Shrinking school budgets make it more essential than ever to find low-tech, low-cost assessment and treatment tools. It's not always easy to find these tools to evaluate and treat children with resonance disorders and nasal emission, and with speech sound errors. Ann Kummer, a senior director at the Division of Speech-Language Pathology at Cincinnati Children's Hospital Medical Center, offers some help. Kummer is also professor of clinical pediatrics and professor of otolaryngology at the University of Cincinnati Medical Center.
What is an example of a low-tech tool that you use?
A simple bending straw can be used to amplify the sound of hypernasality, nasal emission and even oral airflow—just like a stethoscope. A straw is very effective, cheap—less than a penny each—readily available in any cafeteria and disposable. You can also use a "listening tube," which can be purchased in any hardware store. The advantage of a tube is that you can make it as long as you want.
How is a straw or tube used in an evaluation?
To confirm hypernasality and/or nasal emission, put one end of the straw in the child's nostril and the other end near your ear. If there is nasality during the production of oral syllables and words, it will be heard loudly through the straw. A tube is sometimes better for evaluation because you don't have to turn your head to put the end near your ear.
You also use a straw in treatment. How is that done?
First, it's important to emphasize that neither hypernasality nor nasal emission due to velopharyngeal insufficiency can be corrected with speech treatment. This problem is a structural disorder that requires surgery. After surgical correction, treatment corrects compensatory errors that occurred due to the VPI.
Phoneme-specific nasal emission on sibilants, due to pharyngeal placement, is a common postoperative condition. To establish appropriate placement, have the child produce a /t/ with the teeth closed. This will result in a /tsss/. Ask the child to prolong the sound while feeling airflow over his tongue. If the velopharyngeal valve is working, there should be no nasal emission.
The straw is then used to provide auditory feedback. Have the child put one end of the straw in a nostril and the other end near his ear. Have him attempt to produce the oral sound. If nasality occurs, it is heard loudly through the tube. Then ask the child to change the placement, as instructed, to eliminate the sound of air coming through the straw.
How is the straw used to provide feedback regarding oral airflow?
In this case, the end of the straw is placed in front of the child's incisors during the production of the sibilant sound. If the sound is produced orally, the child will hear the airflow through the straw.
Can a straw be used in treatment for speech sound disorders?
The straw is useful in correction of a lateral lisp. Place a straw in front of teeth and produce an /s/. Have the child listen to the air stream going through the straw. Place the straw in front of the child's teeth during the /s/. Have him note the lack of air stream through the straw. Next, move the straw to the side of the child's teeth during production and find where the air stream occurs.
To establish correct production, put the straw in front of the child's closed incisors. Tell him to produce a /t/ and push the airstream through the straw. Have him prolong it as a /tsss/. To transition to the syllable, have the child insert an /h/ between the /s/ and vowel. For example: sss ... ha. Once the /s/ is established, the same techniques can be used to achieve other sibilant sounds.
Are there general principles to follow when treating these disorders?
Yes. Here are some important ones:
- Do not use blowing, sucking, velar or oral-motor exercises. The problem is rarely muscle weakness and these exercises do not work. Instead, use articulation procedures to establish correct placement.
- Motor learning is dependent on feedback. Motor memory is dependent on practice. Make sure the child practices frequently at home. Success depends on the frequency and consistency of practice between sessions.
- If the child is not making progress, discontinue treatment and refer the child to a craniofacial team (not a general otolaryngologist) for evaluation of velopharyngeal function. Surgical intervention or revision may be necessary.
Can you recommend other resources for information about assessment and treatment?
There are chapters on evaluation and speech-language treatment in my book "Cleft Palate and Craniofacial Anomalies: Effects on Speech and Resonance." Handouts are available online.