WELCOME TO 7

TH

CLINICAL
CONFERENCE OF THE
ACADEMIC SESSION
2020-2021
 Management of Articulation disorders
(An ideal therapy plan)

SUPERVISED BY
MRS. VIBHA MAHAJAN
CLINICAL SUPERVISOR
AYJNISHD(D) PRESENTOR
AKSHARA SAXENA
BASLP 3RD YEAR
 Speech Sound Disorders
Speech sound disorders is an umbrella term referring to any
difficulty or combination of difficulties with perception, motor
production, or phonological representation of speech sounds
and speech segments—including phono-tactic rules governing
permissible speech sound sequences in a language.
Speech sound disorders
 What constitutes an Articulation and
Phonological disorder?
• Phonetic (Articulation) disorders are the result of difficulty in
producing the sounds and sound sequences of the language i.e.
difficulty in executing motoric movements for speech sound
production.

• Phonological errors are the result of difficulty in understanding and

implementing the underlying linguistic rules for producing sounds
and sequences i.e. using speech sounds incorrectly in a given
language even though motoric movements can be executed
adequately.
 Potential etiological factors of
Articulation and Phonologic Disorders

Structural , Linguistic and

physiological, Sensory/Perceptual Cognitive academic
neuromuscular

Environmental/ Other factors

Heredity Personal
psychosocial
 Replacing one sound with the other
SUBSTITUTION
e.g., saying wed for red

Produce a sound in an unfamiliar manner. ARTICULAT Omitting/deleting a sound in a word

DISTORTION ARTICULATION
ION
ERRORS
OMISSION
e.g., kerrec for correct’’
ERORS e.g., saying nana instead of banana

Inserting an extra sound within a word.

ADDITION
e,.g., buhlack horse” for “black horse
 What are Phonological Processes?

• Phonological processes are patterns of sound errors that typically developing children
use to simplify speech as they are learning to talk.
• A phonological disorder occurs when phonological processes persist beyond the age
when most typically developing children have stopped using them or when the
processes used are much different than what would be expected.
• The child has difficulty organizing their speech sounds into a system of sound
patterns (phonemic patterns). 
 n
Vow tio
eliza iza
tio at
n pa
l
De

Denasalization
Affric
Gliding ati on
Consonant
Redup deletion
lic ation (initial or final)
Epenthe
sis
Speech sound development
How to assess?
Oral Peripheral Formal
Case history mechanism articulation/pho
examination nological tests

Speech Connected
Stimulability
Assessment
intelligibility speech
measure sample

Auditory
Language Phonological
sensitivity
testing Awareness
Assessment
Photo Articulation Test

 The Photo Articulation Test (PAT) meets the nationally recognized need for a standardized way to document
the presence of articulation errors.
 The Photo Articulation Test (PAT) enables the clinician to rapidly and accurately assess and interpret
articulation errors. This test requires the patient to look at hundred and forty four pictures and speak the
corresponding word. Each word is picked with an aim to elicit a specific phone (sound) at a specific position
such as word initial, middle and ending
 To administer the Photo Articulation Test (PAT), the examiner simply points to each consecutively numbered
photograph and asks the client, “What is this?" The client's response is scored on the Summary/Response Form
to indicate the presence or absence of errors. Based on H-PAT, the kind of misarticulation is decided by the SLP
and the observations are manually noted. A chart is prepared with CSODA - Correct, Substitution, Omission,
Distortion, Addition for each phoneme. Percentage consonant correct (P CC) given as
 PCC = Number of consonants correctly produced /Total Number of consonants

 The results from the Photo Articulation Test (PAT) provide the clinician with a straightforward comprehensive
view of each student's articulation errors.
 General guidelines of Articulation and
phonological intervention
Eliminate or minimize the effect of maintaining
Keep clients actively participating
causative factors
Write behavioral objectives Provide many opportunities for the client to
practice the ‘targets’.
Specify treatment procedures
Use logically Sequenced steps in the treatment plan
Begin at appropriate level
Involve teachers, Parents, Siblings and spouses.
Elicit sounds in a simpler way
Assess the Articulation/Phonological problem and
Teach the distinction between the error sound and progress continuously
the standard production of sound
Include work on transfer and maintainence.
Use a minimum of motivational devices
Select targets that will make an immediate and
Teaching sounds that are stimulable results in more socially significant difference
accurate production than teaching sounds that are
not stimulable Conduct treatment follow-up
 Phonetic treatment
Approaches
Type of tx approach Specific Approach Brief Description
Articulator placement Phonetic placement Instruction in specific placement of the articulators to produce
speech sounds

Palatometric instrument Use of a psuedopalate to provide visual feedback

Traditional Stimulus Auditory training and production practice of target sound in

progressively increasing levels of linguistic complexity

Wedge Target two or more speech sounds at a time using sounds that
have dissimilar phonetic features
Multiple phonemic Target production of all error sounds at a time with each
progression at its own rate
Tactile-kinesthetic Moto-kinesthetic Manipulation by the clinician of the articulators externally on
the face and neck to guide the articulation mechanism in
production
PROMPT Use of multidimensional tactile prompts to guide the
articulation mechanism in production
Type of tx approach Specific Approach Brief Description

Phonetic Context Sensory-motor Bi-syllable and tri-syllable drill for multisensory

awareness of speech sound patterns and production of
error sound in facilitating phonetic contexts that are
gradually expanded
Paired-stimuli Use key words paired with words in which the target
sound is produced incorrectly at the word, sentence and
conversational level
Stimulability Integral Stimulation Imitation of clinician’s multisensory models in stimulable
sounds
Stimulability enhancement Production of consonants in isolation or CV to increase
number of stimulable sounds
Behavior modification Programmed instruction Specification of stimuli, client responses and
consequences (reinforcement, punishment, differential
reinforcement)
Phonological treatment
Approaches
Type of approach Brief Description
Distinctive Feature Distinctive features of sounds are targeted through the production of
contrasting exemplar phonemes, one of which contains the feature and the
other not containing the feature.
Phonological cycling Phonological patterns are targeted in words containing exemplar
sounds/sound contexts for a specified time period through the production of
words
Meaningful minimum Phonological patterns are targeted in contrasting word pairs, one of which
contrasting pairs contains the targeted pattern and the other not containing the pattern
Maximal opposition Production of contrasting word pairs differing in multiple phonetic features
with the goal of increasing the phonetic inventory and complexity level of of
the phonological system
Metaphon Targets phonological rule system through phonological awareness training,
communication awareness training and production of contrasting word
pairs
Non-linear Various segmental and syllable/word structure levels are targeted through
the production of exemplar words for a specified time period
 Phonetic Placement Approach (Scripture 1923)
• The implicit goal is to correct articulation of all speech sounds beginning in isolation
and progresses through syllables, words, sentences and prepared dialogue.
• General relaxation, breathing, tongue and lip exercises are performed by the client.
• Various techniques are used to demonstrate the client where to place articulators
and direct the breathe stream such as
• Manipulation of articulators using tongue blades, sticks, clinician’s gloved fingers
• Breathe indicator for mouth and nose such as mirror.
• Feeling of laryngeal vibrations
• Verbal description and instruction
• Observation of diagrams, pictures and articulation cue cards.
 Stimulus Approach (Van riper 1939)
• To become aware of characteristics of standard phoneme.
• To recognize characteristics of mis-articulations and how they differ from the target
sound.
• To produce standard sound at will and to stabilize or strengthen the use of target
sound in isolation, syllables, words, phrases, and sentences.
• To use the standard sound in spontaneous speech of all kinds and under all
conditions so as to achieve carryover.

Phase 1 Auditory training
Step 1 Identification
Step 2 Isolation
Step 3 stimulation
Step 4 discrimination
a error detection
b error correction
Step 5 Self hearing
Phase 3 Transfer & carryover
Using sounds in
Step 1 Isolation spontaneous speech in all
Phase 2 Production
situation by enlarging
Step 2 Stabilization in treatment
isolation situations( activities ,
Step 3 Nonsense syllable conversational partners,
Step 4 Words settings) with the
incorporation of self
Step 5 Sentences evaluation and
monitoring.
 Long term Goal

To correct articulation proficiency of

the client at conversational level and
spontaneous speech.
 Short term goals
 To correct the production of / / in isolation with 90% mastery.
Activity- To achieve the production of speech sound / / by giving the child opportunity
to see and hear the clinician ; The clinician provides tactile-kinesthetic cues to assist
the client in speech production. For e.g., Clinician will push the tongue to the base of
the oral cavity with the help of tongue depressor, and ask the client to try to lift the
tongue , this will allow the posterior portion of the tongue to touch soft palate.
By using a dice, ask the client to say / / on rolling the dice and the dice will be including
the target sound and those sounds which the client can easily produce.(long speech
sound + short speech sound).
Activities such as drawing a hair a strand on every time a child can produce / / without
any help and practice say / /.
Materials used- Tongue depressor, Visual cues, Mirror, Auditory cues
Approach used-Phonetic Placement Approach
Specified tactile kinesthetic
Stimulation for each sound
 Articulation cue cards

Phoneme dice

Hair strand activity

To correct the production of / / in syllable with 90% mastery.
 Activity- Clinician will assist the client in putting the target sound
separately from the rest of the syllable such as /k/ pause /a/ , clinician will model
the syllable with a pause and then gradually shortens the length of the pause
until there is no pause.
Simultaneous hand movements can be used to provide additional input for the
client, such as moving the left hand as a signal for producing the target sound
and moving the right hand as a signal for the rest of the syllable/word. The two
hands can be farther apart concomitant with a longer pause and gradually moved
closer together showing shorter pauses.
Can be done by using hands an flashcards .

For generalization and practice , we can use hair strand activity or circling the
syllable on every correct utterance.
 To correct the production of / / in all positions of the words ( initial,
middle and final ) with 90% accuracy.
INITIAL: Activity - To say words that begin with the target speech sound / / for eg-
_____,______,______ etc
Clinician will take pictures of words beginning with the target speech sound / / and ask the client
to name or guess them and if the client says /tea/ instead of /sea/, then the clinician can
demonstrate it by s+ea saying the two parts separately and leaving a pause between them and
can gradually make the pause between them shorter.
For practice hair strand activity can be
Used and Clinician can ask questions
To the client such as “ can you tell me
Who gives us milk?
Do you like carrots or candies?
• MIDDLE (Activity)- To say words that contains the target speech sound / / in middle .for
e.g.,- _____,______,______ etc.
• For medial position, break the word up initially into syllables. For example, if the target is /k/ and
the word is “baker,” have the child produce each syllable individually, but in sequence. For
example, she should say “ba…ker.” Gradually, bring the two syllables closer together. The use of
visuals (e.g., a red block for the first syllable and a blue block for the second syllable) can be
helpful.
For practice hair strand activity can be
Used and Clinician can ask questions
To the client such as “ can you tell me
• Name the items blue in color?
• We can go to moon by______?
• FINAL(ACTIVITY)- to say words that end with the speech sound / / For eg-
______,_____,____ etc.
• Clinician will use set of 6 pictures having / / in the end . Clinician will take pictures of words ending
with the target speech sound / / and ask the client to name or guess them and if the client says
/tea/ instead of /sea/, then the clinician can demonstrate it by s+ea saying the two parts
separately and leaving a pause between them and can gradually make the pause between them
shorter. Introduce the final word position of the sound by first breaking up the syllable or word.
For example, if the target sound is /k/ and the work is “bake,” the child should say “baaaa…k.”
• Hair strand activity or circling
the word can be used for practice the words.

When working on the final word position combine it with a word that starts with a vowel. If the
word following the final consonant starts with a vowel, it makes the final consonant similar to an
initial sound. For example, you could have the child say “Bake it.” Have the child pause while
holding the /k/ before going on to the next sound.
 To correct the production of // in sentences with 90% accuracy.
• Clinician will give the client “ the opportunities to say words in phrases by adding one
more word with not having the target sound such as if a clinician is targeting on sound /k/
then clinician will use give the /komb/. And then moving on to sentences and to practice
the words.
• Clinician can ask the client to tell a story based on pictures containing / / target sounds.
• Can you think of something that begins with / / ?
• Can you think of a color that begins with / / ?
• Can you think of a name that begins with / / ?
• Would you like to wear Skirt or a Saree?
Who’s the policeman?
Who’s the tailor? Who is Mrs. Sew?
 To facilitate the production of / / in spontaneous speech
with 90% accuracy.
• Clinician will give the client opportunities to speak
• Oral reading tasks
• Question and answer – introduction, description of pictures , object etc.
• Ask the parents to bring in family pictures, including those of siblings and pets. Look at the
pictures with the child, allowing him/her to narrate the events in the pictures using slow and
easy speech patterns.
 Maintenance
• Enlarging the therapy situation (school, playground, job).
• In designing a practice schedule, the practice frequency and intensity should take into consideration
the following for best results:
• Practice Frequency: Frequent, distributed practice sessions can facilitate both short-term performance and
long-term memory. In fact, it is better to have frequent, albeit short, practice sessions than infrequent, yet
longer, sessions.
• Practice Intensity: The length of a practice session is less important than the number of responses elicited
during the session. In fact, it is the number of correct responses elicited (in therapy or at home) that is
directly related to the rate of progress, not the time spent. As such, drill work is most effective in developing
motor learning and motor memory. A practice session can be as short as a minute or less, particularly if it is
done frequently throughout the day
• Use of tongue twisters and jingles can also be used.
• The best way to obtain teacher and family member involvement in the carryover stage is to engage
them as partners in the treatment process from the very beginning.
• In addition, it is important to give parents specific strategies for practicing speech sound production
at home. In this way, they will be more aware of the child’s speech goals and more helpful in
monitoring and correcting the child’s speech during the carryover stage.
 ORO-MOTOR EXERCISES

• These exercises are designed to increase the range of movement in your tongue,
lips, and jaw, which will help your speech and/or swallow functioning.  
• for strengthening the articulators,
• controlling the articulators, and
• controlling respiration in non-speech functions
Out of clinic Strategies
• Assignments- the clinician may put pictures or words containing the target sound in the
notebook for home practice.
• Extra clinic environments (oral reading within a limited time span (10mins) , oral
discussions, structured conversation about Pre-selected topics)
• Creating discriminative stimuli and reminders in the environment.
• During oral reading, underline difficult words and reinforce the child’s attempt at saying
them correctly.
• Follow ups
Case Presentation
Case Name: XXXXX
Case No: 264.05.2019
Age: 8 years Sex : Female
Mother tongue: Hindi
Language known: Hindi and English
Language mostly used: Hindi
Religion: Hindu
Education: Class-V
Occupation: -
 General Complaint:

Complaint of unclear speech.

 Purpose of visit: Speech therapy
Post natal history- According to ESIC hospital- C/O misarticulation dated 10/05/2019
Developmental history- not known to the informant
Family History- Nuclear Family ( no history of disability )Consanguinity- Negative
 Communication difficulty: Difficulty in academic tasks like oral reading, narration etc.
Educational History- Client Attends regular school at Poorvi Delhi Nagar Nigam Prathmic Vidhyalya

Academic Performance- Good Medium of instruction- Hindi

Recommendation:
1. Articulation assessment
2. Follow up
 Speech and Language Evaluation
• Speech Development history- Not known to the informant
• Mode of communication- Verbal
• Verbal communication – Expression :- Words, phrases, Simple sentences and complex
sentences.
• Comprehension:- Words, Phrases, simple sentences, complex sentences.
• Speech and Language stimulation – Adequate
• Oral peripheral Mechanism Examination-
 Lips

Appearance: Normal
Functions: Puckering- Normal
Retraction- Normal
Diadochokinetic Rate- Normal
 Tongue

Appearance: Normal
Function: Protrusion- Normal
Lateral movement:- Left- Normal and Right- Normal
Elevation- Normal
Retraction- normal
Teeth
Appearance: Normal Bite
Function: Ability to chew- Normal
 Hard palate
Appearance: Normal
 Soft palate
Appearance: Normal
Function: Movement during the production of / ah /
- Normal
- Symmetrical
- Ability to suck through straw:- Present
- Ability to blow:- Present
 Uvula: Normal
 Mandible:

Appearance- Normal
Function- Normal
Vowels - /a/,/i/,/u/,/o/
Consonants- Mentioned in PAT
Blends- mentioned in PAT
• Voice- Trial 1 Trial 2
• Pitch- perceptually adequate /a/ 8s 9.4s
• Loudness-Perceptually adequate /i/ 11s 10s
• Quality- Perceptually adequate /u/ 8s 10 s
• Breath control and phonation duration-
• Supra-segmental aspects (accent, Emphasis ,Intonation ,Phrasing , Rate of speech)- Perceptually
Adequate
• Imitation Skills:
• Gross body- Good
• Speech- Fair
• Speech intelligibility- 1 ( can understand without difficulty, however feel speech is not normal)
• Formal testing- Tests Administered : Photo Articulation Test was administered.
Error analysis
a.Number of sounds correctly produced: 121

Word level:- All vowels and 23 consonants

• Substitution - 21 Omission- 3 Deletion- 0 Addition-0
• Reading and writing skills - letter recognition, word recognition , writing to dictation ,
reading comprehension is present.
• Language Evaluation-
• Cognitive skills – consists of matching, time concept ,logical thinking, concept of conversation,
remembering and problem solving.
• Pragmatics – consists of greetings, topic initiation, topic maintenance, initiate activities, adequate
eye contact.
• Auditory skills – Normal
• Diagnosis- Misarticulation
• Recommendations-
• Speech therapy at AYJNISHD(D).
• Speech and language correction at home.
• Follow up
Photo Articulation Test – Hindi AYJNISHD, Mumbai, 1988
Speech Therapy Plan
Long term Goal-
To correct articulation proficiency of the client at conversational level and
spontaneous speech.
Short term Goals-
1. To correct the production of velar sounds /k/, /kh/, /g/, /gh/ in isolation with 90%
mastery.
2. To correct the production of velar sounds /k/, /kh/, /gh/, /g/ at syllable level with 90%
mastery
3. To correct the production of velar sounds /k/, /kh/, /g/, /gh/ at word level ( initial, middle,
final) with 90% mastery
4. To correct the production of velar sounds /k/, /kh/, /g/, /gh/ at sentence level or
spontaneous speech.
• Materials used- Flashcards, tongue depressor, articulation cue cards and activity
materials
• Frequency- once in a week for 45 minutes
• Parents input- Parents actively participate during speech therapy sessions and same
was repeated over at home and parents often correct the child at home and h
• Approach used –Phonetic Placement Approach, Stimulus Approach
Sno. Short term Approach used Activities
goals
1 To correct the Phonetic placement There is a standard stimulation for each sound, and the clinician
production of velar approach used stimulation each time the sound was produced. The
sounds /k/, /kh/, clinician said the target sound while manipulating the client’s
/g/, /gh/ in isolation articulators, and the client watched the clinician’s face;
with 90% mastery. therefore, the client received kinaesthetic, tactile and auditory
stimulations simultaneously. The client learned the feeling of
movement of the articulators and the feeling of movement
becomes associated with the auditory input of the clinician.
After the feeling of the movement of the articulators, the client
reproduced it through the kinaesthetic sense.

2. To correct the Stimulus Approach Clinician will assist the client in putting the target sound
production of /k/, separately from the rest of the syllable such as /s/ pause /a/ ,
/kh/, /g/, /gh/ in clinician will model the syllable with a pause and then gradually
syllable with 90% shortens the length of the pause until there is no pause.
mastery.
Sno. Short term goals
3. To correct the production of
/k/, /kh/,/g/,/gh/ in all positions of
the words ( initial, middle and
final )with 90% accuracy.
4. To correct the production of
/k/, /kh/,/g/,/gh/ in sentences with
90% accuracy.
Approach used Activities
Stimulus Approach Clinician will take pictures of words beginning with the
target speech sound /k / and ask the client to name or
guess them and if the client says /tea/ instead of /sea/, then
the clinician can demonstrate it by s+ea saying the two
parts separately and leaving a pause between them and
can gradually make the pause between them shorter.
For practice , client was asked to practice the target words
10 times each.
Stimulus Approach Clinician began using target words now in the sentences
and then begin initially with phrases, then simple
sentences (3-4 words) and gradually using complex
sentences using pictures and block of words then
introducing pauses between words and then gradually
decrease the pause between them.
 Progress Report
Progress Report

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%
Isolation Syllables Words Sentences

1st session 10th session Series 3

References
• An introduction to speech-language pathology and Audiology Charles Van
Riper
• Playing with “K” Lucy Sanctuary
• Clinical Management of Articulation and Phonological Disorders Curtis E
Weiss
• www.asha.org
Let’s ASK & DISCUSS