Question
I am working with a 5 year old boy with phonological errors who is making great progress. We have just finished the first cycle with some carryover noted. However, the previous therapist did not write a goal/target for nasality, which significantly impact
Answer
Firstly, you should determine if the patient has any velopharyngeal insufficiency (VPI) that is structural in nature (i.e. hypernasality caused by a leak or opening in the VP port). If the patient is negative for VPI and has adequate port closure, no nasal emission, and adequate shut of nasal airflow during oral sounds then you may attempt some of the therapy activities listed below.
Speech therapy can be very effective in eliminating compensatory articulation productions through therapy. However, hypernasality, nasal air emission and weak consonants can be improved with therapy only under a few conditions. Therapy could be considered for these characteristics if they are mild and inconsistent and the child is stimulable for improvement. Although the literature does contain non-surgical approaches to treat the velopharyngeal mechanism, the preferred approach continues to be physical management via surgery and prosthetic devices.
Visual Feedback is one technique that may improve a patient's awareness of nasality in vowel productions. The Nasometer is a device manufactured by Kay-Pentax and is used to assess and treat nasality. Specifically, this device measures nasalance (ratio of oral and nasal SPL). The visual feedback is gained by placing the headset on the patient and asking them to read sentences loaded with high tense vowels (i.e. /i/, /I/ and eventually /e/). The Nasometer display shows a line at the nasalance level the patient is producing. The patient can watch the line and attempt to lower the nasalance by visual inspection. The clinician can also set a reference line at a specific nasalance value and ask the patient to attempt to produce less nasality (typically vowels have a nasalance below 10%).
Another technique that may yield positive results in reducing vowel nasality may be auditory discrimination training. Have the patient listen to hypernasal speech and then normal oral speech. The samples can be simulated by the clinician or by preparing samples from previous patients. A tube-like device can be constructed where the child can place one end to her ear and the other end under her nose and listen for the audible air emission of nasality that occurs. Kummer (2006), suggests that the feedback can be very "loud." The patient will then make adjustments to reduce the noise in her ear as a result of the nasal production. This technique may be useful for the vowel production of /e/ that you are hearing as being nasal.
Tactile-kinesthetic training involves the patient raising and lowering the velum during vowel sounds to produce nasal/oral contrasts. This has been indicated in increasing the velar sensation and control. You may want to use a tongue blade to lift the velum during the production of the vowel, if the patient has difficulty doing this independently. The best vowel to utilize is /ah/, as the oral cavity is very wide open during production. The patient would then contrast the aided production and the unaided production. If there is a large noticeable difference between the aided and unaided production then this patient may be a candidate for a palatal lift appliance. You may try your specific vowel /e/ using the same method.
Increasing oral volume and activity can also help with decreasing velopharyngeal orifice size. Specifically, increasing vocal effort has been linked to increasing anterior oral activity and increasing posterior oral movement (i.e. velar movement). You may liken the increased oral activity and effort to "mumbling" versus normal conversation. Basically, speaking with a greater oral opening can increase oral resonance enough to promote a noticeable change in intelligibility.
In closing, it is important to keep in mind that increased frequency and intensity of these exercises is paramount to success. The clinician will want to elicit as many responses as possible in one therapy session. Training specific muscles to the activity they will eventually perform is crucial for successful remediation (i.e. if you want to improve VP closure during speech then that is what needs to be practiced). Blowing and sucking have not been found to improve VP closure during connected speech tasks. If the child does not make progress through these remediation techniques then surgical intervention may have to be explored through a reputable craniofacial clinic.
References:
Kummer, A. W. (2006). Resonance disorders and nasal emission: Evaluation and treatment using low tech and "no tech procedures. Asha Leader, 11(4), 4, 26.
Nasometer II, 6400 (2008). Kay Pentax, a division of Pentax Medical Company, 2 Bridgewater Lane, Lncoln Park, NJ, 07035-14488.
Bridget A. Russell is an Associate Professor at the State University of New York Fredonia and directs the Speech Production Laboratory in the Youngerman Centers for Communicative Disorders at the University. She has published in the Journal of Speech, Hearing and Language (JSHLR), Speech and Voice Review. She has presented over 70 peer reviewed presentations at national and international conferences on voice and respiratory disorders. Dr. Russell also has served as an editorial consultant for JSHLR, National Science Foundation (NSF) and DelMar Publishing Group. Dr. Russell's research interests include voice disorders in children and adults, professional voice, and respiratory disorders of speech production.
