standardization
Carrie Eichler

→ Alternative assessment approaches

● Functional assessment is used to evaluate a client’s day to day communication skills in
naturalistic, socially meaningful contexts
● Client-specific assessment is the preferred alternative to standardized tests which
establish functional baselines and target behaviors
● Criterion-referenced assessment is evaluated not against statistical norms, but against
standard or performance selected by the clinician
● Authentic assessment involves naturalistic observation skills, such as sample speech
and language skills in everyday settings
● Dynamic assessment seeks to evaluate a child’s ability to learn when provided with
instruction
● Portfolio assessment involves collecting samples of a child’s work or performance over a
period of time and observing the growth that occurs when instruction is provided
● Comprehensive and integrated assessment involves a clinician selecting an
ethnoculturally appropriate tests and interpret all test results cautiously
iii. Assessing factors that influence communication and swallowing
disorders
iv. Assessment of anatomy and physiology
Carrie Eichler

○ Assessment procedures and assessment

i. Speech sound production
*Generalization of correct sound production to untrained words is greatest if sounds are taught
in high frequency of occurrence and low phonological neighborhood density.
→ Categories of phonological processes
● Substitution
○ Vocalization (bado/bottle)
○ Gliding (wamp/lamp)
○ Velar fronting (tey/key)
○ Stopping (too/shoe)
○ Depalatization (wats/watch)
○ Affrication (chun/sun)
○ Deaffrication (sip/chip)
○ Backing (gan/Dan)
○ Glottal replacement (bo?el/bottle)
● Assimilation
○ Reduplication (wawa/water)
○ Regressive assimilation (bip/zip)
○ Progressive assimilation (kik/kiss)
○ Voicing assimilation (pik/pig)
● Syllable structure processes
○ Weak syllable deletion (mato/tomato)
○ Final consonant deletion (cah/cat)
○ Epenthesis (stopuh/stop)
○ Consonant-cluster reduction (pun/spun)
○ Diminutization (doggy/dog)
○ Metathesis (pasketi/spaghetti)
→ Articulatory errors
● Substitutions
● Omissions/deletions
● Labialization
● Nasalization
● Pharyngeal fricative
● Frontal lisp
● Lateral lisp
● Stridency deletion
● Unaspiration
● Initial/medial/final position errors
● Prevocalic/intervocalic/postvocalic errors
Carrie Eichler

→ Assessment procedure
● Case history
● Orofacial examination
● Hearing screening
● Conversational speech sample
● Evoked speech samples
● Stimulability assessment
● Standardized tests
→ Treatment approaches
● The most effective treatment is to delineate phonological processes in operation and
address them through minimal-contrast pairs
● Imitation lacks communicative intent
● Choose target words that contrast a child’s error patterns
● Elimination of fronting and final consonant deletion should be addressed early, as they
make the biggest difference in intelligibility
● Motor-based approaches
○ Van Riper’s traditional approach: auditory discrimination/perceptual training,
phonetic placement, drill-like repetition, practice (isolation, syllables, words,
phrases, sentences, reading, conversation)
○ McDonald’s sensory-motor approach: training at the syllable level, never in
isolation (heighten the child’s responsiveness to connected motor productions,
train correct production, vary the phonetic contexts, facilitate transfer to natural
communication)
● Linguistic approaches: establish phonological rules in a client’s repertoire
○ Distinctive features/contrast: minimal pairs
○ Metaphon therapy: teach metalinguistic awareness
○ Phonological processes: errors grouped, not discrete sounds → Cycles

ii. Fluency
→ General
● Stuttering = anticipatory, apprehensive, hypertonic avoidance reaction (Johnson); what a
person does to avoid stuttering; social role conflict (Sheehan); when the forward flow of
speech is interrupted by a motorically disrupted sound, syllable, or word or by the
speaker’s reactions thereto (VanRiper)
● Cerebral dominance theory: persons who stutter are less likely than their fluent peers to
have developed unilateral cerebral dominance
● Speech that contains 5% or more dysfluencies may be judged to be dysfluent
● Preschoolers stutter more on function words, while older children stutter more on content
words
Carrie Eichler

Level Age range Core behaviors Feelings and Underlying

attitudes processes

Normal 1.5-6 years Less than 10 words No reaction System playing

disfluency (some normal per 100 words, catch up,
disfluencies show mostly whole competition for
thereafter) word repetitions neural
and interjections resources,
excitement

Borderline 1.5-3.5 years >10 disfluencies Less tense and Demand exceed
stuttering per 100 words, more relaxed, capacity, some
(younger often more >2 units peers don’t react children will
preschoolers) of repetition, more to disfluencies recover, others
repetition and might become
prolongation frustrated and
react with
tension

Beginning 3.5-6 years Signs of tension Child may Extra tension (in
stuttering (older and hurry, many express difficulty an effort not to
preschoolers) repetitions, pitch and frustration, stutter), extra
rise toward the end but doesn’t speed (to get
of the disfluency, appear to have a speaking over as
blocks might be negative self- quickly as
seen, escape concept quite yet possible)
behaviors
(secondary)

Intermediate 6-13 years Tension is the Extremely More classical

stuttering issue, shows up as negative conditioning,
(school-age) blocks and using feelings, child more avoidance
escape behaviors begins to think of and escape
to get out of those himself as a behaviors
blocks, walking “stutterer” and
thesaurus feel ashamed
and guilty about
it

Advanced 14+ years Extreme tension Extreme Must be

stuttering (older and tremors, embarrassment, extremely
teens and repetitions so helplessness, vigilant,
adults) intense that they and shame, culmination of
look like blocks assume others everything that
share self has happened
concept before
Carrie Eichler

● Theories
○ Genetic hypothesis: high familial incidence, high rate in identical twins, well-
established gender ratio in the prevalence of stuttering
○ Neurophysiological hypotheses: abnormal neuromotor organization, aberrant
laryngeal functions may be defective
○ Learning, conditioning and related hypotheses
■ Stuttering is an operant behavior
■ Stuttering as speech disruption due to classically and operantly
conditioned negative emotion (Brutten and Shoemaker)
■ Stuttering as an avoidance behavior (Johnson)
■ Stuttering as approach avoidance (Sheehan)
■ Stuttering as a reaction of tension and fragmentation, due to demands
exceeding capacities, belief that speech is a difficult task (Bloodstein)
○ Stuttering as a form of psychoneurosis: underlying psychopathology
○ Cognitive therapy focuses on changing the client’s distorted beliefs about self-
efficacy and the need to speak with complete fluency
→ Treatment approaches
● The diagnosogenic theory isn’t considered to be an adequate explanation of the factors
that cause developmental stuttering
● Psychological methods of treatments: psychoanalysis, psychotherapy, counseling
● Fluent stuttering method/stuttering modification: stutter-more fluently, goal is modified
stuttering (VanRiper), cancellations, pull-outs, preparatory sets
○ Teach
○ Desensitize
○ Modify
○ Stabilize treatment gains
○ Counseling
● Fluency shaping method: speak-more-fluently, establish normal fluency (Guitar), slow
and deliberate sounding fluency
● Fluency reinforcement method: reinforce fluent speech in naturalistic conversational
contexts
● Masking and delayed auditory feedback techniques
● Direct stuttering reduction models: person who stutters is taught to stop talking after
each dysfluency, withdraw reward
● Prolonged speech reduces part-word repetitions and sound prolongations
Carrie Eichler

iii. Voice, resonance, and motor speech

→ Voice
● General anatomy
○ Larynx = biological valve at the top of the trachea
○ Cover-body theory: epithelium and intermediate layer vibrate as a cover on a
relatively stationary body
○ Tensor palatini pulls eustachian tube open
○ Palatoglossus opposes velopharyngeal closure
○ The posterior cricoarytenoid is the lone abductor
○ The RLN supplies all muscles except the cricothyroid (SLN)
● Voice changes through the lifespan
○ Boys and girls have similar voices before adolescence
○ Men have a MFF of 100-150 Hz with an average of 125, while women have a
MFF of 180-250 Hz with an average of 225
○ 3-4 year old children have a MPT from 7.5-9 seconds, 5-12 year old children
have a MPT from 15-18 seconds, adults aged 18-39 have a MPT from 20-24
seconds, and adults 66-93 have a MPT from 14-18 seconds
● Pitch
○ Determined by the mass, tension, and elasticity of the vocal folds
○ (Fundamental) frequency perturbation (jitter) should be less than 1%
● Volume
○ Determined by the intensity of the signal
○ Amplitude perturbation (shimmer) should be less than 1dB
● Functional voice disorders: mechanisms of respirations, phonation, and resonance:
structurally normal
○ Excessive muscle tension disorders (MTD)
■ Ventricular dysphonia: dysphonia plica ventricularis, vibration of the
false VFs during phonation, associated with severe muscle tension
● Compensatory: in reaction to a true vocal fold disease or disorder
(ex: VF paralysis, surgery to VF)
● Noncompensatory (VFs normal): habitual: often due to excessive
vocal fold use
● Noncompensatory: psycho-emotional: provoked by psychological
or emotional stress
● Noncompensatory: idiopathic: not understood
■ Vocal fold nodules: most common benign vocal fold pathologies,
continuous abuse of larynx and misuse of voice/phonotraumatic
behaviors (singing, yelling, poor vocal hygiene, talking over noise,
frequent throat clearing, coughing, speaking/singing in a non habitual
pitch), found more commonly in young boys
■ Vocal fold polyps: focal abnormality in superficial layer of lamina propria
(elastic), middle ⅓ of membranous VFs, fluid filled, usually unilateral,
sessile (blister like) or pedunculated (stalk), could perceive globus
sensation
Carrie Eichler

■ Vocal fold cysts: chronic stress, benign, mucous filled lesion, near vocal
fold surface, phonotraumatic behaviors
■ Reinke’s edema: chronic, diffuse swelling of superficial layer of lamina
propria, polypoid degeneration of VF, bilateral/unilateral, associated with
smoking, chronic vocal hyperfunction, LPR, exposure to inflammatory
stimuli, abnormal healing, increased mass of vocal folds
■ Laryngitis: voice changes secondary to inflammation of VF mucosa,
reaction to viral/bacterial infections, trauma, autoimmune disease,
traumatic laryngitis: swelling of VFs
○ Psychogenic voice disorders: voice affected by emotion and psychological
state, resistant to change with voice therapy approaches (underlying
psychological component), psychological support/counseling, referral
■ Puberphonia: inappropriate use of the high-pitched voice, beyond
pubertal age in males, seen in postpubertal period (can be a coping
mechanism)
■ Functional aphonia: whispers with prosody and rhythm of normal
speech, no voicing, loss of voice, secondary to laryngeal pathology,
severe systemic diseases, self-refer to SLP/physician (embarrassed by
lack of voice)
● Organic Voice Disorders: structural pathology of VFs
○ Laryngomalacia (air flows through narrow space and causes wheezing sound):
inward collapse of supraglottic structures of the larynx during inspiration
○ Subglottic stenosis: narrowing of space below glottis
○ Esophageal atresia: from birth, failure of esophagus to develop as a continuous
passage, rather seems like a pouch
○ Tracheoesophageal fistula: abnormal opening between trachea and
esophagus, primary concern is dysphagia and secondary is voice
○ Acid reflux disease
■ GERD: gastroesophageal reflux disease → reflux of stomach contents
into esophagus
■ LPRD: laryngopharyngeal reflux disease → superior movement through
the UES
○ Contact ulcers (granulomas): small ulcerations that develop medial aspect of
vocal processes (on arytenoid cartilage → posterior of glottis)
○ Endocrine changes: impact developing larynx, affect pitch (higher)
■ Pituitary gland hypofunction (can cause retardation of laryngeal growth)
● Hypothyroidism: physical changes over time, increased mass of
the VFs (low pitch), controlled by thyroid hormone therapy
■ Premenstrual vocal syndrome
○ Hemangioma: soft, pliable, blood-filled sac, similar to contact ulcers and
granuloma (posterior), relatively rare, posterior part of glottis
○ Hyperkeratosis: pinkish, rough lesion, nonmalignant growth, precursor to
malignant tissue change
○ Infectious laryngitis
Carrie Eichler

○ Leukoplakia: whitish-colored (transparent) patches, additive lesions (on

surface), considered to be benign, precancerous (closely monitored)
○ Recurrent respiratory papillomatosis: wartlike growths, viral in origin
○ Sulcus vocalis: furrowed medial edge of VFs
○ Webbing: web between glottis, inhibits normal VF vibration
○ Laryngeal cancer
● Neurogenic voice disorders
○ Unilateral vocal fold paralysis
○ Bilateral VF paralysis: potentially life threatening
■ Adductory type (adductor muscle paralyzed): vocal folds are in abducted
position (concern for swallowing, aphonia)
■ Abductory type (abductor muscles paralyzed): vocal folds remain at
midline (concern for respiration)
● Spasmodic dysphonia (dystonia = condition causing abnormal muscle
spasms): relatively rare vocal disorder (abductor is most rare), secondary to
laryngeal dystonia (neurological impairment), affects laryngeal adductory and
abductory muscles, site of lesion in CNS for SD: neurological
● Parkinson’s disease: most associated with hypokinetic dysarthria, reduced
loudness, breathy voice, monopitch and monoloudness, intermittent and rapid
rushes of speech, imprecise articulation
● Essential voice tremor: tremors of tongue, velum, pharyngeal, and laryngeal
structures
→ Voice facilitating approaches
● Head positioning
○ Normal, straight ahead
○ Neck extended forward, head tilted down
○ Neck turned unilaterally, heads tilted to left or right
● Inhalation phonation
● Nasal-glide stimulation
● Pitch inflections
● Redirected phonation
● Coughing
● Gargling
● Laughing
● Singing
● Throat clearing
● Trilling
● Um-hmmm
● Relaxation
● Tongue protrusion /i/
● Yawn-sigh
● Alaryngeal speech: TEP speech uses lung air (versus esophageal speech which injects
air *not easy)
Carrie Eichler

→ Resonance
● Hypernasality: when the velopharyngeal mechanism does not close the opening to the
nasal passage during the production of non-nasal sounds
○ Treatment: biofeedback, visual aids, ear training, increase mouth opening,
increase loudness, improve articulation, change speaking rate
● Hyponasality: lack of appropriate nasal resonance on nasal sounds
○ Treatment: focusing, nasal-glide stimulation, visual aids
→ Treatment of resonance
Surgical management
● Pharyngeal flap surgery (flaccid)
● Teflon injection into the posterior pharyngeal wall
Prosthetic management
● Palatal lift prosthesis (flaccid)
Behavioral management: controversial and have generated mixed opinions and results
1. Modifying the pattern of speaking
○ Goal: reducing rate and increasing effort of speech, indirectly reduce the
velopharyngeal impairment
○ Ex: overexaggeration, increasing loudness
○ Improve resonance and reduced nasal airflow with exaggerated jaw movement
2. Resistance treatment during speech (cpap machine used) (flaccid)
○ Goal: strength training of velopharyngeal muscles
○ Positive airflow into nasal cavity and the velopharyngeal muscles must overcome
pressure to result in closure of the VP
3. Feedback: mirror, nasal flow transducer, nasoendoscope
4. Nonspeech velopharyngeal movement
○ Generally, not effective for the production of speech
○ Ex: blowing bubbles, sucking on a straw
Carrie Eichler

→ Motor speech
● Assessment: AMR/SMR is the best differential diagnostic tool
● Apraxia of speech: neurogenic speech disorder characterized by sensorimotor problems
in positioning and sequentially moving muscles for production of speech, caused by
damage in motor-speech planning and programming areas in dominant hemisphere
→ Apraxia
● Neurologic speech disorder
● Reflects impaired capacity to plan or program sensorimotor commands
● Pure apraxia of speech is rare → challenging diagnosis
● Disorder of motor sequencing
● Not caused by: muscle weakness, abnormal muscle tone, range of movement of
muscles is normal, apraxia of speech is not secondary to decreased muscle steadiness
Two main types
1. Ideational apraxia
○ Damage? left parietal lobe
○ Symptoms are usually masked by aphasia → difficult to diagnose
○ May also resolve quickly
○ Difficulty/inability to plan motor movements with regards to an object
2. Ideomotor apraxia
○ Disturbance in performance of movements needed to use object, make gesture,
sequence movements
○ Example: patient understands that hairbrush is for brushing hair, but can’t
execute bring the hairbrush up to hair and combing
○ Typically affects voluntary movements
○ Movement sequencing is easier when a real object is used
○ Imitation is easier than verbal command (waving hand)
○ Inconsistency of errors
Carrie Eichler

Subcategories
● Limb apraxia
○ Inability to sequence movements of the arms, legs, hands during a voluntary
action
○ Usually affects both sides of the body
○ Assessed by having the individual pantomime different actions
● Nonverbal oral apraxia
○ Buccofacial apraxia, facial apraxia, orofacial apracia, lingual apraxia
○ Inability sequencing nonverbal, voluntary movements
○ Groping for correct position in mouth
○ Delay in performing the action
○ Partially completing the action
○ Slow movement
● AOS
○ Deficit in the ability to select and sequence motor commands needed to position
articulators
○ Voluntary production of phonemes
○ Damage to left frontal lobe (Broca’s aphasia)
○ Common co-occurrence with UUMN damage
○ Difficult for differential diagnosis
● Treatment should consist of audio-visual stimulation, oral-motor repetition, and phonetic
placement
→ Dysarthria
Types Locus Primary deficit Speech systems/clusters

Flaccid LMN Weakness Phonatory/resonatory

incompetence

Spastic UMN (bilateral) Spasticity Phonatory stenosis

Ataxic Cerebellum Incoordination Articulation + prosody

Hypokinetic Extrapyramidal Rigidity and Prosodic insufficiency

reduced ROM

Hyperkinetic Extrapyramidal Involuntary Articulation, prosody,

movements phonation

Unilateral UMN Unilateral UMN Weakness/incoord Articulation

ination

Mixed (most More than one More than one FS=ALS

common) AS=MS
Carrie Eichler

● Assessment
○ Conversational sample
○ Imitation
○ Diadochokinetic rate
○ Oral mechanism
→ Treatment for dysarthria
Management of respiration impairment: increasing respiratory support
1. Maximum vowel prolongation
○ Example of goal: Patient should be able to sustain subglottal pressure of 5-10
centimeters for 5 seconds.
○ Duration and loudness should be targeted
○ Feedback: clinician, tape recorder, volume-unit meter
2. Exhaling at a steady state for several seconds
○ Example of goal: Patient will produce several syllables on exhalation.
○ Establish optimal breath group
3. Pulling, pushing, bearing down during speech tasks
○ Example of goal: Patient will improve VF medialization.
○ Not for all patients, especially spastic, muscle tension (hyperkinetic)
4. Postural adjustments
○ Example goal: Patient will optimize physiological support for speech.
○ Depends on the nature of the neuromuscular impairment
○ Flaccid dysarthria: give support, if necessary
○ Spastic dysarthria: give resistance, if necessary
○ Hypokinetic dysarthria
Prosthetic assistance
1. Abdominal binder (corset)
○ Enhance posture, support the weak abdominal muscles, improves respiratory
support and airflow
○ Medical approval and supervision is necessary
○ Positive effects
2. Expiratory board or paddle
○ Leaning on a flat surface during expiration
○ Increase expiratory forces
○ Truncal strength and balance required
Carrie Eichler

Behavioral compensation
1. Inspiratory checking
○ Goal is to reduce excessive air flow through glottic when patient is speaking
○ Inspiratory muscles are used to counter the elastic recoil forces of the respiratory
system
○ Gradual release of air supply to support speech
○ “Take a deep breath and release it out slowly when speaking”
○ Helps to increase syllables per breath group and intelligibility (Netsell)
2. Inhaling more deeply or use more force when exhaling during speech
○ Sustain isolated sounds for 5 seconds while keeping intensity and quality
constant
3. Stabilizing respiratory patterns
○ Goal: reduce maladaptive compensatory breathing strategies
○ Practice strategy for increasing breath group length
○ Reduce neck breathing, glossopharyngeal breathing patterns
Instrumental biofeedback
● Visual feedback about movement, excursion, and coordination of chest wall muscles
Increasing respiratory flexibility: task is to teach natural stress patterning
Management of laryngeal impairment
Surgical procedures
● Laryngoplasty
● Arytenoid adduction surgery (flaccid unilateral VF paralysis)
● RLN resection (spasmodic dysphonia)
● Teflon, collagen or autogenous fat injection (to bulk up VFs)
● Botulinum toxin injection (spasmodic dysphonia)
Prosthetic management
● Portable amplification system (hypokinetic, flaccid)
● Artificial larynx
● Neck braces and cervical collars (provides stability to neck in hyperkinetic)
● Vocal intensity controller (loudness monitoring device, hypokinetic, flaccid)
Behavioral management
1. Effort closure procedures
○ Goal: maximize vocal fold adduction and improve vocal fold strength
○ For patients with unilateral or bilateral vocal fold weakness
○ Grunting, controlled coughing, pushing, lifting and pulling
2. Initiate phonation at beginning of exhalation
○ Goal: reduce air wastage and fatigue, increase loudness and phrase length
3. Lateral digital manipulation/head turn
○ Goal: increase glottal closure and improve medialization
○ Compensatory strategy only (flaccid, unilateral VF paralysis), can test if surgical
procedures would be helpful
Carrie Eichler

4. Developing voluntary phonation

○ Goal: forceful VF adduction (flaccid)
○ Approach
■ Reflexive behavior on a repetitive basis, ex: cough, laugh
■ Production of voluntary phonation
■ Traditional pushing-pulling exercises may be used
Management of velopharyngeal dysfunction
Surgical management
● Pharyngeal flap surgery (flaccid)
● Teflon injection into the posterior pharyngeal wall
Prosthetic management
● Palatal lift prosthesis (flaccid)
Behavioral management: controversial and have generated mixed opinions and results
1. Modifying the pattern of speaking
○ Goal: reducing rate and increasing effort of speech, indirectly reduce the
velopharyngeal impairment
○ Ex: overexaggeration, increasing loudness
○ Improve resonance and reduced nasal airflow with exaggerated jaw movement
2. Resistance treatment during speech (cpap machine used) (flaccid)
○ Goal: strength training of velopharyngeal muscles
○ Positive airflow into nasal cavity and the velopharyngeal muscles must overcome
pressure to result in closure of the VP
3. Feedback: mirror, nasal flow transducer, nasoendoscope
4. Nonspeech velopharyngeal movement
○ Generally, not effective for the production of speech
○ Ex: blowing bubbles, sucking on a straw
Management of articulation
Goal: improve the accuracy and precision of sound production
● Surgical management: neural anastomosis, botox
● Prosthetic management: bite block (hyperkinetic)
● Strengthening management: controversial, limited data regarding the effectiveness,
romotor exercises: speech and nonspeech, Iowa Oral Performance Instrument
● Relaxation: may improve muscle tone in patients with spasticity or rigidity (spastic)
● Stretching: prevent joint and muscle contraction and modulate spasticity, no positive or
negative evidence regarding the effects on speech
● Instrumental biofeedback: EMG, electropalatography
● Traditional approaches: integral stimulation, phonetic placement, phonetic derivation,
minimal contrasts, intelligibility drills
Carrie Eichler

Management of rate
● Normal speaking rates are task dependent
● Paragraph reading rates (160-170 words per minute)
● Sentence reading rates (190 words per minute)
● Modifying the rate of speech usually involves rate reduction which often uses pause time
● Delayed auditory feedback: 50-150 milliseconds is most optimal
● Pacing boards
● Alphabet board supplementation
● Hand or finger tapping
● Visual feedback
● Rhythmic cueing
Management of prosody and naturalness
● Naturalness: overall adequacy of prosody
○ Contrastive stress tasks
○ Referential tasks
Carrie Eichler

iv. Receptive and expressive language

→ General
● Specific language impairment: not always secondary to other developmental disabilities,
no known etiology, generally intelligence is within normal range, sequence of language
development is same as typically developing kids, articulatory and phonological
problems, late to start talking, use less conjunctions and elaborated noun phrases, much
heterogeneity, 2 explanations: underlying deficits and normal variation
● Autism - SCERTS model: social communication, emotional regulation, transactional
supports
● Discrete trial procedure: shaping/teaching skills
● Basic behavioral techniques: instructions, modelings, prompting, shaping, manual
guidance, fading, immediate response-contingent feedback
● Expansion: expands telegraphic/incomplete utterance
● Extension: comments on utterances and adds new and relevant information
● Focused stimulation/hybrid language intervention: repeatedly models a target structure,
clinician does not correct
● Milieu teaching: teaches communication skills through natural interactions
(communication temptations)
○ Incidental teaching: adult waits for child to initiate a verbal response
○ Mand-model: clinician uses attractive stimulus-materials in play setting
○ Time delay: clinician waits for child to initiate verbal responses
● Joint routines and interactions: routinized/repetitive activities
● Joint book reading: repetitive use and practice of the same concepts and phrases
● Narrative skills training: cohesive, logically consistent, temporally sequenced manner
● Story grammar
● Parallel talk: comments upon what the child is doing
● Recasting: child’s sentences is repeated in a modified form that is grammatically more
complex
● Self-talk: clinician describes own activity
→ Assessment basics
● MLU=number of morphemes/number of utterances
● TTR=number of different words in sample/number of words in sample
● Infants/toddlers: family-centered communication, begin as early as possible, team
approach
● Elementary-age children: assess production of morphologic skills with pictures, have
parents make word lists, assess narrative skills, note comments that indicate lack of
comprehension
● Adolescents: assess length of sentences, word-retrieval problems, maze behaviors,
grammatical errors
Carrie Eichler

v. Social aspects of communication, including pragmatics

→ Social communication in students with ASD:
● Involves the ability to achieve communicative competence through the child
“communicating and playing with others in everyday activities and sharing joy and
pleasure in social relationships”
● Communicative competence is an important predictor of outcomes in adulthood
● Consists of 2 critical elements
○ Capacity for joint attention (use)
■ Joint attention involves the capacity to attend and respond to the
overtures of others through the sharing of attention, emotions, and
intentions
■ Provides basis for reciprocal communication and should develop across
communication partners/settings
■ Crucial pre-linguistic skill ~ child learns knew words when engaged with
communication partner and they coordinate their attention toward each
other and/or the object
■ Child with ASD has difficulty with “following into and directing others’
attention and interest to objects in their shared world.”
■ Decreased language learning
■ Powerful indicator or hallmark of ASD in young children
■ Examples: difficulty orienting to speech sounds in infancy, reduced
referential looking, decreased pointing and showing, difficulty following
other person’s attentional focus, reduced social referencing, decreased
use of gestures coupled with attentional focus at communication partner
the gesture is intended for, trouble following and using eye gaze in
conversation
○ Symbol use (form and content)
■ Comprehension/use of nonverbal communication (i.e. gestures, facial
expression, intonation, etc.)
■ Comprehension/use of words and combinations of words
■ Development of object use & play development
■ Comprehension/use of social conventions involved in reciprocal
communication
■ Refers to use of syntax, semantics, and morphology
■ Difficulty developing “conventional and symbolic aspects of
communication.”
● Decrease in use of gestures ~ extended use of presymbolic
gestures
● Use behavior to communicate
● Gestalt processing (rote memory for big chunks of language
without understanding) rather than analytic processing (develop
language according to hierarchy ~ single words to 2-word combos,
etc
● Engage in echolalia as their symbolic understanding increases
Carrie Eichler

● Echolalia
○ Can be immediate or delayed
○ Immediate = repeat what was just said
○ Delayed = repeat utterances previously heard
○ Mitigated = immediate or delayed echolalia with some change in the original
form/wording
○ Consistent with gestalt processing
○ Functions of echolalia include requesting, affirming, protesting, calling, labeling,
providing info, or giving direction
○ Echolalia helps the child by…
■ Acting as a learning strategy similar to imitation by typically-developing
child
■ Providing rehearsal so child can remember or comprehend given
information
■ Functioning as self-talk to help child complete a task
Carrie Eichler

vi. Cognitive aspects of communication

→ Aphasia

● Nonfluent
○ Broca’s: damage to Broca’s area in posterior inferior frontal gyrus, supplied by
the middle cerebral artery
○ Transcortical motor: damage to anterior superior frontal lobe (below or above
Broca’s), supplied by the anterior cerebral artery and anterior branch of middle
cerebral artery, laborious, halting, telegraphic, akinesia, bradykinesia, apraxia,
good repetition
○ Global: most severe form, extensive damage to all language areas (perisylvian
region), supplied by middle cerebral artery, verbal and nonverbal apraxia, strong
neurological symptoms
○ Mixed transcortical aphasia: damage to watershed areas/arterial border zone,
severe echolalia and reading and writing difficulties, unimpaired automatics,
associated with bilateral UMN and visual field deficits
Carrie Eichler

● Fluent
○ Wernicke’s: damage to Wernicke’s area in the posterior portion of the superior
temporal gyrus, supplied by the posterior branch of the middle cerebral artery,
paralysis is uncommon
○ Transcortical sensory: damage to the temporoparietal region (posterior portion of
the middle temporal gyrus), supplied by the posterior branch of the middle
cerebral artery, good repetition
○ Conduction: damage to supramarginal gyrus and arcuate fasciculus (between
Broca’s and Wernicke’s), good to normal auditory comprehension
○ Anomic: damage to different regions including angular gyrus and temporal gyrus,
language functions other than naming are generally normal
● Subcortical: areas surrounding basal ganglia and thalamus, fluent speech, word-finding
problems
● Assessment
○ Repetition
○ Naming
○ Auditory comprehension
○ Comprehension of single words
○ Comprehension of sentences/paragraphs
○ Reading
○ Writing
○ Gestures/pantomime
○ Automated speech and singing
● Alexia: loss of previously acquired reading skills due to recent brain damage
● Agraphia: loss of normally acquired writing skills due to lesions in the foot of the second
frontal gyrus
● Agnosia: impaired understanding of the meaning of certain stimuli even though there is
no peripheral sensory impairment
Carrie Eichler

→ Dementia
● Dementia of the Alzheimer Type (DAT)
○ Cortical dementia
○ Neuropathology: neurofibrillary tangles, neuritic plaques, neuronal loss,
neurochemical changes
○ Early-stage symptoms: subtle memory problems, pronounced difficulty learning
new tasks, poor reasoning and judgement, behavior changes
○ Later-stage symptoms: severe problems recalling remote and recent events,
widespread intellectual deterioration, hyperactivity, restlessness, agitation,
seizures
○ Language problems: verbal and literal paraphasias, problems comprehending
abstract meanings, impaired picture description, echolalia, palilalia, logoclonia
(repeating the final syllable of words), empty jargon
● Frontotemporal dementia (including Pick’s disease)
○ Presence of Pick bodies and cells (dense intracellular neurons)
○ Symptoms: behavior changes initially, emotional disturbances, impaired
judgement
● Associated with Parkinson’s: brainstem degeneration, presence of Lewy bodies, frontal
lobe atrophy, bradykinesia, rigidity, reduced volume, dysarthric speech
● Associated with Huntington’s: subcortical, huntingtin (malformed protein) kills brain cells
that control movement, chorea, deterioration of intellectual functions, dysarthria
● Infectious dementia: HIV, Creutzfeldt-Jakob
→ General:
● Cognitive: attention, executive function, memory, awareness, processing speed,
agitation
● Language: word finding, social pragmatics reading, writing, verbal expression
● Speech: motor speech, voice
● Other: strategies used before, education level, swallowing/nutrition, family
involvement/caregivers, physical impairments, past medical history or therapy, past
habits (alcohol, smoking, exercise), medication, neuroimaging, interests, ADLs, living
situation, hearing, diabetes
● Jill’s list: medical comorbidities, Glasgow (scales), multiple trauma, diffuse TBI
implications, tracheostomy tube status (can it be capped?), minimally responsive, g-tube
feeding status, means of communication, levels of agitation and tolerance/attention to
evaluate, cognitive functioning, environmental concerns, premorbid
skills/lifestyle/education, multidisciplinary team members’ roles/referrals
● Strengths and weaknesses
→ TBI:
● Accident: location of infarct, neuroimaging, time since accident, type of injury
(penetrating/nonpenetrating)
● Recovery: infections, where they recovered, amnesia, coma
Carrie Eichler

→ Non-traumatic BI:
● Etiology: time since diagnosis, toxicity (overdose?), anoxic (no oxygen) or hypoxic (low
oxygen)
● Recovery: reparative surgery, time since event, metastatic tumor to the brain, pump-
head (poor cognition and recovery after bypass surgery), chemo-brain (diffuse cognitive
damage after chemo)
→ Minimally conscious:
● Current state:
○ Glascow Coma Scale=scores range between 3-15
■ Eye Opening: spontaneous=4, too loud of voice=3, pain=2, none=1
■ Verbal Response: oriented=5, confused/disoriented=4, inappropriate
words=3, incomprehensible sounds=2, none=1
■ Best Motor Response: obeys=6, localizes=5, withdraws=4, abnormal
flexion posturing=3, extension posturing=2, none=1
■ 9=vegetative state, emerging from coma
■ the scale is more objective and can be used to tell a good rehab
candidate (if they get to a 10-11 in the first month or two)
○ Galveston Orientation and Amnesia Test (GOAT)
○ Orientation
○ Ranchos Los Amigos Scale of Cognitive Function
■ I=no response, can’t do anything for them
■ II=generalized response, can’t do much, looking for evidence of moving to
III
■ III=localized response, beginning to do something purposeful
■ IV=confused and agitated, SLP: look at attention capacity, awareness,
orientation
■ V=confused and inappropriate, family will think is okay & ready to go
home, very dangerous not yet safe to go home
■ VI=confused and appropriate, family is beginning to understand more
■ VII=automatic and appropriate, more safe to be home
■ VIII=purposeful and appropriate
Carrie Eichler

vii. Augmentative and alternative communication

→ Assessment
● The candidacy model is the dated model, and the idea and someone has to reach a
certain qualification/prerequisite skills to use AAC and involves cognitive referencing.
The participation model focuses on allowing people to access life and participate in an
equal environment to their peer without disabilities.
● *10 principles of AAC assessment (Binger & Kent-Walsh, 2010)
1. Everyone can and does communicate
2. AAC assessments must be consumer responsive (client and family must be main
stakeholders in process, not just the clinician)
3. AAC assessment must be conducted by collaborative teams (make sure roles
are clear)
4. AAC assessment must focus on functional, daily life activities (consider peers)
5. Focus on functional implications of the disorder, not the disorder itself
6. Focus on strengths and abilities (what CAN she do?)
7. Focus on feature matching (match the skills of the client with the system, use
words if literate)
8. Adhere to the law of parsimony (go with the simplest solution, don’t make it more
complicated than it has to be, do something!)
9. Assessment is an ongoing process
10. AAC assessment should result in positive change (if their life’s not getting better,
try something different)
● Framework 1 focuses on identifying participation patterns and communication needs,
including taking a participation inventory and identifying barriers (opportunity and
access) for the user. Framework 2 is the SETT framework that focuses on the student,
environment, and tasks, then selecting the possible tools.
● Opportunity barriers include:
○ Policy: for example, children can’t take school electronics home
○ Practice: for example, no electronics in the classroom
○ Knowledge: for example, undereducated SLP or teacher for device use
○ Skill: for example, skills for using device don’t match knowledge
○ Attitude: for example, teacher’s expectations for student with special needs
● We assess the following: positioning/seating, motor capabilities, cognitive/linguistic
capabilities, literacy skills, and sensory/perceptual skills. SLPs focus mainly on
cognitive/linguistic capabilities.
● Cognitive communication is made up of awareness, communicative intent, word
knowledge, memory, symbolic representation, and metacognitive skills.
● We can assess language by looking at vocab and syntax and using adaptations of
standardized tests, matching, and asking yes/no.
Carrie Eichler

i. Hearing
Hearing results Air conduction Bone conduction Air-bone gap

WNL WNL WNL Not significant

Conductive loss Loss WNL Significant

Sensorineural loss Loss Loss Not significant

Mixed loss Loss Loss Significant

● Elasticity and inertia allow things to vibrate
● Normal frequency for humans to hear is 20-20,000Hz
● Speech frequencies are 125-8,000Hz
● Retrocochlear: display disproportionately low word recognition in comparison to pure
tones, worst type of HL for word recognition, acoustic neuroma
● Carhart’s notch: dip in audiogram at 2000Hz due to stapes fixation
● Pseudohypacusis = faking it
● Speech recognition/reception threshold: part of speech audiometry, uses spondee words
(equal stress, cowboy)
● OAE: measures function of outer hair cells, absence of response suggests issues with
the inner ear
● ABR: abnormal response implies auditory neuropathy (retrocochlear problem)
● Acoustic reflex delay: reduced suggests retrocochlear problem, positive suggests
possible acoustic tumor
● Tympanogram: graphical plot showing eardrum compliance at different values of air
pressure
○ Types
■ A: normal
■ As: shallow compliance (otosclerosis, beginnings of ear infection)
■ Ad: deep compliance (ossicular disarticulation)
■ C: negative pressure (eustachian tube dysfunction)
■ B: flat - no pressure or compliance
● ECV < normal → outer ear problem, probe against EC
● ECV = normal → middle ear problem
● ECV > normal → hole in tympanic membrane, PE tubes
Carrie Eichler

Degree of hearing loss Hearing loss range (dB HL) Speech sounds

Normal -10-15 All

Slight 16-25 May miss some consonants

Mild 26-40 May miss some speech

sounds

Moderate 41-55 Will miss most speech at

normal level

Moderately severe 56-70 Will not hear any speech at

normal

Severe 71-90 Will not hear any speech and

almost any other sounds

Profound 91+ Will not hear any speech and

probably only very loud
sounds
Carrie Eichler

ii. Feeding and swallowing

→ General
● Swallowing (deglutition) is the semi-automatic motor action of the muscles of the
respiratory and GI tracts that propels food from the oral cavity to the stomach.
● Swallowing is the physiologic behaviors responsible for safe and efficient movement of
food, liquid, and saliva through the mouth, oral cavity, pharynx, esophagus and entry into
the stomach through the GE junction.
● Dysphagia is the difficulty to move food/liquid/saliva from the mouth to the stomach. It
involves one or more anatomic or physiologic component. It can occur in the oral,
pharyngeal, or esophageal stages of the swallow across all age groups and can be
sudden or onset.
● Penetration: entry of bolus to a variety of levels due to inadequate laryngeal elevation
and/or incomplete laryngeal closure
○ Prior to swallow: bolus entry into larynx before triggering of pharyngeal
swallowing
● Aspiration: entry of bolus into airway and falls below the VFs
○ Aspiration before swallow:
i. Lingual weakness
ii. Premature spillage
iii. Delayed initiation of pharyngeal swallow
○ Aspiration during swallow:
i. Reduced hyolaryngeal closure
○ Aspiration after swallow:
i. UES dysfunction
ii. Pharyngeal wall weakness/paralysis
Carrie Eichler

→ Pediatric issues
● Two important anatomical changes occur between infancy and adulthood. First, the
angle between the nasopharynx and skull base approaches 90 degrees. Secondly, the
oropharynx develops.
● The phases of swallowing for infants mirror the phases of swallowing for adults. First,
infants experience a very shortened oral preparatory phase that is voluntary and varies
depending on the food texture. Infants must close their lips, form a cohesive bolus, place
the bolus against the hard palate, elevate the tongue, lower the soft palate, and breathe
through their nose. Next, in the oral phase there is voluntary neural control due to the
posterior propulsion of the bolus and is transmitted to the medulla (NTS). Next, in the
pharyngeal phase, the soft palate is elevated, there is hyolaryngeal excursion, opening
of the UES, laryngeal closure, tongue propulsion, and contraction of pharyngeal
constrictors. Finally, during the esophageal stage, there are automatic peristaltic waves
that carry the bolus to the stomach and only takes 6-10 seconds in children.
● The gag reflex is important for infants. It is stimulated by touching the posterior tongue or
pharynx and should be responded with by a contraction of the palate and pharynx. The
gag reflex is controlled by cranial nerve 9 and 10 and persists into childhood but
diminishes around 6 months of age. The rooting reflex is another important reflex for
infants. It is stimulated by the touch to the corner of the infant’s mouth. It’s desired
response is a head turn toward the touch, controlled by cranial nerves 5, 7, 11, and 12. It
typically disappears by age 3-6 months.
→ Cranial Nerves for Swallowing:
5: Trigeminal (*afferent swallowing, efferent swallowing - mastication, buccinators, floor of
mouth)
7: Facial (*afferent swallowing, efferent swallowing - lips and cheeks)
9: Glossopharyngeal (*afferent swallowing, efferent swallowing - pharyngeal constrictors and
stylopharyngeus)
10: Vagus (*afferent swallowing, efferent swallowing - palate, pharynx, larynx, esophagus)
12: Hypoglossal (*efferent swallowing - intrinsic tongue muscles)
→ Stages
● The 3 basic stages/phases of swallowing are the oral phase, pharyngeal phase, and
esophageal phase.
● The oral preparatory stage includes the formation of the bolus, sensory recognition, and
oral manipulation.
● The oral phase is initiated by the posterior movement of the bolus.
● The pharyngeal phase is triggered when the pharyngeal swallow begins, when the bolus
head passes the ramus of the mandible.
● The pharyngeal swallow is initiated by the stimulation of the oral and pharyngeal
receptors, sensory impulses to the nucleus of the tractus solitarius, and by cranial
nerves 5, 7, 9, and 10. The efferent (motor control) function of swallowing is mediated by
the nucleus ambiguus (NA). Cranial nerves 5 (mastication, buccinators, floor of mouth),
7 (lips and cheeks), 9 (pharyngeal constrictors and stylopharyngeus), 10 (palate,
pharynx, larynx, and esophagus), and 12 (intrinsic muscles of the tongue) are involved.
Carrie Eichler

→ VFSE Observations:
Anatomy: find hyoid, airway (open/closed?), vertebrae (osteophytes, posture?), flaps, pouches
Oral Preparatory: bolus formation (separate/together?), tongue strength, tongue range of
motion, teeth (mastication ability?)
Oral Propulsive: premature spillage, residue, aspiration, penetration, nasal regurgitation
Pharyngeal: initiation at ramus of mandible or later (severity?), laryngeal closure
(complete/incomplete?), residue (location/amount?), UES (flow, opening?)
The pharyngeal swallow is as follows:
1. Elevation and retraction of the soft palate (to seal the nasal cavity)
2. Hyolaryngeal excursion (superior-anterior/up-back movement of the hyoid and larynx)
3. Closure of the larynx (true VFs, false VFs, arytenoids and epiglottis all meet together to
close air flow)
4. UES opening (helped by UES pressure by bolus, hyolaryngeal excursion and neural
impulses)
5. Tongue base and posterior pharyngeal wall action
6. Contraction of pharyngeal constrictors
→ Oral Dysphagia (think: everything is voluntary/motor!):
● Inability to hold food in mouth anteriorly (lip closure, mouth breathing)
● Cannot form or hold bolus (lack of strength, coordination, control)
● Materials in sulci or midline of tongue (lack of lingual and facial strength,
pocketing/residue)
● Abnormal bolus position (tongue thrust)
● Delayed oral onset of swallow (apraxia, initiation)
● Residue/stasis on tongue
● Reduced anterior-posterior lingual movement (oral propulsive, multiple tongue
movements, slow eating)
● Repetitive lingual rocking (Parkinson’s, posterior tongue not lowering)
● Premature loss of liquid or pudding into pharynx (compared to normal loss when eating
solids)
● Piecemeal swallowing (multiple attempts, secondary to fear)
→ Pharyngeal Dysphagia (think: everything is sensory!):
● Delayed pharyngeal swallowing (bolus triggers swallow when at the level of the
valleculae, compared to normally at the ramus of mandible)
● Cervical osteophytes (protrusions from vertebrae, globus=perception that something is
stuck in the throat region)
● Unilateral/bilateral pharyngeal wall and/or pyriform sinus residue (think anterior-posterior
view on VFSE)
● Vallecular residue after swallow (on the sides of the epiglottis)
● Reduced hyolaryngeal elevation (mild=residue, moderate/severe=reduced laryngeal
closure, penetration and/or aspiration during and after swallowing, think about video, not
raised up enough to clear bolus)
Carrie Eichler

→ Esophageal Dysphagia:
● Esophageal pharyngeal backflow (failure of LES to relax, reflux, aspiration after swallow)
● Tracheoesophageal fistula (hole between trachea and esophagus)
● Zenker’s diverticulum (sagging of muscles that causes pouch near UES, no reason why)
● Gastroesophageal reflux disorder - GERD (painful heartburn/swallowing due to
inflammation from acid)
● Laryngopharyngeal reflux disease (above esophagus)
● Esophageal stenosis (narrowing of lumen (diameter of esophagus), rings (between
esophagus and stomach), webs (between esophagus and pharynx))
● Cricopharyngeal bar (failure of muscle to fully open around UES area)
● Pharyngeal pouch (collection of bolus associated with UES dysfunction, caused by
increased pressure)
Carrie Eichler

→ Evaluation
● Screening
● Clinical/bedside evaluation
○ Preparatory examination:
■ Medical history: congenital/neurologic disease (medical complications,
side effects from medications), surgical procedures, systemic and
metabolic disorders, respiratory impairment, esophageal disease, test
results, advanced directive
■ Clinical observations...make sure to observe the following: feeding
tubes, tracheostomy tubes, respiratory pattern, mental status
■ Symptoms: onset, worsening, variation with consistencies and volumes,
mid-swallow behaviors, biggest problem, coughing/choking, previous
assessments/radiographic examinations, denial, GERD
■ Signs: objective measures or observations of behaviors that are elicited
or observed
■ Oral motor examination:
● Skills assessed: labial appearance and function, lingual
appearance and function, chewing function, soft palate, larynx
● Oral reflexes (reappear when someone has an accident because
of the lack of inhibition): hyperactive gag reflex, tonic bite, suck
reflex
○ Swallowing examination:
■ Patient preparation: management of trach
■ Food attempts: variety of consistencies, bolus sizes, 4 finger method or
simply laryngeal palpation
■ Tasks after swallowing: phonation, panting, head turn, coughing
■ Cervical auscultation: listen to swallow sounds, inexpensive, noninvasive
● Imaging techniques: Videofluoroscopic Swallowing Examination (VFSE), Flexible
Fiberoptic Endoscopic Evaluation of Swallowing (FEES), Ultrasound (not used
anymore), Scintigraphy (not used anymore)
○ VFSE, compared to FEES is less invasive, and gives objective data. All stages
of the swallow can also be seen on VFSE. FEES surpasses VFSE in the way
that it is less expensive and can be performed by only the SLP, doesn’t require
radiation exposure and is extremely portable.
● Instrumental techniques: Electromyography (EMG, manometry, cervical auscultation
● Dysphagia screening tools include:
● Toronto Bedside Swallowing Screening Test
● Guggling Swallowing Screening (GUSS)
→ Tests for swallowing include: Mann Assessment of Swallowing Ability (MASA) and McGill
Ingestive Skills Assessment (MISA).
● Some scales used for infants and children feeding assessment include: Holistic
Feeding Observation form, Schedule for Oral Motor Assessment, Multidisciplinary
Feeding Profile, and Developmental Pre-Feeding Checklist.
Carrie Eichler

● Some of the areas important for a critical pediatric assessment include: state/behavior
(sleepy, cuing, transitions, agitation, initiation, rhythm), oral-motor control (sucking
pattern, history of changes in nipple/enlarging nipple hole, initiation, GERD), endurance
(sleepy, frequent colds, chronic nasal congestion, disorganized sucking, slow rhythm,
long feeding times), coordination (prefers spoon to sucking, chronic nasal congestion,
uneven rhythm, forgets to breathe, coughing, choking), and tactile responses
(excessive gagging, particular about the nipple shape, difficulty with transitions, history
of tube feeding).
● Common signs and symptoms of pediatric dysphagia include: poor feeding efficiency,
food refusal, failure to thrive, choking, coughing, anterior loss of material,
decreased control of oral secretions, pooling in sulci and valleculae/PS, aspiration,
delayed pharyngeal swallow, piecemeal deglutition and/or tongue thrust.
→ Treatment
● The 3 postural techniques for treatment include positions that change the head/body
posture and redirect the food flow. These can be temporary or permanent and include
the following:
○ Chin-down/chin-tuck/head flexion: touching chin to neck, pushes anterior
pharyngeal wall posteriorly, tongue base and epiglottis pushed closer to posterior
pharyngeal wall, airway entrance narrowed, valleculae widened, used in cases of
delayed pharyngeal swallow, reduced tongue base retraction, and reduced
airway closure
○ Chin-up/head extension: raising chin, draining food from oral cavity using
gravity, valleculae narrowed, patients with reduced tongue control, oral/lingual
deficits, only used when the pharyngeal swallow is intact
○ Head rotation/head turn: rotation to damaged side (twists pharynx, closes
damaged side, food floods down normal side), unilateral pharyngeal wall or
unilateral vocal fold impairments, associated with increased UES opening
(allowing for a drop in pressure)
Carrie Eichler

● The 6 swallow maneuvers for dysphagia therapy include:

○ Supraglottic swallow: hold your breath (at true VFs) before and during swallow
and cough after, for patients with delayed pharyngeal swallow, reduced or
delayed initiation of laryngeal closure (*closes airway)
○ Super-supraglottic swallow: EFFORTFUL hold breath before and during
swallow and cough after, enhances airway closure by closing false VFs,
arytenoids and epiglottis, and true VFs (*closes airway at 3 points)
○ Effortful swallow: squeeze hard with all muscles during swallow, improved
tongue base movement, posterior movement, and lingual pressure
○ Mendelsohn maneuver: sustain peak laryngeal prominence elevation during
swallow for a few seconds, improves coordination of swallow, increases extent
and duration of laryngeal elevation, duration and width of UES opening
○ Masako maneuver: tongue-hold maneuver, place tongue between teeth and
allow pharyngeal wall to move anteriorly to base of tongue
○ Shaker maneuver: head-lift exercise to improve UES opening, raise head from
ground leaving shoulders at rest, supposedly elevates suprahyoid or submental
muscles
● Exercises for specific swallowing deficits include the following:
○ Reduced labial closure: labial exercises (ex: E→U with cheek resistance),
postural head tilt
○ Reduced lingual ROM: oral motor exercises (ex: protrude, lateralize)
○ Reduced ability to hold bolus in normal position: gauze pad with bolus, move side
to side, bolus control exercises
○ Reduced lingual elevation: prosthetics, head tilt, place bolus more posteriorly
○ Reduced lingual strength: lingual bulb array
○ Reduced tongue base retraction: Masako maneuver, effortful swallow
○ Delayed or absent triggering of pharyngeal swallow: chin tuck, modification of
bolus consistency (thicker)
○ UL pharyngeal paralysis: head turn, modify to thinner liquids
○ Cervical osteophyte: modify to thinner liquids, alternate solid/liquid
○ UES dysfunction: Mendelson maneuver, Shaker maneuver, dilation, modification
to thinner liquids
○ Reduced laryngeal elevation: Mendelson maneuver, effortful swallow
○ Reduced laryngeal closure - airway entrance: super-supraglottic swallow
○ Reduced laryngeal closure - vocal folds: supraglottic swallow, chin tuck
Carrie Eichler

○ Etiology
i. Genetic
● Angelman Syndrome
○ Cause: chromosome 15
○ Symptoms: seizures, stiff and jerky gait, happy manner, easily excitable
personality, hypermotoric behavior, hand-flapping
○ S/L: short attention span
● Apert Syndrome
○ Cause: FGR2 at 10q25-26
○ Symptoms: varied number of fingers and toes are fused together (syndactyly),
head is unable to grow normally, sunken appearance in the middle of the face,
bulging and wide-set eyes, a beaked nose
○ S/L: underdeveloped upper jaw leading to crowded teeth and class III
malocclusion, thickened alveolar process, long or thickened soft palate, cleft
palate, hyponasality, alveolar consonants, and labiodental sounds affected
● Beckwith-Wiedemann Syndrome: macroglossia
● Cri du Chat Syndrome
○ Cause: absence of short arm of 5th chromosome
○ Symptoms: high pitched cry like a cat, low set ears
○ S/L: narrow oral cavity, laryngeal hypoplasia, microcephaly, micrognathia, oral
clefts, articulation and language disorders
● Crouzon Syndrome
○ Cause: autosomal dominant inheritance
○ Symptoms: craniosynostosis (fusion of the cranial suture → conductive hearing
loss) and hypoplasia of the midface, maxilla, or both, hypertelorism (eyes that are
far apart)
○ S/L: class III malocclusion, conductive hearing loss, articulation disorders
associated with hearing loss and abnormalities of the palatal oral cavity,
hyponasality, language disorders
○ maxillary advancement is helpful
● Down Syndrome
○ Cause: extra chromosome 21
○ Symptoms: hypotonia, flat face, small ears/nose/chin, brachycephaly
○ S/L: hearing loss, language delays, articulation disorders
○ Older students have difficulty with final consonant deletion
● Fragile X Syndrome (leading cause of intellectual disabilities in men, sons of women
carriers have 50% chance of inheriting)
○ Cause: Cytosine-Guanine-Guanine (CGG) nucleic acid repeats
○ Symptoms: dysmorphic facial features, avoid eye contact, withdrawn socially,
limited attention spans, autistic-like social deficiencies
○ S/L: jargon, perseveration, echolalia, lack of gestures/nonverbals
● Goldenhar
○ Symptoms: incomplete development of ears, nose, soft palate, lip, mandible
○ S/L: feeding difficulties due to unilateral facial weakness
Carrie Eichler

● Hurler’s Syndrome (1 out of 10,000 births, usually die before 10 years)

○ Cause: deficiency in X-L iduronidase
○ Symptoms: dwarfism
○ S/L: fatigue and hoarseness when talking, compromised intelligibility
● Landau-Kleffner Syndrome
○ Symptoms: seizures
○ S/L: sudden/gradual aphasia between ages 3-7, difficulty comprehending and
speaking language
● Moebius Syndrome
○ Cause: agenesis or aplasia of motor nuclei of cranial nerves
○ Symptoms: 5, 7, 12 nerves involved
○ S/L: labial/lingual difficulty with control and weakness, feeding issues in infancy,
conductive hearing loss
● Nager Syndrome
○ Symptoms: small jaw (micrognathia) causing airway obstructions
○ S/L: underdeveloped cheek bones, cleft palate, conductive hearing loss
● Pierre-Robin Syndrome/Stickler
○ Cause: interference with the normal development of the mandible during early
gestation
○ Symptoms: micrognathia, glossoptosis, joint problems
○ S/L: cleft palate
○ mandibular lengthening because of temporary airway obstruction
● Prader-Willi Syndrome
○ Cause: deletion in long arm of chromosome 15
○ Symptoms: short stature, low muscle tone
○ S/L: cognitive impairments, constant feeling of hunger
● Russell-Silver Syndrome
○ Symptoms: low birth weight, dwarfism, asymmetry of arms and legs, craniofacial
disproportion, mandibular hypoplasia, microdontia (small teeth)
○ S/L: hypernasality, feeding problems in infancy, articulation, language disorders,
high pitched voice
● Tourette Syndrome
○ Symptoms: facial tics, other motor tics
○ S/L: uncontrollable vocal sounds and repeated involuntary movements or
involuntary inappropriate words and phrases
● Treacher Collins Syndrome
○ Cause: autosomal dominant inheritance or spontaneous mutation
○ Symptoms: upper airway obstruction, underdeveloped facial bones, mandibular
hypoplasia, Coloboma (lesion or defect of lower eyelid), stenosis, malformations
of the ear
○ S/L: hearing loss, hypernasality and nasal emission, articulation disorders with
hearing loss and oral structures
Carrie Eichler

● Trisomy 13
○ Cause: extra copy of chromosome 13
○ Symptoms: life-endangering severe birth defects, congenital heart defects, brain
abnormalities, spina bifida, eye defects, polydactyly (extra finger and toes)
○ S/L: cleft lip and palate
● Turner Syndrome (females)
○ Cause: missing or deformed X-chromosome
○ Symptoms: ovarian abnormality, swelling of the feet, neck and hands, cardiac
defects, webbing of the neck, low posterior hairline
○ S/L: right hemisphere dysfunction, hearing loss, ear infections, language and
articulation disorders, visual, spatial, and attentional problems
● Usher Syndrome
○ Symptoms: 50% of individuals deaf and blind, night blindness, limited peripheral
vision
○ S/L: cochlear abnormalities, sensorineural hearing loss, language and
articulation disorders consistent with hearing impairment, hypernasality, and
nasal emission
● Van der Woude Syndrome
○ S/L: lower lip pits, cleft lip/palate
● Velocardiofacial Syndrome (most associated with cleft palate)
○ Cause: small part of chromosome 22 is missing
○ Symptoms: middle ear infections, learning problems, unique facial
characteristics, wide nose, small ears, microcephaly, micrognathia
○ S/L: feeding problems and failure to thrive
● Williams Syndrome (1 of every 20,000)
○ Cause: abnormality to chromosome 7 including gene that makes protein elastin
○ Symptoms: “elfin-face syndrome,” small boned and short with a long upper lip,
wide mouth, full lips, small chin, puffiness around eyes, low IQ’s but can have
high intelligence for music, language, and interpersonal skills, charming
personalities, not afraid of strangers, dental problems, narrowed pulmonary
arteries and aorta.
○ S/L: difficulty with conceptual and relational vocabulary, short term memory is
relative strength
● 22q11.2 Deletion Syndrome
○ Symptoms: medial displacement of carotid artery/pulsations on the pharyngeal
wall
○ S/L: hypernasality w/out cleft palate, difficulty with reading and math, and a
childhood history of middle ear effusion (otitis media)
● VATERR
○ Symptoms: vertebral deficits, anal atresia, radial and renal dysplasia
○ S/L: tracheo-esophageal fistula
ii. Developmental
Carrie Eichler

→ Cleft lip/palate
● Cleft lip: usually upper lip and associated with cleft palate, males at higher risk
● Cleft palate: hard/soft/both, not always associated with cleft lip, more often unilateral and
on left, females at higher risk
● Prevalence: most often Native Americans, Japanese, Chinese, Caucasian, and African
American
● Testing: anything below .89 on oral manometry is especially indicative with problems
and hypernasality
● Eustachian tube dysfunction is mostly related to the lack of contraction of the tensor veli
palatini muscle
● Etiology
● Environmental: fetal alcohol syndrome, illegal drug use, prescription drugs,
rubella
● Mechanical: intrauterine crowding, twinning, uterine tumor, amniotic ruptures
● S/L
● Hearing loss secondary to otitis media, eustachian tube dysfunction
● Articulation disorders: difficulty with unvoiced sounds, pressure consonants,
audible or inaudible nasal emission, distortion of vowels
● Language disorders: delayed language development, normal receptive skills,
significant language disorders when the clefts are part of a genetic syndrome
● Laryngeal disorders: vocal nodules, hypertrophy and edema of the vocal folds,
vocal hoarseness, reduced vocal intensity, reduced pitch variations, and
strangled voice, resonance disorders
iii. Disease processes
→ Localizing nervous system disease and course
● Neurologic signs and symptoms: localization of disease
Localization of neurologic disease categorized as
○ Focal: single area (left temporal lobe)
○ Multifocal: involving more than one area
○ Diffuse: may involve bilateral regions of the nervous system, can be symmetrical
(Alzheimer’s)
● Course or temporal profile: development of symptoms
○ Acute: within minutes
○ Subacute: within days
○ Chronic: within months
● Evolution of disease:
○ Transient: symptoms resolve completely after onset
○ Improving: severity is reduced, symptoms are not resolved
○ Progressive: symptoms continue to progress, new symptoms appear
○ Exacerbating-remitting: symptoms develop, resolve/improve, recur, worsen
○ Stationary/chronic: unchanged symptoms over time
Carrie Eichler

→ Etiology
● Degenerative disease: gradual decline in neuronal function, neurons may atrophy,
disappear or more specific changes, (ex: ALS, AD)
● Inflammatory disease: inflammatory response to microorganism, toxic chemicals,
immunologic reactions (ex: encephalitis)
● Toxic-metabolic disease: vitamin deficiencies, thyroid hormone deficiency, genetic
disorders, drug toxicity, etc
● Neoplastic diseases: chronic/subacute, progressive, focal (carcinoma)
● Trauma:
○ Identifiable event: auto accident, gunshot wound
○ TBI: closed/open head injury
● Vascular disease: most common cause of MSDs, infarcts (ischemic/hemorrhagic)