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EPG2012Clinical Workshop23rd April

Alan Wrench & Sara WoodEPG assessment and therapyCleft palateHearing impairmentApraxia of speechDysarthriaNeurological (acquired and developmental)Functional articulation disordersLateralisationDowns syndromeDysfluency GlossectomyMalocclusion and osteotomy

EPG therapyClient selectionaetiological or maintaining factors:sensory lossstructural and functional abnormalities cognitive abilityauditory discrimination or linguistic difficultiesmedical factorspoor attention / motivationdentitionpractical issues related to wearing the palateage of clientAssessment protocolBefore assessment you must check the EPG palate is functioning and clients must have acclimatised to the palate EPG is an additional assessment procedurestandard word listadditional probe listshigh quality audio recordingsminimum of 3 recordingsprior to therapyon completion of therapy3 months or more after completion of therapyEPG patterns described according to error classification scheme Creating word listsConsider using vowels from different areas of the vowel quadrilateral including a central vowel3 vowels (e.g., open closed mid)5 vowels (e.g., open front open back closed front closed back mid) sample different syllable positions. Consider syllable-initial word-initial (kitkat), syllable-final within-word (kitkat), syllable-initial within-word (kitkat), and syllable-final word-final (kitkat)sample both singleton and consonant cluster contexts (e.g., top and stop)

Creating word listsConsider coarticulatory effects (e.g., if examining velars, consider words that do and do not contain alveolars such as cap vs. cake vs cat vs catkin)sample both high and low frequency words sample both monosyllabic and polysyllabic wordsConsider the most suitable modality for your clients age, literacy level, and co-occurring condition (words, pictures or both). spontaneous and imitated productions. pre-fix sample words with either the or a in order to provide an open mouth posture prior to the target.

Error patterns revealed with EPGSpatial abnormalitiesDiffer qualitatively from idealized patternsincreased spatial variabilitybroader or increased tongue-palate contactfrequently affect fricativeslateralized fricatives are a heterogenic groupskewness on sibilantsovershoot and undershootIncreased spatial variability

9Increased area of lingual palatal contactsAlveolar closure during a tap produced by a 9 year old girl with DS

Undifferentiated gestures(UG)Impaired motor controlerrors appear relatively frequently in the speech of school-aged children with functional speech disordersat maximum constriction, contact in the midsagittal region is not confined to the anterior region of the palate for alveolar targetscontact extends back into palatal and even velar regions

UG doorCovert contrastsInstrumentally measurable differences between target phonemes that are neutralized in listeners perceptions (Hewlett, 1988)originally reported using acoustic analysis to measure spectral and temporal aspects of normal child speechall studies describing covert contrasts using EPG have investigated children with speech disordersCovert contrasts

OvershootAnomic aphasic a sharkTemporal and serial ordering abnormalitiesAbnormal durationsstutterersfunctional articulation disordersacquired neurogenic speech disordersincreased temporal variabilitymisdirected articulatory gestures (MAGs)abnormal transitional timing for successive articulatory gesturesrepetitionsmetatheses

Abnormal duration of contactsMisdirected Articulatory Gestures (MAG)Gestures that are spatially normal but that occur in an inappropriate place in the target utterancenot always detected through auditory analysisnever seen in the speech of non-pathological speakers

Inaudible double velar/alveolar MAG produced during bilabial stop by Conduction aphasic

Distorted spatial patterns10-year old boy with functional articulation disorder

Sequencing clock (control)

Sequencing clock (control)

Disturbed temporal overlap (apraxic)

Disturbed temporal overlap (Brocas)

Sequencing kitkat (control)

Disturbed temporal overlap (conduction aphasic)Target selectionConsider typical sequence of consonant acquisitionConsonants that most impact intelligibility Socially important targets Non-developmental errors (e.g., lateralization)Variable or inconsistent errors Stimulable consonants are less likely to be selectedmay respond to more traditional non-instrumental interventionstimulable consonants are selected in EPG intervention if clientbecomes de-motivated success has been limitedprogress has plateaued. EPG therapyDemonstration and verbal explanationsrelationship between tongue patterns and resulting soundlinking visual display to clients own tongue and hard palatehighlighting the difference between clients patterns and those of normal speakerLearning new motor skillsTransfer into naturalistic contextsremoving visual feedbackremoving palateTherapyFrequency & Duration: important because client may outgrow palatePortable Training Unit (PTU)

Session One (post assessment)Orientate client to EPG display, allow them to play around for a while. Ensure they understand the relationship between themselves and the screen, but there is no need at this point to talk about their particular errorsChoose one, or two if you can, lingual-palatal consonants that you know are in the clients phonetic inventorySpend the first week copying patterns for these soundsFollowing sessionsBasic articulation therapy with visual feedbackStart by demonstrating the pattern you would like the child to achieve, talk about its distinctive featuresTry to get the child to achieve the pattern may be achievable without phonationTherapyUse the EPG feedback windowTake turns to attempt the patternAsk the client to identify when you achieve the correct pattern (you can freeze the palate display by clicking on the palate- children enjoy doing this for both themselves and the therapist)

EPG Feedback

ClientTargetHome Practice

Target patternsWhere a child has atypical anatomy they may achieve an acceptable speech sound with an atypical pattern. You can save the clients pattern and use it as a model.(Silent posture)Consonant + schwa or facilitative vowel (CV or VC)Consonant + other vowels, VC and CVCVCSingle words with and without visual feedbackMeasuring clinical effectivenessRecord short target sound wordlist every week to monitor progressUse recordings as a therapy tool by playing back recordings to children and have them rate themselves, both for the way it sounds and the way the pattern looks to increase self monitoring and awareness skillsTherapy: complex wordsChildren with dyspraxia may be able to achieve the sound but find it difficult to achieve it in complex words (words with varying place of articulation)Make an EPG map of key vocabulary

c a tCase StudiesIntractable Speech DisordersSpeech sound production errors persisting beyond stage of normal childhood developmentUnresponsive to conventional speech therapyClinical Headache!Expensive for service providers in terms of time and resourcesIncrease waiting times

Possible detrimental effect on childs educational and social developmentClinical EffectivenessAccurate diagnosis absolute pre- requisite for clinical effectivenessStandard clinical test procedures are subjectiveintra-subject variabilityinter-subject variabilitynormalisation of subtle distinctionsCase study 110 year old with Downs Syndromebilingual - Hungarian & Englishreferred to SLT when 7 yearsinitial assessment highlighted significant articulation difficulties, delayed expressive and receptive languageregular SLT to improve articulation

AssessmentEAT revealed: velar fronting (k, g, t, d, n) palato-alveolar fronting (sh s) cluster reduction for tr, kr,str, kl, fl,pl voicing errors vowel distortions raw score 29, age equivalent