2.03.2014

Remediating Lateral and Frontal Lisp

Ms. B the SLP is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to amazon.com. 

I learned nothing about remediating lisps in grad school! How could this be? I can transcribe like a boss using the IPA, calculate MLU in my sleep, rattle off the order of acquisition of speech sounds... But fix a lisp? No clue. Until I was thrown into an elementary school, that is! I quickly realized I was going to have to figure it out on my own. MNSU has done a great job collecting the resources out there, and I found some other helpful sites as well. Some of my favorite are:

Tricky Sounds: Correcting for Lateralized Airflow (Lisa Geary)

I've recently created my own resource available for purchase on TeacherPayTeachers. It gives therapy plans, activities, and parent education handouts for the first month of treatment. I promise it is worth the $3 :)

Perhaps the most thought-provoking seminar I've attended in my professional career thus far was at the ASHA conference this year. Stephen Sacks gave a presentation on thSystematic Articulation Training Program Accessing Computers (SATPAC) program. This program systematically generates individualized lists of targets to promote rapid acquisition of even the most stubborn speech sounds (r, s), and avoids other speech errors. Sacks has been a school SLP for 33 years, works closely with artic genius Pam Marshalla (her books are all on my materials wishlist) and is also the recipient of the 2011 ASHA Rolland J. Van Hattum Award, given for "outstanding commitment and contribution to the delivery of speech-language pathology services in a school setting" soooo I think we can trust what he has to say :). To be clear, I haven't purchased the program, nor do I endorse it's content. The advice I'm presenting to you was delivered at the conference and I've put it to use time and time again in my own therapy. So it's anecdotal at best, but coming down from a great clinician with a credible articulation program. 

With that caveat noted, here's what I learned - gathered from all sources mentioned above:

1). Start at the very beginning! (Great, I have Julie Andrews in my head now!). Difficulty with tongue spreading, front/back differentiation, and jaw stabilization are typically underlying problems associated with lisping. In order to correct these, it is important to do some pre-practice training in order to increase the child's awareness of different parts of the articulatory system. I like to use a tongue depressor or lolli to train the child to recognize the side, tip, front, and back of the tongue. It is also helpful tactile feedback to have the child gently bite the sides of his tongue with back teeth (as long as you reinforce that they do not do this while speaking!). The ability to narrow, or point, the tongue tip is also very important. If the child is not able to do this, you'll want to start with "tongue pops," where the child says "eeeeee" then pops tongue by sucking air and releasing. "Eeeee-pop freeze tag" (instruct child to do an "eeee-pop" but freeze on your command - tell them to freeze when tongue hits alveolar ridge) is helpful to train tongue differentiation. Use of an infant tongue depressor slid back between molars can help reinforce the degree to which the jaw should be open during production of "tttts."

2). Don't be afraid to use nonsense words! I know, I know, the jury is still out about this advice. But from my experience, when dealing with a habit reinforced behavior, associated with stigma and frustration, nonsense words often allow students to focus on placement without interference of all of that other junk. For example, I started working with one student whose eyes welled up with tears whenever I even mentioned the "s" sound. But after using silly words like "peets" and "beetsi" in therapy, she has made exponential progress and actually requests to work on her /s/ now (and we moved to real words after only 3 sessions).

3). Use the entire bag of tricks. Some kids are going to respond well to visuals, others are going to need you to break out the lollipops and give some tactile information. I've used straws to demonstrate streaming air, tongue depressors, play doh and yogurt cups to demonstrate the tongue in the oral space, videos of other therapy sessions... Whatever you can think of, DO IT! Every kid is different and will benefit from different  kinds of information.

4). Shape target using principles of coarticulation. The /t/ sound has a powerful influence on the correct placement/production of /s/. See Caroline Bowen's Butterfly Technique article for some wonderful tips and helpful imagery to teach. Before even thinking of working at the word level, I spend some time with the "long t," as Pepper Richardson calls it, the "lazy t," or as Sacks named it, the "French T." I don't even allow the student to try an /s/ until we've done a LOT of t-t-t-t-t-t-t-t-ssssssss. We always practice in front of a mirror (or PhotoBooth on the computer for more fun), and talk about where the articulators are placed, using kid language For example, "keep your tongue in it's cage" (behind the teeth). And my favorite, "Press your tongue elbows against your back teeth" (to facilitate tongue spreading and contact with molars. I'll actually have the kid put out their elbows like wings and put my hands against them while they push out - gives some concrete tactile reinforcement). Below is an example of a typical homework page I would give early on targeting the tsss sound in nonsense words. Grab your copy in my GoogleDocs

Don't stop with nonsense words! Continue using coarticulation to your advantage with /ts/ sentences and even /st, sn, sl/ inital blends. Lisa Beth Schopf has made a great list available on TPT. The Materials Exchange from Speaking of Speech has loads of s-blend stimuli if you're in need of some. Here is a more advanced version without facilitative contexts.

5) Practice sentences using a variety of inflectional contours. Too often we get stuck in carrier phrase land, and forget how helpful it can be to vary suprasegmental properties in order to facilitate generalization. A variety of questions, exclamations, and statements produced with the same targets can have wildly different degrees of difficulty for some students. Also remember to try to keep rate normalized in order to promote normal motor planning and earlier generalization, without prosodic disruption. Grab a short sentence level homework page with nonsense /ts/ words here.

6) Utilize principles of motor learning. As important as massed practice is (see below), you'll want to be sure that practice is distributed widely. That means, use high frequency, intense sessions rather than one longer session each week. I've seen the most gains with students that I see 10 minutes 4 times per week, than those that I see 1 time weekly for 40 minutes. See my Speedy Speech post for more on this. You also want to consider the type of practice during the session. Blocked practice (same target over and over again) is important in the initial learning stages, but random practice (different targets in succession) promotes better motor learning. Dice games, like the one above, can help you get in some random practice. I've also found that making the student wait a few seconds in between some of the repetitions helps facilitate motor learning (e.g., "Say "beetsi" each time I raise my finger." Do 3 trials in rapid succession, then pause for a few seconds before requesting the next production).

7) Kids love keeping their own data! I've found that the majority of my students can be trained to keep pretty accurate data on themselves, and this activity helps train meta-cognitive skills (crucial for artic remediation) as well as keeps them occupied and productive during group sessions so I can spend some individual time with each student. We've made it a goal to get each student to have least 50 productions each session. At first the kids thought that was impossible, but now I'm finding I can get 50-100 reps per student depending on the target. This massed practice ("drill and kill") is so important, but it can get a bit boring. I've eliminated most of the "games" from therapy, but I don't think the kids mind. Remember that focused attention is absolutely necessary for motor learning, so you'll need to spice things up a bit in order to keep attention throughout the session. Some of my favorite artic activities that don't limit the number of repetitions include:

  • Sheets of target sentences to use with dice - see examples above.
  • Memory with 2 sets of target cards (can branch up to phrase level)
  • Hopping Frogs - After a set number of repetitions, students earn a hopping frog. They keep it in a bin in front of them (no wandering hands!) until the end of therapy, when they can try to hop each frog back into the bucket. I set the rule that each frog only gets one turn - if you miss you pick it up and put it in! This way, we're done in 30 seconds :)
  • Partner practice - Again, kids love keeping data! Partner them up and give on student a clipboard with a grid. Instruct them to make check when they hear correct productions, minuses when they don't Of course, you'll want to make sure you're guiding the data collection to help train their ear
  • Ball toss - I like the Velcro mitts the best. Each time you get the ball you say your phrase 3 times. We won't do this the whole session, and it gets put away if it gets rambunctious.
  • Angry Birds - I'll set up Angry Birds on a separate table. After a set number of repetitions, the student can go to the table, take one shot, and then come back. This and other mini breaks that get the student up and moving are great.
  • Stations - Once again, getting the students moving around is great to prevent fatigue, and there have been some studies that show that learning and memory are improved with motion. I will tape targets or sentence pages up on the walls, and the students move from one to the next to practice phrases. 
  • BOOM! Put pieces of paper with numbers 2-5 on them. Add in a couple that just say "BOOM." The student pulls a piece of paper before their turn to determine the number of times they must say the target. After producing the target, the student earns a chip (or the actual card if using picture cards). If the student draws "BOOM," he must say each of the targets her has collected one time, and then put them all back. I've found we can play this a whole session without any complaints of boredom!
One last tip to increase productivity - Have the students repeat EVERYTHING at least once. There should be constant productions throughout the entire session, unless you are correcting placement.

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