發展遲緩介入治療之新趨勢 :語言治療

Current Speech Therapy for Children with Current Speech Therapy for Children with Developmental DelayDevelopmental Delay

Emily Lin, PhD ( 林永芬 )Department of Communication Disorders

University of CanterburyChristchurch, New Zealand

Taiwan Academy of Physical Medicine and Rehabilitation Conference:

Current Intervention for Children with Developmental Delay Taoyuan, TaiwanDecember 2, 2006

大綱• 背景

發展遲緩兒童 語言治療的過去和現在﹕以聽障兒童為例 語言 / 言語發展遲緩 語言 / 言語發展里程碑

• 發展遲緩兒童的語言 / 言語障礙分類• 語言 / 言語障礙的諮商和評估• 語言治療

原則和方法 未來方向

(E. Lin)

發展遲緩兒童(Children with Developmental Delay)

• Definition: young children who are below expectations in one or more areas of development

• Population: children who are at risk for becoming disabled or who do have a disability present, including those with:

genetic disorders present at birth delays in speech and language development visual and/or hearing impairment emotional and behavioural problems medical and physical problems resulting from a premature birth

Note: diagnostic assessment vs. functional assessment (c.f., Down Syndrome, autism)

(Benner, 2003)(E. Lin)

• 早期介入治療 (early intervention): more likely to target those with:

at least 40% delay in one developmental domain* or at least 25% delay in at least 2 developmental domains

*The 4 developmental domains to consider are: Cognition Language and communication Gross and fine motor development Social-emotional development

(Benner, 2003)

(E. Lin)

問題的惡化 : 骨牌效應 (Domino/cascading Effects Model of Risk)

例如 (Oller et al., 2006):

• 一個輕微的聽力問題 , 會擴大成為溝通和學習障礙• 生理發展問題會影響心理發展 , 進而造成認知和行為問題• 心智和行為障礙 , 會降低溝通和社交發展

(E. Lin)

語言治療的過去和現在﹕以聽障兒童為例

(E. Lin)

過去 現在•問題發現較晚•聽到聲音較晚•老舊的科技•入學較晚•期待低•音聲品質差•專業協助少•治療方式和範圍局限

•發現問題的敏感度高•測試和治療科技先進 - 早期聽力測驗 - 早期聽力輔助 - 早期介入語言治療 - 助聽器品質提昇 - 人工電子耳

•口語訓練增強

(Gustus et al., 2006)

語言遲緩 (Speech/Language Delay)

和發展障礙 (Developmental disability) 的關係

• 語言發展在出生後前幾年迅速發展• 語言發展遲緩通常是發展障礙的第一警訊

e.g., auditory expressive language development: “Rule of 4s” (Coplan, 1985):The child’s age divided by 4 = the proportion of the child’s speech that should be understandable to strangers.1 year-old: 1/42 year-old: 2/43 year-old: 3/44 year-old: 4/4

(E. Lin)

語言的定義

(E. Lin)

語音Phonology

語意Semantics

語法Syntax

語用Pragmatics

語言Language

接收Receptive

表達Expressive

•語言 (language): 包括口語和非口語的接收和表達•言語 (speech): 儘包括口語表達

言語表達的形成

(Bernthal & Bankson, 1988, p. 8)(E. Lin)

Normal Language Development• Auditory expressive language development

– Vocalizations– Vocabulary size– Speech intelligibility

• Auditory receptive language development– Alerting to sound (cessation of sucking, eye widening, heart rate changes)– Orienting to sound (e.g., failure to orient to a bell at 8 months of age despite normal hearing

is associated with increased likelihood of language disability at age 8 years, Winitz & Darley, 1980)

– Following commands

• Visual language development– Visual recognition of faces (6-10 weeks) and later objects– Gesturing (e.g., visual-auditory association by 6 months of age, engaging in gesture games

by 7-9 months, finger pointing by 12 months of age, finger counting around age 3 years)

• Other features of speech and language– Pragmatics (e.g., by 3 months of age, taking turns in “conversation”; often impaired in

autism)– Prosody (e.g., often impaired in autism)– Fluency– Voice

(Coplan, 1993)(E. Lin)

Disorders of Speech and Language Development• Affected: 10-15% of all preschool children• Language features differ in various developmental

disabilities.Prevalence & signs:– Developmental language disorders: 5-10%– Mental retardation: 3% of children (50% of children with CP are

mentally retarded)– Hearing loss: 1/1000 children born with severe to profound bilateral

hearing loss; 1% with permanent partial hearing loss (15% of children with CP have some degree of sensorineural hearing loss).

– Dysarthria: 3 per 1,000; symptoms: excessive drooling for age, grimacing, involuntary facial movements

– Autism: 2-4 children per 10,000 (60-70 per 10,000 with mild form)– Stuttering: warning signs include more than 4 years of age, impaired

fluency (the shorter the repeated segment, the greater the likelihood of stuttering) greater than 6 months, history of stuttering in sibling or parent, signs of distress

– Voice disorders/anatomic abnormalities(Coplan, 1993)

(E. Lin)

言語發展與身體構造發展的關係

(E. Lin)

例如 :

(Kent & Murray, 1982; from Bernthal & Bankson, 1988, p. 73)

兒童的•聲腔較短•咽腔較短•舌頭較前•口咽道轉折較淺•聲帶位置較高•軟顎咽部位和會厭軟骨 較近 ( 所以鼻音較重 )

(Bernthal & Bankson, 1988)

平常 (Common)

(E. Lin)

語言 / 言語發展遲緩

無臨床意義(Nonclinical)

具臨床意義(Clinical)

不平常 (uncommon)

異常(disorder)

正常發展錯誤(normal

developmental errors)

遲緩(delay)

平常 (common)

語言 / 言語發展里程碑(Milestones of Speech/Language Development)

• 瞭解的目的 : 及時辨識是否有面臨障礙的風險 (identify risks)

區分不同障礙所面對的問題 (differential diagnosis)

以便治療 ( 治療目的 : 防止惡化 , 改善問題 )

(Oller et al., 2006)

(E. Lin)

1 month 2 months 3 months 6 months5 months4 months

able to discriminatebetween languages(mostly likely basedon rhythm)able to differentiatehappy speech fromother emotionalstates in their nativelanguage

able toassociate lipshaping withvowel

entrainment (interactional synchrony) inbodily movementshow orientation responserespond to social interaction (peekaboo)

cryvocalizationwith limitedresonance;(nearly)closed mouthsyllabic nasal

PhonationStage

vocal play (squealing, growling, yelling,bilabial trills)adult-like vowelsmarginal babbling

Expansion Stage

velar consonant likesound ("goo")some sign ofsyllabificationlaugh

Cooing Stage

(E. Lin)

Speech/language Milestones: 1 - 6 months

7-8 months 1.5 years 2 years1 year 3 years

Jargon b, d, m, n10-20 words2-wordcombinations

CV repetitionuseintonationalcontours forsocialfunctions

CanonicalBabbling

First trueword(people ornouns)Imitationstops, nasals3-5 words

VariegatedBabbling

k,g,ng,f,s

recognize own nameunderstand simpleinstructions & actionsinitiate gestures &sounds

recognizepicturesuse verbalrequestpoint,gesture, &followsimplecommands

understand dailyroutines

p, t, w, hsentencelength:2 words onaverage;up to 3words

understand questionsuse own name & negativevocabulary: 300 wordsincreased attention span

name color(s)vocabulary:1000 words2nd orderpredicates

identify objects by functionidentify conceptsanswer "where" questionscombine verbs & nouns

z90% vowelsanddipthongs;2/3consonantssentencelength:3-4 words

2.5 years

(E. Lin)

Speech/language Milestones: 7 months - 3 years

Speech/language Milestones: 4 - 8 years

4 years

follow 2-3 stepcommandsask questionsunderstand &verbalizespatialconcepts

8 years

v, j,affricates,liquid (l, r)sentencelength:4-5 words

understand oppositesidentify spatialconceptsuse many sentencetypesable to distinguishpretending fromnonplay activities

5 years

generate creative sentenceunderstand time/space conceptsreport a coherent narrative sequence ofeventssharply distinguish innocent errors &deliberate lies

th, shsentencelength:5-6 words

phonologicalawareness skillssound segmentationskills

6 years 7 years

(E. Lin)

發展遲緩兒童的語言 / 言語障礙

溝通障礙的分類可根據 :• 病因 (etiology)• 症狀 (symptomology):

認知和心智能力 感情 ﹑ 情緒 ﹑ 行為 身體狀況 : 感覺 ﹑ 動作 ﹑ 神經生理

• 治療 (therapy): 醫藥 飲食 復健 ( 動作 ﹑ 構音 ﹑ 音聲 ﹑ 輔助溝通 ﹑ 吞嚥 )

(E. Lin)

(Oller et al., 2006)

• 醫師諮商治療師是需要獲得 : 診斷建議 治療建議 測驗或程序的執行 (Lee et al., 1983)

• 語言治療師應及時描述 : 語言運作特徵 運動性言語或音聲症狀 口腔運動能力

(Guilford et al., 2007)

語言 / 言語障礙的諮商和評估

(E. Lin)

• 評估方法 Perceptual

Descriptive Rating Standardized vs. criterion-based

Instrumental Acoustic Physiological

Nasometer Airflow (spirometer, pressure transducer) Electropalatography Electromagnetic articulography Strain gauge Visual tracking device etc.

語言 / 言語障礙的諮商和評估

(E. Lin)

語言治療 : 原則和方法

• 療程三部曲 (Bernthal & Bankson, 1988):

引伸(facilitation of generalization)

維持(maintenance)

(E. Lin)

確立(establishment)

Two levels of generalization:• Linguistic context• Situational

語言治療 : 原則和方法

(E. Lin)

TherapeuticApproach

認知(cognitive)

語言(linguistic)

運動(motor)

語言治療 : 原則和方法

(E. Lin)

Therapy Structure

(Shriberg & Kwiatkowski, 1982)

Drill DrillPlay

StructuredPlay

Play

TargetResponse

Instructionalplay-like activity

Response

Motivation

Instructionalstimulus

Response

Instructionalstimulus

Response

• Key teaching strategies: Direct modeling Indirect modeling Shaping by successive approximation Prompts Fading Expansion Negative practice Target-specific feedback

(Roth & Worthington, 2005)(E. Lin)

語言治療 : 原則和方法

語言治療 : 原則和方法

(E. Lin)

I. Articulation disorders:• Motor approach:

Traditional (Perceptual + production training): Van Riper (1939, 1978), Powers (1957, 1971), Winitz (1975),

Van Riper & Emerick (1984)

Multiple phonemic: McCabe & Bradley (1975)

Programmed conditioning: Baker & Ryan (1971)

Stimulus shift: McLean et al. (1976)

Sensory-motor: McDonald (1964)

Paired-stimuli: Weston & Irwin (1971)

Auditory-verbal therapy: Estabrooks (1994)

語言治療 : 原則和方法

(E. Lin)

• Cognitive-linguistic approach: Distinctive features:

McReynolds & Bennett (1972) Costello & Onstein (1976) Weiner & Bankson (1978) Blache (1985)

Phonological Processes: Auditory bombardment (Hodson & Paden, 1983) Elimination of instability, elimination of homonyms, &

establishment of new contrasts (Ingram, 1976) Minimal contrast therapy (La Riviere et al., 1974;

Elbert et al., 1980; Weiner, 1981) Phonological awareness (Gillon & Dodd, 1994; McLeod & Bleile,

2004)

語言治療 : 原則和方法

(E. Lin)

II. Voice Abnormality (Andrews, 1999):

For example,

• Hearing impairment:e.g., activities to improve vocal quality, resonance, vocal variety, rhythm &

rate, pitch, auditory, oral, tactile & visual monitoring

• Cerebral palsy: Facilitative strategies Compensatory strategies: e.g., phrasing, slow rate of speech, phonetic

approximation Early intervention & parent involvement Behavioral therapy: e.g., elimination of undesirable habits Posture & physical manipulation Treatment of velopharyngeal incompetence

Use of Appropriate Positioning

(E. Lin)

(Workinger, 2005)

Jaw Control

(E. Lin)

(Workinger, 2005)

• Modification of environment• Behavioral therapy:

Whole language approach: Gibbs & Carswell (1991), Kumin (1998)

Social stories: Norris and Dattilo (1999)

Picture Exchange Communication System (PECS): Frost & Bondy (2002)

TEACCH (treatment and education of autistic and communications impaired handicapped children):

Jordan (1999)

語言治療 : 原則和方法III. Others (Autism, Down Syndrome, etc.)

(E. Lin)

語言治療 : 未來方向

• Early intervention• Higher expectations• Holistic approach

– More parent involvement– Specialized & Interdisciplinary– Multidimensional assessment/management

• More technological advances– Instrumental measurement– Biofeedback device– Assistive and Augmentative Communication

• Multi-cultural sensitivity

(E. Lin)

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