“And then I watched her perform the speech and language stimulation and it looked like I was doing it,
and noticing she had a certain confidence and was doing quite well!
Then I realized it wasn’t me, it was the person I mentored.” -Ittleman 2005-
The other day I was working with a caregiver whose son had been in a motor vehicle accident. He was left with an apraxia, dysarthria, and an expressive aphasia. For the layperson or student, he had difficulty articulating accurately, even with intensive articulation stimulation. The words he was having difficulty with had to be broken down into individual syllables, and articulator placement stimulation had to be done before the actual attempt at speaking.
When I was a speech pathology student it was always a cardinal rule that placement of the articulators was a prerequisite prior to verbal production of the target sound or the phoneme. Correct articulation of a sound is often rather simple to stimulate with many clients if they have a good “eye” and “ear,” but with this young man the speech model a.k.a. therapist had to break a complex word down into syllables and assure the sounds within those syllables were said accurately. Even though this young adult had a moderate to severe apraxia, he was stimulable to produce words accurately if the correct principles of articulation therapy were followed.
But that’s not the point of this article. This young man also had a severe expressive aphasia and receptive language component. That means he had severe trouble finding the words he wanted to express in addition to severe difficulty comprehending spoken language when it was directed to him in rapid succession; typical of the way normal speakers communicate with machine gun-like speech rate.
So what is the approach to speech and language stimulation for this person whose speech was almost completely unintelligible (apraxia), who couldn’t comprehend normal spoken language (receptive aphasia), and who had lost the ability to string simple word pairs or phrases-sentences together? (aphasia)
- Stimulate only single 1 or 2 syllable words (eat, drink, play, sing, go, talk,) or
2 word phrases of single syllable words (drink milk, play guitar, play chess etc. in response to very short questions.
- Cue speech with intensive mirroring (as outlined in The Teaching of Talking text) with very slow, over-articulated model, face to face within 3’. Speech model and the person with the communication difficulty moving their articulators in unison. (like dancing a waltz, slow dance, fox trot, or 2-step)
- Cue speech visually and auditorally with written-printed cues if necessary, and facial prompts by having him watch and mirror correct movement of the articulators and production of words. The speech model prolongs the vowels of each syllable in words in order to have the client see and hear each syllable, while maintaining 2-3 syllable expressive utterances. (The client has an immediate memory for only 1-3 words.) Therefore questions posed were only in 2-3 word strings by the speech model/therapist since that was the length he could comprehend.
- To deal with the dysarthria he was given models of 1-3 words with latency of about 1 second between words. This also gave him time to process and decode what was said. Many beginning clinicians and caregivers do not realize that often people who have symptoms like this need a considerable amount of time to decode or comprehend, therefore necessitating spoon-feeding language in small, bite-sized units. In this way language can be digested and realized.
The point is that students, inexperienced therapists or caregivers can learn to do speech and language stimulation like an expert if they have an expert to model. An expert who can demonstrate a procedure and then immediately have the “student” do it. Speech and language stimulation can be like a round robin. The expert or therapist models the procedure that gets successful recognition, comprehension, and imitation and then immediately gives the same task to the student or caregiver. This is then repeated for each utterance stimulated in the session: therapist—>client for the first successful trial followed by caregiver–>client until trial is accomplished successfully in a similar manner.
It is amazing for the Master to see a student or caregiver after training, do speech and language stimulation with confidence, efficiency and accuracy. He is also impressed that the complex tasks that took him so much time to acquire are easily learned by working with both the caregiver or student and the client simultaneously; Therefore the process teaches the therapist or caregiver, while improving the speaking of the client.