Introduction:

This section aims to give an overview of the available therapy techniques for treating childhood dysarthria. A review of the literature showed that there is a lack of research undertaken in this area. Many authors suggest that numerous techniques developed for use with adults are also beneficial with children if adapted appropriately, however there is little supportive empirical evidence for this (Yorkston, Beukelman, Strand & Bell, 1999; Love, 1992 ). For the purposes of this website empirical evidence has been provided where possible otherwise treatments have been adapted from those used with adult clients and are based on expert opinion.

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Additional Considerations:

Hodge & Wellman suggest that there are a number of factors that will affect the type of intervention selected. These include; whether the disease is congenital or acquired, underlying etiology nature and course of disease, subsystems affected, severity and cognitive abilities, personality and physical limitations of the child.

Types of Techniques

The majority of the techniques provided on this website are behavioural or instrumental techniques that can be administered in a clinical setting. It should be noted however, that there are a number of surgical and pharmacological interventions that can also assist with treating childhood dysarthria.

Subsystems

There are five subsystems that can be affected by dysarthria and targeted in therapy (Duffy, 2005) they are:
- respiration
- laryngeal function (phonation)
- velopharyngeal function (resonance)
- articulation
- rate and prosody

Dworkin (1991) suggests the following hierarchy for dysarthria treatment.
1. Respiration subsystem and resonation subsystem
2. Phonation subsystem
3. Articulation subsystem and prosody subsystem

• Assessment results will help determine which subsystems need to be targeted in therapy.
  

Alternative and Augmentative Communication (AAC)

The primary goal when treating dysarthric children is the production of the best possible oral speech that the child is capable of producing given their physical and cognitive limitations. However, Love (1992) stated that Augmentative and Alternative communication (AAC) may be used in conjunction with oral speech. He further notes that if a child has little potential for oral speech, then augmentative speech may be relied on solely. AAC therapy techniques have not been provided on this website as there is already numerous resources available. Below is a reference that may be useful if it is determined that a child needs the use of AAC devices/techniques.

• Beukelman, D. & Mirenda, P. (1998) Augmentative and alternative communication: management of severe communication disorders in children and adults, Baltimore: Brookes Pub.
  

Family and Caregiver Intervention

Hodge & Wellman suggest that it is necessary to work as a team and to take a holistic view of the child with dysarthria when considering treatment. This includes involving the family or caregiver of the child in all aspects of treatment. The following reference gives details of how to integrate families and caregivers into the speech therapy process.

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RESPIRATION

• Expiratory Muscle Conditioning Program and other breathing exercises
• Sustained Phonation
• Postural Adjustments for flaccid dysarthria
• Postural Adjustments for spastic dysarthria
• Postural Adjustments for hypokinetic dysarthira
• Inspiratory checking

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Title:
Expiratory Muscle Conditioning Program and other breathing exercises.

Who:
Cerny, Panzerella and Staphopoulous (1997)

Explanation:
Cerny et al (1997) suggest that a child will be able to generate greater air pressure and thus produce a louder voice if the muscles of their chest wall are strengthened. Strengthening the muscles of respiration also increases vital capacity and may also result in a child’s ability to talk for longer periods of time and produce more syllables on the one breath. Inability to do this could possibly reduce intelligibility and affect naturalness, thus affecting prosody. Other functions of speech can also be affected by poor respiration, such as phonation (Yorkston, Beukelman, Strand & Bell, 1999).
The program itself is based on other expiratory muscle strengthening techniques used for decades, such as blowing through a straw (Hixon, Hawley & Wilson (1982).

Population:
Any child who:
- Cannot sustain steady subglottal air pressure of 5 to 10cm of water for 5 seconds. (This is assessed using a glass monometer)
- Does not have enough respiratory support for phonation.
- Cannot produce more then one word per breath group.

Procedure:
- A qualified clinician is required to administer this therapy.
- Child wears a face mask that covers the mouth and nose and they actively exhales until a threshold resistance is reached.

A more detailed explanation of this procedure can be found in:

• Cerny, F., Panzarella, K. & Stathopoulos.E. (1997) Expiratory muscle conditioning in hypokinetic children with low vocal intensity levels, Journal of Medical Speech- Language Pathology, 5, 141-152.

A more natural and accessible approach to increasing respiratory muscle strength is to blow bubbles in a glass of water using a straw (Hixon, Hawley & Wilson, 1982) or other blowing techniques such as blowing through pursed lips. Additionally, Mecham (1996) suggests blowing into the manometer which is used within the assessment of respiratory function.

Cerny et al’s study (1997) was implemented on children above preschool age. Therefore, the appropriateness of this technique needs to be considered for children individually. If compliance is difficult to obtain with the face mask then using the glass manometer or glass and straw may be more beneficial. Making the therapy more enjoyable may also be helpful. Blumberg (1955) suggested a novel approach to increase compliance. He dressed the glass as a doll and told the child the aim of therapy was to blow into the glass to make the doll grow taller.

Resources:
- Face mask or
- Glass manometer or
- Glass and straw

Time frame:
15 minutes per day, 5 days a week for 6weeks.

Evidence:

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Title:
Sustained Phonation

Who:
Cited in Yorkston, Beukelman, Strand & Bell (1999)

Explanation:
In order to achieve adequate respiratory support for speech, it is necessary to have treatment goals that use speech tasks rather than non-speech tasks such as those described previously (Duffy, 2005). This approach aims to increase respiratory support for speech by training clients to produce consistent air pressure whilst phonating. (Yorkston, Beukelman, Strand & Bell 1999). Increasing respiratory support whilst phonating may also help to increase loudness. The aim of this technique is to be able to sustain phonation for five seconds as this is the average duration of an utterance spoken on one expiration. (Hodge & Wellman, 1999)

Population:
Any child who is:
- Able to maintain a steady subglottal air pressure for 5 seconds. Assessed using a manometer.
- Is unable to maintain respiratory support for phonation and normal speech.

Procedure:
- The child is instructed to exhale at a steady rate for as long as possible. They are then instructed to phonate while exhaling. Phonating steadily for 5 seconds should be the set goal. The intensity level of this sound is measured using a VU meter or a device such as a Visipitch, or feedback provided by the clinician.
- Once the child has achieved enough respiratory support for sustained phonation, tasks that are more like normal speech should then be attempted, For example: repeating syllables whilst exhaling.
- To increase compliance and make this technique more suitable for a preschool aged child the technique could be incorporated in to an enjoyable activity such as playing a game or using pictures.

This is a much more difficult task than the non speech blowing tasks mentioned previously (Yorkston et el, 1999). Therefore, the child may need may need extensive modeling in order to understand what they are supposed to be doing.

It should be noted that adequate laryngeal control is needed to achieve this task. If laryngeal function is not adequate then this needs to be addressed in therapy before speech respiratory tasks can be undertaken.

Resources:
VU meter or Visipitch

Time frame:
Sustained phonation is to be targeted in therapy until 5 seconds of steady phonation is able to be achieved at which point syllables are to be practiced.

Evidence:

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Title:
Postural adjustments for flaccid dysarthria

Who:
Nwoabi & Smith, 1986

Explanation:
Yorkston et al (1999) comment that postural adjustments aid in the maintenance of adequate physiological support for respiration for speech. The need for and type of postural adjustment is often determined by the neur'omuscular impairment that the child presents with. For flaccid dysarthria it is often more beneficial to have the child in the supine position (laying on back with face upwards) for some parts of therapy work. This is based on the fact that when laying in this position the diaphragm is pushed up into the thoracic cavity by the abdominal contents which may help with expiration. Collins, Rosenbek & Donahue (1982) suggest that using an adjustable chair so that the child is leaning backwards may also be beneficial.

It should be noted that whilst it may be beneficial to lay in the supine position during therapy it may not be appropriate or practical during everyday situations. Therefore, for everyday situations positions that facilitate speech intelligibility and efficiency should be selected. (Yorkston et al, 1999)

Population:
Children with flaccid dysarthria as well as reduced respiratory function.

Procedure:
- The child is instructed to lie in the supine position while undertaking various therapy techniques.
- The child is placed in a chair that has an adjustable back or if they use a wheelchair the back is adjusted horizontally.

Resources:
A chair or wheelchair with an adjustable back.

Evidence:

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Title:
Postural adjustments for spastic dysarthria

Who:
Nwaobi & Smith (1986)

Explanation:
Yorkston et al (1999) comment that postural adjustments aid in the maintenance of adequate physiological support for respiration for speech. The need for and type of postural adjustment is often determined by the neuromuscular impairment that the child presents with. For spastic dysarthria the best position to facilitate speech performance are those positions that help to reduce excess muscle tone. Occupational therapists are qualified to determine the best postural adjustments for children with spastic dysarthria.

Population:
Child with spastic dysarthria as well as reduced respiratory function.

Procedure:
Refer to an occupational therapist for an individualized seating system.

Evidence:

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Title:
Postural adjustments for hypokinetic dysarthria

Explanation:
Yorkston et al (1999) comment that postural adjustments aid in the maintenance of adequate physiological support for respiration for speech. The need for and type of postural adjustment is often determined by the neuromuscular impairment that the child presents with. If the child sits in a ‘hunched’ forward position then their respiratory position may be compromised. To optimise respiratory performance to aid speech they should sit upright.

Population:
Children with hyokinetic dysarthria as well as reduced respiratory function.

Procedure:
Encourage child to sit upright when talking or place them in a chair or wheelchair with the back upright.

Evidence:

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Title:
Inspiratory checking

Who:
Netsell (1992)

Explanation:
This theory suggests that if you take a deep breath in and then a long breath out when speaking, lung capacity and pressure for speech will increase. As a result the number of syllables per breath will increase and therefore intelligibility will increase.

Population:
Any child who does not have adequate respiratory support for speech.

Procedure:
- Children are instructed to take a deep breath in and then breath out slowly.
- This breathing cycle is practiced without phonation until it has been mastered by the child.
- To generalise this breathing cycle to speech they are then instructed to phonate whilst breathing out and finally to use the technique in conversation.
- To adapt this technique for preschool aged children in could be incorporated into different games. For example pretending you are scuba divers, etc

Resources:
There are no resources required for this approach.

Time frame:
The breathing cycle of taking a deep breath in followed by a long breath out should be practiced in therapy until the child has demonstrated they can adequately produce the breathing cycle. Phonation should then be practiced.

Evidence:

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LARYNGEAL FUNCTION (PHONATION)

• Effortful Closure Techniques
• Muscle Relaxation Techniques
• Voice Amplifier/Voice Enhancer

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Title:
Effortful closure techniques

Who:
Practor & Swift (1984)

Explanation:
Duffy (2005) suggests the primary goal when working on phonation is to increase the length of utterances per breath group, and to increase loudness levels to a socially acceptable level. When a patient presents with vocal fold weakness or paralysis associated with flaccid or hypokinetic dysarthria, they are unable to adduct their vocal folds to achieve adequate loudness (Yorkston et al, 1999). Patient’s with severe dysarthria may not be able to phonate at all. Effortful closure techniques strengthen the movement of the vocal folds and thus increase loudness, or in the case of severe dysarthria help to initiate phonation. The exercises typically involve forceful muscular activity such as pulling, pushing or lifting.

Population:
Any child who:
- has difficulty producing adequate loudness for speech.
- is unable to initiate phonation

Procedure:
The following techniques are taught to the child. They are instructed to do them whilst phonating. The type of technique selected may vary depending on physical limitations.

- pushing down on arm supports
- lifting objects
- pulling up on a chair
- squeezing palms together

When a child with severe dysarthria is able to phonate voluntarily using the above techniques non speech oro-motor exercises should then be targeted in therapy followed by articulation therapy (Yorkston et al, 1999).

Evidence:

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Title:
Muscle relaxation techniques

Who:
Moncur & Brackett (1974)

Explanation:
Hypertonicity of muscles is most commonly found in children with spastic dysarthria. Inability to adequately move muscles affects a number of functions, including respiration. This theory suggests that if muscles are relaxed respiratory support for speech will increase.

Population:
Any child with hypertonicity as the result of spastic dysarthria.

Procedure:
- The clinician passively stretches muscles in the opposite direction to their hypotonicty.
- For example slowly moving the child’s head from side to side or forward and backwards.
- To generalise this technique ask the child to vocalise quietly whilst their muscles are being relaxed.

Resources:
There are no resources required for this technique.

Time frame:
Undertaken for short periods every day especially at the beginning of a treatment session.

Evidence:

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Title:
Voice amplifier/ Speech enhancer

Who:
Cited in Yorkston et al (2002)

Explanation:
If patients are unable to improve their vocal loudness through behavioural techniques, the use of a voice amplifier may be beneficial. It increases the loudness of what is said but does not clarify speech. Greene and Watson (1968) suggest that articulation is improved when individuals with dysarthria no longer have to put so much effort into increasing loudness. A regular portable battery operated voice amplifier such as the Cooper-Rand or the Speech Enhancer (Weiss, 2000) may be used.

Population:
Children who are unable to achieve adequate vocal loudness through the use of behavioural techniques.

Procedure:
- The portable amplifier is mounted in an appropriate position such as the body or wheelchair
- The microphone is mounted behind the ear.
- The child is taught how to turn the amplifier on and to use it.

Resources:
A voice amplifier such as the Cooper-Rand or Speech Enhancer.

Time frame:
It may not be necessary to use the voice amplifier/Speech Enhancer in all settings. They are most beneficial in noisy environments.

Evidence:

Although it has been reported that the use of a voice amplifier may be beneficial for children, there is no evidence to support this. Therefore, the individual child and the appropriateness of a voice amplifier needs to be considered before opting for it as a treatment option.

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VELOPHARYNGEAL FUNCTION (RESONANCE)

• Palatal Lift Prosthesis

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Title:
Palatal lift prosthesis

Who:
Cited in Duffy (2005) & Yorkston et al (1999)

Explanation:
A palatal lift is an intra oral prosthesis that lifts the palate into a closed position in order to separate the oral and nasal cavities. The successful use of a palatal lift prosthesis results in decreased hypernasality, improved articulation and thus increased intelligibility. Palatal lift prosthesis’s are often used in conjunction with behavioural techniques (Duffy, 2002).

Population:
Children with:
- Velopharyngeal incompetence (structurally adequate soft palates that function inadequately)
- Adequate respiratory support

Further guidelines for eligible candidates for use of a palatal lift prosthesis can be found in the following reference:

Duffy, J.R, (2005). Motor Speech Disorders: Substrates, Differential Diagnosis and Management,(2nd Ed), St Louis: Mayo Foundation for Medical Education and Research

Procedure:
- Once it has been determined that a child is eligible they are referred to a prosthodontist who custom makes the palatal lift.
- The lift may be fitted in stages if the child is unable to tolerate objects in their mouth as the result of a hypersensitive gag reflex.
- Behavioural techniques for improving resonance may then be targeted in therapy whilst the lift is being worn.

Evidence:

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RATE AND PROSODY

• Pacing Board
• Inter Word Pause Strategy
• Fokes Sentence Builder
• Contrastive Stress
• Intelligiblity Drills

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Title:
Pacing board

Who:
Helm (1979)

Explanation:
Certain types of dysarthria result in an increased and unnatural speech rate which results is reduced intelligibility. Traditionally pacing boards were developed to be used by adults with hyperkinetic dysarthria as the result of Parkinson’s disease. However it has been reported that a pacing board can be adapted for the use of children who have an unnatural speech rate or difficulties with phrasing and may help to increase intelligibility (Helm 1979).

Population:
Any child who has an increased rate of speech, unnatural rate of speech or difficulties with phrasing.

Procedure:
- Child is given a pacing board. This is a board that contains different coloured squares.
- They are asked to touch one square per word or short phrase.
- Child is also reminded to slow down when they speak.

Variations of the use of a pacing board include hand/finger tapping or using a metronome during therapy sessions (Duffy, 2002)

Resources:
A pacing board or metronome.

Time frame:
There is no specified time frame for this technique.

Evidence:

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Title:
Inter-word pause strategy

Who:
Cited in Hustad & Sassano (2002)

Explanation:
In most cases of dysarthria, speaking rate is already decreased (except for clients with hypokinetic dysarthria who present with increased speaking rate). It may therefore seem counterproductive to slow down rate even further. However this theory suggests that slowing down rate even more by deliberately pausing between words and focusing on one word at a time, helps to increase intelligibility. (Hustad & Sassano, 2002).
Duffy (2002) comments that modifying rate improves intelligibility as it allows for increased time for articulatory movements, more time for coordination and improved phrasing.

Population:
Any child whose speaking rate affects their intelligibility.

Procedure:
Child is instructed to take a short pause between each word when speaking. When teaching this technique to a child a great amount of modeling and practice may be needed.

Resources:
There are no resources required for this technique.

Time frame:
There is no specified time frame for this technique.

Evidence:

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Title:
Fokes Sentence Builder

Who:
Fokes (1976)

Explanation:
This program was originally developed to help children improve speech and language
skills through a systematic approach to constructing sentences. (Fokes, 1976) It has been reported that it can also be used to teach children correct syntax and to therefore learn to phrase appropriately. As a secondary consequence of doing this, children are also taught to decrease the amount of words they say per breath thus increasing the naturalness of their speech (Murdoch, 1990)

Procedure:
- A set sequence of steps are followed that generate sentences and thus help children to understand the concept of correct phrasing
- These steps can be transferred into games where carrier phrases are used to facilitate correct articulation and phrasing.
- Exercises are extended into conversational speech.
- Pictures are available for children who are pre-literate.

Resources:
Kit containing Fokes Sentence Builder (1979)

Time frame:
There is no specified time frame for this technique.

Evidence:

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Title:
Contrastive stress

Who:
Cited in Swiggert (1997)

Explanation:
Children with dysarthria often present with prosodic difficulties with pitch, loudness and phrasing. This theory suggests that teaching them to vary pitch and loudness by adding stress to different syllables, words or parts of phrases will improve prosody and intelligibility (Swiggert, 1997).

Population:
Any child who has prosodic difficulties.

Procedure:
Hodge & Wellman (1999) suggest the following stages to highlight different stress patterns and help a child improve their prosody:

- Initially the clinician models and then encourages the frequent use of different vocalisation modes that vary in pitch, loudness, quality and duration.
- Once the child has demonstrated the ability to use these different vocalisation modes activities are practiced that encourage the use of consistent and contrastive vocalisations for different emotional states. For example very happy or excited , versus mildly happy, versus mildly unhappy, versus very unhappy or upset.
- Syllables that use the different vocalisation modes are then introduced . For example “ba ba ba” could be said in a very happy mode or a mildly happy mode, etc.
- Stress is added to different syllables (e.g the first syllable, second syllable, etc) to illustrate different stress patterning.
- Real words and phrases are then practiced using the contrastive vocalisation modes and stress patterning outlined above. Falling and rising intonation patterns are also modelled to and practiced by the child . For example “Puppy is hungry? Yes, the puppy is hungry”.

Evidence:

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Title:
Intelligibility drills

Who:
Yorkston et al (1999)

Explanation:
Hodge & Wellman comment that in order to develop intelligible speech a child needs to establish the consistent use of phonetic contrasts at different levels of production. Yorkston et al (1991) suggests that intelligibility drills may help with this as they provide immediate feedback to the child as to how well a listener has understood what they have just said.

Population:
Any child with prosodic difficulties.

Procedure:
- A small set of words are selected (2-10) words .
- The words focus on contrasts that are appropriate to the child’s level of production.
- Below is an example of how intelligibility drills can be used for targeting production of one versus two syllable utterances for a child who can make bilabial consonants and some vowels. It is adapted from Hodge & Wellman (1999)
- Three words (pictures) are selected E.g. “ pea”, “paw” and “poppy”
- Child is taught the word for each picture to ensure they have the vocabulary.
- Three copies of each word (picture) are shuffled and placed in a pile face down.
- The child takes a card and says what it is to the clinician. The clinician says what they think the child said. If it is incorrect the child is asked to say the word again. If the clinician cannot identify the word the child is encouraged to think of another way to help the clinician understand the word such as gesture.
- Once the child is able to make the contrast of one syllable versus two syllable utterances other contrasts can be selected.

Resources:
Pictures of words being targeted.

Time frame:
There is no specified time frame for this technique.

Evidence:

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ARTICULATION

• Non-Speech Oromotor Exercises
• PROMPT (Click here to view this treatment option as described in CAS section)
• Phonetic Placement (Click here to view this treatment option as described in Articulation/Phonology section)
• Traditional Articulation Therapy (Click here to view this treatment option as described in Articulation/Phonology section)
• Non-Linear Phonology (Click here to view this treatment option as described in Articulation/Phonology section)

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Title:
Non-speech oromotor excercises

Who:
Cited in Netsell (1991)

Explanation:
This theory suggests that as dysarthria results in imprecise movement of articulators, repetitively practicing exercises to strengthen the muscles of articulation will help improve articulatory precision and thus increase intelligibility.
It should be noted that there is much conjecture in the literature about the effectiveness of non-speech oromotor exercises and there effectiveness. (Duffy, 2005, Hodge & Wellman, 1999)

Population:
Any child whose speech intelligibility is decreased due to imprecise articulatory movements.

Procedure:
Children are instructed to practice various exercises depending on the movements that they have the most difficulty with. It may help to ask the child to look into a mirror to see if the are making the correct movements.

For example:
- Rounding and spreading lips
- Protruding the tongue tip up to the alveolar ridge then down again
- Protruding tongue tip and moving it from side to side

A detailed description of exercises that can be incorporated into therapy can be found in the following book:

Swiggert, N. (1997). The Source for Dysarthria. Illonois: LinguiSystems

Resources:
A mirror

Time frame:
Lingebaugh (1983) suggested strengthening exercises be practiced 3-5 times per session.

Evidence:

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