Speech Intelligibility:

Clinical Treatment Approaches for

Children and Adults
Connie Keintz, Katherine Hustad, Jane
Garcia, & Estelle Klasner
 Roadmap of the session
□ Introduction to intelligibility and related
concepts
□ Variables that influence intelligibility
□ Interventions to enhance intelligibility
□ Listener barriers and strategies to intelligibility
 Traditional view of intelligibility
□ Deficit belongs to the speaker
□ Identify subsystem problems
□ Provide intervention to remediate subsystem
problems
□ No consideration of partner-related
variables and their contribution to
intelligibility deficits
 Multi-dimensional view of intelligibility

□ Communication is dyadic
□ Speaker and listener play equally important
roles
□ Meaning is co-constructed in real
communication situations
 Speech Intelligibility
□ The extent to which a signal, produced by a
speaker, can be deciphered by a listener
 Measurement of Intelligibility
□ Orthographic transcription
□ Scaling procedures
□ Percentage estimates
 Measurement of intelligibility
□ Listen to the following sentences
□ Write down what you hear.
 Measurement of intelligibility
□ We talked about the situation.
□ The idea for it was mine
□ When you are through, write a report.
□ There are two methods for soaking dry
beans

26 possible words
 Clinical uses of Intelligibility measures

□ Index of severity
□ Index of functional limitation
□ Measure of change over time
□ Treatment progress
□ Recovery
□ Degeneration
 Limitations of intelligibility measures

□ No information about underlying reasons for

problem
□ Nature of listener difficulties
□ Nature of production deficits
□ Intelligibility influenced by many factors
□ Clinical measures are a “snapshot” of
performance in a specific context
□Usually NOT a real communication situation
 Comprehensibility
□ Contextual intelligibility
□ The extent to which a listener can recover a
message, produced by a speaker, when
the listener is given contextual information
that emulates real communication
contexts.
 Measurement of Comprehensibility

□ Orthographic transcription with contextual cues

□ Cue: communication
□We talked about the situation.
□ Cue: thinking
□The idea for it was mine
□ Cue: homework
□When you are through, write a report.
□ Cue: cooking
□There are two methods for soaking dry beans
 Comprehensibility vs. intelligibility

□ Intelligibility measures deliberately omit

contextual information
□ Both measure employ orthographic
transcription
□ Both measures provide %correct scores
 Listener comprehension
□ The extent to which a listener is able to
understand a spoken message
□ Higher level processing
□ Value of individual words comprising the
message de-emphasized
□ Gestalt of primary importance.
 Measurement of comprehension
□ Answer open ended questions about the
content of a spoken message
□ Answer yes/no questions about the content of a
message
□ Re-tell the narrative (emphasis on content, not
specific words)
 Measurement of comprehension
□ Listen to the following short narrative
 Measurement of comprehension
□ Answer these questions:
□ What is the topic of the story?
□ What was the final outcome of the story?
□ What may have happened beforehand to
make the event described in the story
necessary?
□ Based on the outcome of the story what might
happen next?
 Measurement of comprehension
□ Target sentences produced by the speaker
□ Jason needed to buy a car.
□ He considered two different models.
□ He did not have much money to spend.
□ He bargained with a salesman for two hours.
□ The final price was within his budget.
□ A used jeep was what he purchased.
 Differences between measures
Mean percent correct by measure and speaker

100 Intelligibility
90 Comprehension

80

70
Percent correct

60

50
40

30

20
10

0
1 2 3 4 5 6 7 8 9 10 11 12
Profound Severe Moderate Mild
Severity
Relationship between measures
 Which measure is best?
□ Intelligibility, comprehensibility, and
comprehension measures each provide
different, yet complementary information.
□ Select measures that are appropriate for
your clinical purpose.
□ To characterize the functionality of speech, use
measures that capture information-bearing
capability
Connie Keintz, Ph.D. CCC-SLP

Assistant Professor
Communication Sciences & Disorders
Florida Atlantic University
Boca Raton, Florida
 Variables that influence intelligibility

□ Linguistic characteristics of the message

□ Semantic Cohesion
□ Length of Message
□ Semantic Predictability

□ Visual Information
 Semantic Cohesion

□ Research Factors
Key words/Cohesion = higher scores
(Drager & Reichle, 2001 and Hustad & Beukelman, 2002)

□ Clinical Considerations
□ Keep ideas related for listener benefit
□ This works in our favor in natural communication
 Length of Message

□ Research Factors
□ Word is harder to understand in isolation than in a
sentence (Miller, et al, 1951, Sitler, et al, 1983, Yorkston & Beukelman,
1981)

□ Clinical Considerations
□ Provide context whenever possible
□ Teach your speakers to present it
□ Instruct your listeners to look for it
 Semantic Predictability

High versus Low Predictability

She is drinking from her _____. cup
Bob would consider the _____. pole

□ Clinical Considerations
□ High will allow listeners more information
Visual Speech Information

Buy Bobby a puppy.

Here is his hand.

Dysarthria types

Sound different

Appear different
 Intelligibility

“the degree to which a speaker’s

intended message is recovered by a
listener”

Kent, Weismer, Kent, & Rosenbek (1989)

Measurement Tools Speech Tasks Listener Tasks Presentation
Modes
Tikofsky & Tikofsky (1964) Single words Transcription AO
Tikofsky, Glattke, & Tikofsky
(1967)
Tikofsky (1970)
Platt & colleagues (1977, 1978, Single words Transcription AO
1980)
Yorkston & Beukelman (1980) Single words Multiple choice AO
Assessment of the Intelligibility of
Dysarthric Speech (AIDS) Sentences OR

Yorkston, Beukelman, & Tice Transcription

(1996) Sentence Intelligibility Test
Enderby (1983) Words “Therapist” On-line
The Frenchay Test Sentences Transcription Audio-record
Conversation for reliability

Kent & colleagues (1989) Single words Multiple choice AO

 Measurement tools

Rely on auditory-only information

Visual information
not critical
may benefit listeners
 Model of Intelligibility
Yorkston (2003)

Impairment
Presentation Familiarity
mode

Speech Signal Listener

Transmission
Compensations Experience
 Visual Information Research
□ AV = Auditory Visual

□ AO = Auditory Only

□ Medium/Transmission is compromised in
“normal” studies
Visual information intelligibility studies:

Normal AV > AO
Hearing-impaired AV > AO
Laryngectomee AV > AO

Dysarthria mixed results

 Speakers with dysarthria

Intelligibility scores across moderate:

AV > AO

Intelligibility scores across severe:

No difference in AV/AO

Hunter, Pring, & Martin (1991)

 Speakers with dysarthria

Intelligibility scores across speakers:

AV > AO in 1 of 5 speakers

Hustad & Cahill (2003)

 Speakers with dysarthria

Intelligibility scores across speakers:

AV > AO in 3 of 8 speakers

More benefit in more severely impaired

speakers

Keintz & Bunton (2004)

 Intelligibility scores for individual speakers for AO and AV modes
(* indicates significant results).

100
AO
AV
90
*
*
80
Intelligibility (%)

70 *

60

50

0
A B C D E F G H

Speaker
 Visual Information
□ Influence on intelligibility may be linked to
severity

□ More research is needed to explore

facial movements, severity, types of
dysarthrias
 Visual Information
□ What does this mean clinically?
□ Consider each patient specifically
□ Evaluate with listeners having access to visual
information
□ Allow for visual information, if useful in communicative
context
□ Remember that with most speakers, it will be
beneficial
 Visual Information
□ Are there speakers who may be hindered
by visual information?
□ Moebius Syndrome
□ Amyotrophic Lateral Sclerosis
□ Hyperkinetic Dysarthria
Supplemental Cues: Speaker
Strategies that Augment
Listener Understanding

Jane Mertz Garcia

Kansas State University
Manhattan, KS
 What is speech supplementation?
□ Speaker implemented strategies that
augment or enhance natural speech
□ Hand gestures while speaking
□ Alphabet cues (pointing to the1st letter of
each word while speaking)
□ Topic cues (“prep” listeners about topic)
□ Predictable messages (sentence
form/semantic content)
□ Voice output AAC devices (to supplement
speech) or writing/drawing key points
 Simply stated…

Supplemental strategies provide “clues”

and “extra” sources of information that
help listeners understand less intelligible
speech
 Supplemental strategies …
□ Take advantage of the interactive and
dynamic aspect of speaker-listener interactions
□ Recognize that listeners naturally apply multiple
sources of “shared” information in a difficult
listening situation
□ Provide listeners additional content information
to help understand less intelligible speech

Result…Speakers with dysarthria are more

effective communicators as messages are
understand with greater accuracy.
 Candidates for Supplementation

□ Severity of intelligibility impairment

□ moderate to severe/profound reductions
□ speaker will have difficulty communicating
with behavioral interventions alone
□ Current speaking skills & overall motor abilities
□ strategies may interact in positive or
negative ways with current communication
abilities
□ Type of dysarthria (should be less important)
 Hand gestures (Gesticulations)
□ The natural hand movements people use when
speaking
□ By definition…they occur while talking & are
idiosyncratic in nature
□ There are various forms of gesticulations that vary
in information content and function
□ Iconic—illustrates some aspect of the spoken
message (concrete representation of action,
event, or object)
□ Beat—adds emphasis & accentuates speech
(no content information)
Application as a supplement strategy
(particularly iconic hand gestures)

□ Maximize a natural aspect of communication

(hand gestures naturally occur while speaking)
□ “Unaided” technique (nothing required external
to the body)
□ Add meaning and illustrate the content of a
spoken message
□ Provide listeners 2 signals (nonverbal +spoken)
about the same underlying message
 Audio+Visual Listening Condition
(Garcia & Dagenais, 1998)

100

80

60
No Gesture
40 With Gesture

20

0
Speaker 1 Speaker 2

Key point: Intelligibility scores improved by 20% and 35% with

the addition of hand gestures while talking
 Case study illustration
□ 12 year-old-male (approximately 3 months TPO)
□ Cranial nerve damage following removal of
brainstem tumor
□ Speaking pattern--Flaccid dysarthria (hypernasal
resonance & imprecise articulation)
□ 27% Sentence Intelligibility Test (142 wpm)
□ Strengths: cognitive & language abilities;
UE control for gesturing; motivation & family
support
 Treatment Approach
Goal-- Increase use of content (iconic) gestures
□ “Take what you do naturally, but do it more
often”
□ Phases of therapy-- controlled to less structured
speaking tasks
□ Add gestures in sentences conveying similar
language concepts (actions, descriptive words,
pointing gestures)
□ Apply gestures to “random” sentences
□ Increase gestures in “controlled” discourse tasks
 Study: Impact of Hand Gestures
(Garcia, Crowe, Redler & Hustad, 2004)

□ Natural speaking situation (self-generated

monologues and gestures)
□ Monologues—similar in length, speaking
rate, and amount of iconic gesturing
□ Impact of gesturing:
□ Words identified correctly (percent intelligibility)
□ Message comprehension
 Methods
□ Cue Conditions
□ Full view (all visual cues including
gesticulations)
□ Face cues (edited to only show the speaker’s
face while speaking)
□ Audio-only (eliminated the video signal)
□ 36 everyday listeners heard different monologues
in each condition
□ Counterbalanced (presentation order &
assessment format)
 Percent of Understanding
Intelligibility (Words Correct) of Monologues

100
90

80
Percent Understanding

70
69.2
60
50 57.6

40

30
20
19.5
10

0
Full View (including Face Cues only Audio-only
gesticulations)

Natural hand gestures while speaking enhanced

intelligibility (compared to face & audio only) (p < .05)
 Message Comprehension
What phrase or sentence could you write to describe
the main theme of this speaker’s story?
If you were having a conversation with this speaker
and he told you this story, what question or comment
would you use to add to the conversation?

What people and/or objects were mentioned by the

speaker in his story?
What actions were mentioned by the speaker in his
story?
In what location would this speaker’s story take
place?
 Message Comprehension
Comprehension of Monologues

100

90

80
Percent Understanding

70 75.3
60

50
52.5
40

30
20
20.8
10
0
Full Vie w (including Face Cues only Audio-only
ge sticula tions)

Natural hand gestures while speaking enhanced

message comprehension (p < .05)
 Specific Questions
90

80

70
Percent of Comprehension

60 Audio-only

50 Face Cues only

40 Full View (with

ges ticulations )
30

20

10

0
Ma in Add Actions Obje cts Loca tion
The me Comm e nt

□ Full & Face cues exceeded auditory only

□ Main theme, Add comment, Actions were superior in Full
view vs. Face cues condition
 Alphabet supplementation
□ “Aided” strategy—speaker points to the first letter
of each word on an alphabet board as he or she
says it.
□ Speaker…
□ Decreases rate of speaking by about 70%
□ Provides additional time to execute motor
movements (improve articulation)
□ Listener…
□ 1st Letter cue narrows range of word choices
□ Increased processing time for listeners
□ Creates clear word boundaries
 Sample alphabet board
A B C D E F
• You misunderstood
G H I J K L
• Wait a minute
M N O P Q R
S T U V W X • I’ll say it again

Y Z space delete • I’ll spell it

0 1 2 3 4 5 6 7 8 9

• I will point to the first letter of each word that I’m saying.

• Please repeat each word after I say it so I know you

understood me.
 Research Findings: Sentences
□ Consistently positive benefits for most
□ Linguistic cues alone (superimposed while
speaking) increase intelligibility by 25%
(Hustad & Beukelman, 2001)
□ Reduced rate of speech alone increases
intelligibility by 25% (Crow & Enderby, 1989)
□ When rate is reduced AND speakers have first
letter information, intelligibility may be
increased by up to 44% (Beukelman &
Yorkston, 1977; Hustad, Jones, & Daily, 2003)
 Application of alphabet
supplementation to therapy
□ Improving speaker understanding by enhancing
listeners’ linguistic knowledge
□ Increasing redundancy in signal
□ Modifying speakers’ production characteristics in
helpful ways
□ Useful for resolution of communication
breakdown
□ Relatively “easy” to instruct patients in its use
 Integrating supplementation
strategies
□ Most individuals with dysarthria can benefit from
having multiple communication options
□ Hand gestures and alphabet supplementation
are not mutually exclusive strategies
□ In fact, some individuals benefit similarly from
both strategies
 Hand Gestures Vs. Alphabet Cues
(Hustad & Garcia, 2005)

100

90
Audio-only ƒAlphabet cues
A-V
80 & hand gestures
70
scores were
Mean Intelligibility Score

60

50 similar for
40
Speaker A & C
30

20

10
ƒSpeaker B—
0 Alphabet cues
No Cues

No Cues

No Cues
Alphabet

Alphabet

Alphabet
were
Gestures

Gestures

Gestures
Cues

Cues

Cues
Speaker A Speaker B Speaker C significantly
higher than
Cue Condition by Speaker

hand gestures
 Hand Gestures Vs. Alphabet Cues
(Hustad & Garcia, 2005)

□ Changes in speaking rate

Speaking Rate

180
160
140
Words Per Minute

120
Habitual
100
Gestures
80
AC
60
40
20
0
Speaker A Speaker B Speaker C
 Cost-Benefit Ratio: Hand Gestures
□ Costs:
□ Must have strong metacognitive abilities
□ Must have adequate motor skills
□ Adequate respiratory support for “chunking”
□ Benefits:
□ Considered an “unaided” strategy– nothing
extrinsic to the body is needed for strategy
□ May contribute to naturalness– given
adequate respiratory
 Cost-Benefit Ratio: Alphabet Cues
Costs:
□ Considered an “aided” strategy (you need an
alphabet board)
□ Must have functional literacy skills
□ Reduces naturalness
Benefits:
□ Easy to learn (compared to incorporating hand
gestures)
□ Basic motor skills for pointing to letter cues
□ Rate reduction may benefit production
 Current Understanding of Speech
Intelligibility

□ Speech intelligibility is an outcome measure in

dysarthria
□ Speech intelligibility is reduced in all types of
dysarthria
□ Research focus has primarily been on speaker
□ Listener role is beginning to be studied
 Questions

□ Do barriers to intelligibility vary as a function of

dysarthria group, ALS versus HD?

□ Do strategies for listening vary as a function of

dysarthria group, ALS versus HD?
 Study Overview

Subjects Task Components

Individuals with Dysarthria Read/ Record SIT sentences

(n=10) varying length

Judges (n=65) Transcribe SIT

Focus groups (n =4x12) LTCD Scales

Content Analysis

Pilot Listeners (n=6) LTCR Revised Scales

Everyday Listeners (n= 65) LTC R Endorsement Patterns
Mean Barrier Scale Categories
Scale
Scores
4

* A L S

3 * *
H D

Segmental Suprasegmental Linguistic Cognitive

Mean
Strategy Scale Categories
Scale
Responses A L S
4
* H D

Segmental Suprasegmental Linguistic Cognitive

 ALS Barrier Responses

Mean Scale
Responses

Segmental Suprasegmental Linguistic Cognitive

 HD Barrier Responses

Mean Scale
Responses

Segmental Suprasegmental Linguistic Cognitive

 ALS Strategy Responses

Mean Scale
Score

Segmental Suprasegmental Linguistic Cognitive

 HD Strategy Responses

Mean Scale
Responses

Segmental Suprasegmental Linguistic Cognitive

 Contact Information
□ Connie Keintz (ckeintz@fau.edu)
□ Katherine Hustad (Kchustad@wisc.edu)
□ Jane Mertz Garcia (jgarcia@humec@ksu.edu)
□ Estelle Klasner (enk@nmsu.edu)