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Episode

Kate Grandbois: Hello everyone. Welcome to SLP Nerd Cast. Today's episode is a little different than our typical SLP Nerd Cast episode. I am here today with our resident doctor of speech language Pathology, Dr. Anna Paula Mui, and she is here to [00:02:00] answer a listener's question.

Welcome, Anna. Paula. 

Ana Paula Mumy: Thank you. I'm excited. 

Kate Grandbois: So today's question comes to us, um, out of a school-based setting, uh, related to persistent speech sound errors. Before we read the question and kind of get into all of the research that you did to answer this question, I do wanna quickly read our learning objectives.

Learning objective number one, explain the use of non-word facilitative contexts, contrastive stress, and repetitive drills to stimulate the production of difficult speech sounds and learning. Objective number two, describe essential motor learning principles for speech remediation. For anyone listening to this course for ASHA's CEUs, all of our financial and non-financial disclosures can be found on the website on the landing page.

The link to the landing page [00:03:00] should be in the show notes. You can also find the post-test to earn a certificate of completion or optional ashe's CE processing on our website. Any questions, email us [email protected]. Okay. Now that we've got that behind us, Anna, Paula, could you read us the clinical question?

Ana Paula Mumy: Yes. This clinical problem comes to us from Aana s on remediating severe lateral lisps, and she works in a public elementary school, is working with a fourth grader, um, nine years old, who has a severe lateral lisp when producing S-Z-S-H-C-H, and the just sound.

Um, this child has been in speech since he was se or excuse me, three and has made little to no progress. She's. Tried multiple strategies without success. So for example, she gave a few like E to the SH or the flat tire sound, or [00:04:00] a straw method for forward airflow, uh, butterfly method for correct tongue posture, auditory free feed.

So lots of different things, um, but reports that he demonstrates little motivation to change his, um, production and his speech. And she's also tried, um, shorter, more frequent sessions with him, um, sending speech work home. Um, but it sounds like productions are still incorrect. 

Kate Grandbois: That's a great summary. Um, I have not worked with a client like this myself, but I know what it's like to feel stuck. You know, you try, I. One intervention strategy doesn't work. You try another one, doesn't work. You change the service delivery model, you take an extra CE course.

So this is a, a feeling that I think a lot of us can identify with in terms of, um, running as fast as we can to stay still or throwing spaghetti at the wall and seeing what works, right? There's all these, you know, little, um, idioms for this feeling. I [00:05:00] would love to know what the literature says about this.

So what did you discover? Where did you go to? Uh, help answer this question.

Ana Paula Mumy: Yes. So I, I'm. Going to begin with a quick story. Just my first performance evaluation by a principal, um, when I started out in the schools, because it deals with a lateral lisp case. And I just, my mind went to that immediately. Um, so I was working with this child, very similar profile, so SHCH, lots of, um, distortions.

It was all. You know, lateral airflow happening. And my principal was, um, watching the session, of course, and he's just, you know, taking notes and he's observing me. And this is like my first or second year out of, you know, grad school or out of my cf. And so of course I'm nervous and I'm just going through my, um, little, you know, all, all the things that I, that I.

Did to, to try to, um, [00:06:00] I don't remember at this point if I was like gauging stim ability or whatever, but I was essentially like producing the error to show him the difference, right? And so I was like, you know, I'm just kind of doing this thing. And then, um, anyway, the, the child was done and he left, um, and.

We shut the door and my principal looks at me and he was like, how do you do that? Because he was just so in awe that I could actually mimic what was happening in his mouth. Oh, 

Kate Grandbois: interesting. 

Ana Paula Mumy: You know. Because he was like, I, yeah, sure, I hear the difference. Right. But he was like, I could never have isolated like what to do in my mouth to produce that error or to do what he was doing.

Right. And so that speaks to, um. Our understanding of lateral Yeah. Lateralization in terms of, you know, it's primarily a manner of, um, articulation [00:07:00] error, right? So we know that a lot of times maybe the place is correct, but we know that the issue here is that lateral airflow, right? And so he's not directing the airflow, um, you know, down the middle of his mouth, uh, or at the center.

And so. Even if the tongue is in the right place, sometimes that slush enough that distortion is the airflow path, right? That is incorrect. And so anyway, just I, I felt really, um, in, in that evaluation like, Hey, well, let me tell you, 

Kate Grandbois: I, I love that story. I also think it speaks to maybe the frustration of the person who wrote in.

Um, because sometimes we need to remind ourselves and validate that we do know. What we're doing, um, you know, we were trained explicitly in this, so even if it feels frustrating, um, keep going, right? Mm-hmm. We have, we have the right training. Yes, absolutely. So, okay, so where did you go from here? 

Ana Paula Mumy: Yeah, so one [00:08:00] of the best workshops that I've attended, um, in relation to these recurring issues, and I just wanna pull from some of, um, his programming just to illustrate some of the principles that I'm gonna cover.

Um, my colleague, his name is Steven Sachs, um, he developed. What is called the sat pack program. It's essentially a software for addressing articulation errors. Um, and it's a just a very systematic way to go about it. Um, and you can establish and then practice the target sounds in, in this systematic way.

And I'm not necessarily gonna go through the sat pack program, um, but I do want to just talk through some of those key components. Um, that I feel are important to consider, um, when we're tackling difficult sounds, um, particularly when we're talking about these persisting sounds that just. Don't seem to go away like lateral lis.

Um, I will do a side note here. Um, Steve does have an excellent three hour course that he offers for free Asha [00:09:00] CEUs on r and s, so I highly recommend that our, um, members access that course through him that I learned. Um, lots of different strategies and just a, a different way to address, um, some of these challenges.

Um, in terms of eliciting s. From the T Sound, for example. Um, calling it a long T and which we'll talk about here in a bit. But it just, um, helped me brainstorm and just think through, you know, some other possibilities. So with the long T and, and, and this is where, um, I, I think, um, plays into. Us utilizing, um, words or another context to help children arrive at something that if you just say, just, you know, just make the s like this, you know, they're gonna go back to their usual pattern or their, you know, air, um, they're not gonna be able to.

But if you are like, okay, can you make a tea? [00:10:00] And the child says, and then you say, okay, let's make it long now, right? So. And now they're, they are, they have this long T sound, um, which of course works beautifully, um, to direct airflow right down the middle and not out of the size of the mouth. And so we're using this, um, essentially facilitative context to, because we have the, we can make the tea.

We know most kids can produce the tea, right? And so then. If we can help them extend that T and think about it as a long T instead of an S, they don't have that previous association that they've already made. If you say do S, then they're gonna do, they're gonna revert back to that old pattern. And so, um.

Using that as kind of the, um, the trigger or, or the way to stimulate that sound and saying, okay, so we're not, let's, let's forget the s you know, we're gonna just talk about a different sound for now. Right? Almost like it's something completely different. And so starting there, [00:11:00] um, and then the key components being using non words, um, which ties to, again.

Trying to disassociate from any words that they're already accustomed to making in the wrong way. Right. And then the facilitative context, which I, I just talked about, um, natural posity, which, um, just plays into like, if we're gonna get to generalization, then we have to be able to practice words. In conversational context or in ways that mimic natural proses instead of it sounding robotic or like, they're still very much consciously aware, right, of how they're producing that sound because we want it to become, of course, more automatic.

And then, um, doing sometimes with that natural, we can do contrastive stress, which we'll talk about in terms of saying. The same sentence maybe, but in a different way, or emphasizing a different word where then you're kind of playing around with the intonation and you're contrasting the stress in some [00:12:00] way.

Um, a again, to try to get to generalization and then drill, drill, drill. We'll start with non words.

Because the child has no associations with non words, right? So real words, right, will trigger old patterns. Interesting. So we're essentially trying to like remove the interference, right, of old motor patterns and with non words. You can also present lots of similar words, but maybe with small changes to help the child develop.

A new consistent motor pattern for that particular sound. So, and I'm gonna provide an example from sat pack here in a bit with, uh, facilitative context. We're using carefully chosen words or syllables. So those are the, the context, but that naturally encourage a child to produce the difficult sound. Um, so the example.

Um, could be that, for example, with r you wouldn't wanna use maybe w words because [00:13:00] that rounding that ooh, is going to essentially, um, provoke the woo, right? So if you're trying to do away with the w you're not gonna choose that directly or, or right away, because that's gonna interfere, right? So. Thinking about what are those facilitative contexts?

What is it that might, um, reduce, again, more interference? So, um, when it comes to the, um, example, so going back to our long t if, um, so an example of a seed word is what Stevens program calls it, A seed word. Um. Where the long T is in the middle. So we're gonna say, you know, we're gonna do our long T sound and we're gonna put it in the, in the middle of, of these non words.

You know, they're just, you can call 'em whatever you want, you know, with the child. They're silly words, they're made up words, whatever. [00:14:00] So the, the seed word would be beat C, so beat seat. So they're actually doing it in medial position. And because the B is a bilabial and requires no tongue positioning, right?

The e of course gets the tongue wide and it's stabilized on the back molars. Um, and then the tip is already kind of in the Ovular area because of the T. Um, so you're kind of just making everything fit right and. Getting the tongue tip, the size, everything in motion in place. Um, and then of course you're getting the S by lengthening the duration of the T in the E, right?

So beat, beat seat, um, and it turns into that s um, followed by the e and the T to keep the tongue still in the same position, right? So you're not creating any interference. It's all EC, right? Um, now you don't necessarily want the, the child to be like. Because Right. The, the, that facial [00:15:00] ness you then would have to do away with that later.

Right, right. You don't, you want there to be as much naturalness as possible. Um, but that's the idea behind, you know, just using, um, a, a seed word that has that in the middle and then. What the PAC program provides, which you can do, which I'll show you here in a bit through like chat, GBT if you wanted to come up with words or targets is then the program just provides lots of variations.

So like beat seat, MIT seat wait seat, feet seat. Fe seat. Va seat. So the. Word variations include, um, different vows, different dip thongs. And once you establish and, um, stimulate the target, then you're just. Essentially kind of drilling through these words at a natural pla uh, pace, going through, um, multiple lists [00:16:00] with lots of accuracy and consistency, and then you're increasing the tempo while maintaining accuracy.

So you're wanting to start with, so maybe we're not doing like a. Be seat, MIT seat, wait seat. Fe seat. Vat seat. Maybe it's just, you know, be seat and there's a really prolonged, you know, production and then it's MIT seat. So you're starting very much, you know, at a slower pace, making sure that there's accuracy there.

You don't want to move into, um. Uh, a pace that's going to compromise the accuracy. Right? So, um, but then once you see that the child is able to sustain that correct production, then you would want to increase the speed to maintain accuracy because that's what's, um, going to bring that automaticity, right?

Because you're wanting them to. Just be able to do it and not even think about it. And it become essentially kind of second nature. Um, sometimes, like I've used [00:17:00] even a metronome for increasing and maintaining a steady tempo. Um, but again, the key is retaining the accuracy. So just so that kids can kind of, 'cause like I have natural rhythm and so I can keep a beat, but you know, there are kids that can't necessarily keep a beat in their head or so having something that's kind of.

Monitoring the beat or giving them that auditory cue for the beat so that they can stay, um, consistent can be helpful. For some kids, it may be a deterrent or it may like be something that just, uh, distracts too much and so it might not work right, but it's worth a try in terms of just getting them, you know, that practice.

Then we move into sentences with contrastive, um, stress. So for example, a boy bought a beat seat or I bought a beat seat, or a boy bought an old beat seat. So then you're just adding this non-word [00:18:00] right into these random sentences where they're putting it in and then you're seeing like, can they maintain the accuracy mm-hmm.

Of the production. Can they, um. Also alter the stress, you know, and be thinking about like natural posity in order to, um, continue, you know, with those correct productions. So you're just providing lots of opportunities for correct productions, but then in sentences mimicking natural posity and connected speech, or essentially not robotic conversation, right?

You want real conversational, um, flow. Does that make sense? 

Kate Grandbois: It does. And I've been smiling intermittently as you've been talking because it just sounds kind of fun. I, every time when you're saying like, bit seat, mi seat, I know I already said Dr. Seuss book, but I can just imagine having a lot of fun, kind of being silly with creating all of these, you know, extra sounds and made up words and, and all that kind [00:19:00] of stuff.

I also think this sounds so, um, I, I don't know, as you were talking, I have no. I had no previous exposure to these concepts, and so I'm coming at this very much with a novice lens and hearing you say, you know, talk about the influence of the context, right? So getting the kid. Out of their, getting the student out of their head, so to speak, in terms of, well, I'm not saying s I'm saying long.

T it makes so much sense. This, this, this feels very logical. Um, it feels, my reaction was like, well, duh, this is, that makes so much, that makes so much sense. Um, and I appreciate that there is this additional free resource we'll put

all of the links to this program and the free CEUs in the show notes. 

Ana Paula Mumy: Awesome. Yeah. Well, I'll touch on now just some of the principles of motor learning that are evident in this approach, um, which I think are important to, to talk through because there is, um, I, I think evidence to support [00:20:00] that when we think about motor learning principles, we, um, can only, um.

Grow and, and do better, right? When it comes to our approach to working with articulation. And so, you know, one being high repetition, high intensity. So we know we need lots and lots and lots and lots and lots and lots of trials, right? Um, two for new neuro pathways to form, right?

So, um, high repetition, high intensity. Um, but of course you don't want high repetition or intensity if the sound is not being produced accurately, right? Right. You want first to establish that sound and you don't want. The target sound to be still slushy or distorted. You want there to be accuracy and consistency before you can demand in a sense, right.

That high repetition. Um, and there's lots of ways, you know, I think this particular program, um, allows for that repetition to just happen seamlessly because there are wordless [00:21:00] lists and you're kind of playing through these word lists and, and you can, um. Have fun with it. Of course, it's not tied to, you know, games or, um, something else that would.

Potentially be more engaging for some kids versus others, but still, like, I think you can make it fun. You can, um, some kids that I've worked with have enjoyed using like a, a digital tracker, you know, so that they're right. Pressing something or somehow tallying themselves, you know, so there's different ways that you can, or different things you can use or ways that you can bring up that motivation to do lots of drill.

Um. Mm-hmm. But I think. When we're adding some kind of motor component or something that they're doing, um, it doesn't feel like drills, so then I think kids are more likely to engage in it. Um, the other thing is, of course, the repetitive drills. Then they're learning a new motor plan that's [00:22:00] needed, and then they're mixing targets and context to apply skills differently, um, and build that automaticity.

And then the contrastive stress. Part, um, promotes that generalization to connected speech. So, um, you have, you know, all these things kind of working together. Um, and then the, the last thing is, um, task complexity. So you're starting with more simplistic and then you're adjusting the difficulty as you go, right?

So first it's maybe just the seed word, you're saying it again and again. Maybe then you add some of the other words. Um. And then you're adding the, the speed component, right? So it's very much a gradual process, um, to get kids where you need them to get. Um, and you of course can be the judge of how to adjust that level of difficulty depending on how they're responding.

Um, so. An adaptation that you could use. So if you're not using the sat [00:23:00] pack program, um, if you wanted to, let's say, come up with a word list. So I, I played around with chat, GPT and if, if we were to say, starting with the, um, the long T sound, so that's, but in final position, let's say we start there. Um, this is where AI can be a great tool, and so I, I tend to use Claude, but chat, GPT of course would work too.

But here's the prompt that I put in. I said generate 20 words with that's, and I put, you know, ts in final position focusing on bi labials, labial dentals, and ERs in initial position. So again, I'm trying to exclude right potential. Confounding factors, right? Um, and then I said 10 words with e vowel, um, and 10 with a variety of vows and dip thongs.

So I was wanting some variation there in the vowels that were being used. So then it kind of spit out some options for me and it gave me 20 [00:24:00] words, non words that ended with, so, um. It came up with things like, you know, Peets Meats, FETs, even though FETs obviously is a word, but FETs is not. Um, Keets. Geets.

Now, I did also come up with some others like Preet or cleats. 

Kate Grandbois: Ooh, 

Ana Paula Mumy: um, like K-L-E-E-T-S, but. I would potentially exclude those. So like I went through and said, oh, mm, I don't think I would use this one. I don't think I would, I would use this one because, or like bets. 'cause now you're adding this like L component and you're adding a, A cluster, right?

Or, um, adding complexity with an R or. An l if those are also affected, which sometimes they are, right? So like 

Kate Grandbois: Right, 

Ana Paula Mumy: it'll depend on your child, of course. But I, I just am very mindful of, I don't want there to be any interference, so I'm gonna really just stick to [00:25:00] those, um, sounds that I know are going to be safe.

Right. So. Then some of the, um, very varied vowels in dip thongs. It had things like, uh, pots, fos, mutts, GOs, and it came up with lots of others. And I also had to remove a few, like, um. Quartz or pelts. 'cause again, LT or RT could potentially be more difficult. So I wanted something that was just really straight that kids can just go through more quickly.

So, um, that's just an example, right? Of. Coming up with words. Now, you, I could have asked for or put in my prompt where I wanted that to be in the middle, or I wanted that to be at the beginning, right? So I wanted that long T um, you could vary it up. Um, but then I can also then generate these simple sentences with non words for the practice, right?

So. I [00:26:00] eat whatever it is every day, or he eats blank every day, or do you eat blank every day? Um, and just coming up with kind of random. Um, and again, you can use chat GPT if you don't wanna sit there and think about 20 different or 10 different sentences, um, to insert this random non word. You can use a prompt to help you get there, um, and save you time.

Kate Grandbois: I, while you were talking a, a minute ago, um, just about the components of motor learning and the importance of getting a lot of trials and, uh, repetition, repetition, repetition, everything we know from motor learning science, it made me think of a story about my own, uh, experience early in my career where I had a mentor say to me.

That speech language pathology was both a science and an art. And the reason that I thought about that while you were [00:27:00] talking was, you know, you're, you're, you're talking about so much speech science, right? So choosing these nonsense words as a means of facilitating tongue placement and, and, and pressure and, and all of these different things that we know as speech pathologists, as as speech science.

But the art component here is choosing activities that are engaging, knowing the kiddo in front of you and adjusting your therapy based on their fatigue, based on their interests, right? To really try and facilitate as many trials as possible. In a way that is fun and engaging and aligned with that science of motor learning and speech science.

And I, I love this story because I feel like it's such a blend of that concept of, of science and art. Um, and of course my contribution is not at all scientific or helpful, but, but hopefully that, hopefully that resonated with someone. I dunno. 

Ana Paula Mumy: Absolutely. Um, and, you know, just to, I'll speak to that a little bit.

You know, I, [00:28:00] I say to my students that I teach, um, you know, in the professor role that I hold, I say that to them all the time. Articulation therapy is about essentially, um, doing the same thing, but in a hundred different ways, right? Mm-hmm. So you're having to find. All these different ways to engage the child, to do these drills, to do it over and over and over to where they're not pulling their hair out.

Right. And where they are willing and motivated and excited to do it. And so I use lots of different, you know, like chips, you know, um. Putting chips into a bucket or building a tower or, you know, there just, there's so many different ways that we can make the drill component not feel that way. Mm-hmm.

Because we do need a ton of repetitions. Right, right. The research shows we need a hundred plus repetitions, um, for there to be really, for it to affect change. Right. We need. Every session that we have, [00:29:00] you know, my target is always a minimum of, of a hundred repetitions, you know, and if you are in a group, especially, you know, in the school setting.

When you are working maybe with groups of two or three kids, or maybe even four kids, right? Right. You have to be super, um, intentional and like, okay, how is it that I'm gonna make sure that every child walks out of here with a hundred repetition? Right? So you have to just really plan, you know, um, an activity in a way that.

Yields that or, or is more conducive to that level of repetition? Because if you're just getting, you know, if you're playing a game and you end up with 10, 15 repetitions at the end of a game for each child, then you're not doing your job right. We're not doing, or we're not doing the best that we can for that student because we know they need lots and lots and lots of reps.

Kate Grandbois: Right. And of course, all of us work within the restrictions of our environments and our infrastructures. [00:30:00] Right? I mean, in terms of asking questions like, should this child even be seen in a group? And that's a whole other episode. You know, that's a, that's a whole other conversation. 

Ana Paula Mumy: Yes. 

Kate Grandbois: Um, I appreciate absolutely everything that you've brought to the table.

So much. Is there any other bits of wisdom that you would like to share with our audience before we wrap up? 

Ana Paula Mumy: Yeah, I just, two things came to mind that I haven't mentioned. One is, of course, I, I was strictly talking about the s although our reader, or our, our member was asking about, um, the, all the, the fricatives, right?

The sh, the ch. So the same process of course would, would take place. And once they figure out that, um, airflow that is more centralized, it's easier than to. Add that on, you know, to the other sounds. So sometimes, um, you may not even have to necessarily address all of them individually. Mm-hmm. Um, once they figure out like, oh, for shh, and, and, and eng, right?

All of [00:31:00] these have that central airflow, um, you may not have to directly address all of them. So hopefully there's a little bit of carryover that's just a byproduct of working on that central airflow. Um, and then the last thing I would say is just when it comes to homework, because I know that a lot of times, um, individuals, you know, uh, we, we like to send home things for kids to do and I am not for homework until the child is a hundred percent easily simul and consistent because I feel like.

I don't wanna put parents in a position where they have to teach the sound. Right. Um, or even where, like, do they really know how to correct or how to give feedback? Um, they, in my mind, it, they're just mere facilitators of maybe that short practice. And I say to parents like, three minutes, you know? Your child can get to a hundred [00:32:00] repetitions in three minutes.

You know, I don't want, not, not even, you know, five, like literally we could get, you know, if he says 10 words, 10 times, he gets to a hundred repetitions, you know? And so I just, um. Encourage families to, once there is that consistency, and I know that they're not gonna have to be correcting them, um, I say, you know, find a time that you can build into your existing routine right within your day.

So maybe it makes sense to do it right after snack when you get home from school. Or maybe it's right before you brush your teeth, um, before you go to bed, right? So that it's that consistent thing that's happening every week and every day, or at least, you know, three to five times a week. Um, so that. It feels manageable and within the family structure, within the family schedule, so that it's not something that is too difficult, you know, for parents to, um, essentially encourage.

Um, but again, I just never, ever, ever will send home homework if I don't feel like the [00:33:00] child is fully stimulus and, and really consistent with me first. 

Kate Grandbois: I think that's a great suggestion. And while you were mentioning all of the brilliant reasons you had for that suggestion, I also thought of wanting to make sure that we're controlling for positive experiences so that producing those sounds 

Ana Paula Mumy: mm-hmm.

Kate Grandbois: Doesn't get associated with something that's frustrating or something that's negative. Right. We wanna set up our kids for as much success, our clients for as much success as possible. Um, and it's really hard to do that if you send them out into the wild with something that's just. Too difficult for them to do without scaffolding, prompting, feedback, all of those kinds of things.

So, um, I appreciate all of that. Thank you so much for your time and for doing all of this research. We really, really appreciate it. Um, and I look forward to having you back against. Soon to talk more about our, uh, listener questions. It's been a really wonderful experience for us to read all of these questions that come in.

Um, for anyone [00:34:00] listening who would like to use this episode for ASHA's CEUs, you can find all of the information about this course, course disclosure course Disclosures, financial and Non-Financial Disclosures on our website. You can also find a link to the website and the post-test in the show notes.

Thank you so much again, Anna, Paula, for being here. 

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Announcer: Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study.

Please check in with your governing bodies or you can go to our website, www.slpnerdcast.com all of the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at [email protected]

thank you so much for joining us and we hope to welcome you back here again soon.

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