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Monday, August 30, 2010

Back To School Screenings and Evaluations -Part 4

Itʼs Monday again! Todayʼs entry will be short and sweet. Iʼll be talking about S/Z ratios. I am not an expert on voice nor would I ever pretend to be. Infact, I inwardly donʼt even feel competent to work with that impairment, although Iʼve attended training sessions from the best in our field. When Iʼm screening a child, if I hear a suspected voice disorder I will literally cringe. That is my least favorite disorder, but we all have to deal with what comes our way.

Voice disorders make up a very small percentage of our case loads therefore we donʼt encounter them frequently. Sometimes we cannot readily recall the information we need in making our initial screening judgements. Remembering how to do obtain the S/Z rations may have slipped out minds, as well as what is acceptable, and when to refer, so here is a quick refresher on S/Z rations.

You will need a stopwatch to time the sound durations.
1.Ask the child to take a deep breath and produce the /s/ for as long as they can. (I demonstrate this) Record the number of seconds he was able to sustain the /s/.
2.Now ask the child to do the same thing but saying the /z/ sound and record that time.
3.Repeat the above steps until you have 3 samples of /s/ and of /z/.
4.Calculate the S/Z ration by dividing the longest /s/ that was produced by the longest /z/ that was produced.

Now that you have your calculation what does that tell you? In a nutshell, A NORMAL RATIO IS BETWEEN 0.6-1.4 If the child has a ratio greater than 1.4 refer to an ENT.

TIP: The length of time a person can sustain a sound varies according to their age:

7-10 years old should be able to sustain a sound for 8 seconds;
11-15 years old should be able to go 12 seconds;
16 - adult female about 15 seconds;
16 - adult males about 20 seconds.

NOTE: If the child canʼt sustain the sound for the appropriate length of time after several trials Iʼd want to rule out issues affecting breath support such as dysarthria.

The factual information in this blog came from this website:

Next Monday I want to address mastery guidelines for articulation and using them when making placement decisions. Enjoy your kids this week!

Sunday, August 22, 2010

Back to School Screenings and Evaluations-Part 3: Submucosal Clefts

Good Morning! I hope you are well caffeinated and ready to start another week with enthusiasm.

Todayʼs entry is predominately for the “mature” SLP who has been out of school for a while. This little nugget of information has to do with submucosal clefts. In my 35 years, I can only recall having one sub-mucosal cleft on my case load, which happened in the later part of my career, at least 25 years after I had completed my education. So did I recall what to look for or what was significant when staring into that childʼs mouth? No, of course not, and letʼs be honest here, neither would you. I can remember looking and not seeing anything remarkably unusual, but fully expecting to see his entire palate missing from the way he sounded. He sounded like he had a full fledged cleft of the palate, but everything “looked ok” not what I had seen from the few cleft cases I had seen in the past. I was stumped, so I called upon a very dear university professor, who gave a day of his life to drive the 6 hour trip to my school to help me with this child. Not only did he help me, but he also instructed me so that if I ever encountered it again I would know what to do. So please allow me to share with you the simple little things I learned and/or refresh your memory if youʼve been out of school for a few years.

There are 3 clinical signs of a submucosal cleft.
1.A bifid uvula. The uvula will be split, but does not have to be split all the way. It can sometimes be divided slightly or might even just be dimpled.
2. V-notch. With a gloved hand you can run your finger down the midline of the palate and just where the soft and hard palate meet you will feel an inverted “V” This is where the palatal shelves did not completely come together.
3.Zona pellucidum. You will see a blue line running anterior to posterior down the mid-line of the palate.

NOTE: You do NOT have to have all 3 signs to have a cleft. If you come across any of these, on a child who sounds very nasal, Iʼd refer just to “rule out” a possible submucosal cleft. The child I have been talking about did not have a blue line and only a slight divide on his uvula. He did, however, have a V-notch but I didnʼt know to check for that.

Also, in my career I only had the opportunity to work with 3 children who had clefts of the lip and palate, so deciding what I should do with them usually involved much time refreshing and researching the topic. So if you are facing a similar situation and canʼt recall what you are to do with them, this website would be a good starting place.
This link provides you with a succinct outline of your role as an SLP on the cleft team, as well as what you are to do at every age from birth to adult. The site is a little gold nugget in and of itself.

I hope this helps you should you find yourself faced with a similar situation this year. If not perhaps you can keep this as a quick reference guide.

Next week, will be a very quick refresher on S/Z ratios. Have fun with your kids this week and Iʼll see you next Monday!

Sunday, August 15, 2010

Back to School Screenings and Evaluations-Part 2

Last Monday, I talked about the importance of doing a complete oral exam and focused on nasality screening. Today I want to talk about and open a discussion on the importance of doing those diadochokinetic rates.

How many times have you been tempted to just skip over those because the child does not “appear” to have motor sequencing issues? Or, as one SLP said to me, “He does not have his back sounds (/k/-/g/) so we canʼt do that.” With eyebrows raised in astonishment I say, “What? Oh but yes you can!” There are ways to screen for motor sequencing issues without back or even front sounds.

Typically we have the child do the puh-tuh-kuh, or buttercup, or maybe patty-cake. So what do you do when they donʼt have those back sounds? You have them say a rapid sequence of tip-lip-tip movements by saying “lippity-lippity-lou.” You do not time them as you would the puh-tuh-kuhs. You simply have them say it quickly three times. Can they sequence those oral movements efficiently? Now should the /l/ be missing from their repertoire have them say “dippity-dippity-doo.” If they donʼt have any front sounds (/t/-,/d/) at all have them say “gippity-gippity-goo.” If you hear "gippy-gippy-goo" with the omission of /t/ don't worry about it. They are giving you a rapid back to lip-back to lip-back sequence. Again remember you are screening for motor sequencing not the articulation of sounds. Regardless of which sound pattern you have them do, the scoring is the same: can they say it three times, rapidly, fluidly, without breaking down. Remember the focus of this particular screening task is for the detection of possible motor sequencing issues and to determine the need for further testing in that area. And too, remember this is just a screening task not an entire oral motor evaluation.

There has been much discussion in later years regarding is it apraxia or a severe phonological disorder. In my opinion, the best place to start is with a simple check of diadochokinetic rates and the above tips should allow you to check those on any child.

Next week, I will be talking about sub-mucosal clefts. Until then, have a great week with your kids!

Disclaimer: You are reading a blog which is just our opinions and our tips and tricks. It is not intended to replace sound teachings.

Monday, August 9, 2010

Back to School Screenings and Evaluations-Part 1

It’s Monday! I’m ready and raring to go with this first series that I’m calling “Back to School Screenings and Evaluations.” When pondering where to begin all these blogs, I let mass screenings be my deciding factor. These first six blogs will all relate to screenings, evaluations, and placement considerations.

I felt the most appropriate place to start would be with a quick refresher of the oral mechanism examination. If your workload is anything like that which I faced, you’ll find yourself rushing through the oral mech or just doing a cursory exam. I found, after doing therapy for many years, that when a child presented as a simple artic disorder my exams tended to consist of a quick look inside the mouth and a few basic tongue movements. Not good. You’ll get into therapy and a few weeks or possibly months later find that this kid has an oral deficit that you didn’t pick up during the oral exam. So you have to back up and start again and that might even involve having to rewrite your IEP goals/benchmarks/objectives, and that means scheduling another meeting. You really don’t want to have to do another meeting do you? Me either! So do a thorough oral exam the first time and avoid creating headaches for yourself later in the year. The time spent now will save you frustrations later.

I can’t recommend one specific exam over another, but I can strongly urge you to do a complete exam. Beyond checking the structure and function of the lips, teeth, tongue, and palate, you need to really look at and note ALL findings. Many times we do note them on the oral mech record sheet but then ignore it as insignificant when considering the child’s overall assessment, or can’t remember what the implication of that would be. The next few blogs will target some of these, but today I’ll simply refresh your memory regarding nasality.

A quick screen for nasality is to simply have the child occlude their nostrils and say “oo”. I always demonstrate the procedure as I give the direction. The sound should be produced completely out the mouth. There should be no sound from the nose. If you hear nasality have the child try it two more times with additional instruction on how to do it correctly. Some children just don’t understand what to do the first time, and can be successful on subsequent attempts. If they are unable to do this correctly after three attempts, then that is a red flag that you should consider referral to an ENT.

Now for a refresher tip: when I am looking in the child’s mouth instead of having them say “ah” I have them say “uh-uh-uh” (three short repetitive sounds) because it lifts the velum higher and more than once, so I can clearly see the movement. Is it lifting up as it should? Is it lifting on one side higher than the other? This is your first indicator of possible neurological involvement (nerve damage) or velopharyngeal incompetency or insufficiency.

NOTE: Velopharyngeal insufficiency and incompetency are NOT interchangeable terms. Velopharyngeal insufficiency is an anatomical defect. It is a physical problem and could warrant surgery. You do not do therapy for that.
Velopharyngeal incompetence is not anatomical. It is an articulation problem and you would address it in therapy.