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Student 6 is a young adult female with a profound sensorineural hearing loss.  She is a second year student at RIT, majoring in Business Administration.  She is third generation deaf in her family and all family members prefer to communicate using ASL.  She has had minimal speech therapy and has unintelligible speech; she exclusively uses ASL or writing to communicate.  Voice is characterized by moderate to severe tension and a pitch much above optimal level.  She has not worn hearing aids since elementary school.  Student 6 made the decision to enroll in speech therapy to explore her potential to develop functional speaking skills for specific situations and possibly for her future job.  

Degree of Deafness/PTA

Profound sensorineural loss/PTA Right: 103 dB Left: 103 dB

Etiology

Hereditary

Age of Onset/Date of Detection

Birth

Use of Amplification

She has not worn hearing aids since elementary school.  She is interested in exploring the possibility of purchasing new aids.

Speech-Language Therapy History

Minimal speech therapy, only until age 8.

Educational History

Student 6 began her education at Texas School for the Deaf (TSD). From 4th through 9th grade she was mainstreamed in a public school for half a day and attended TSD for the other half. For high school she attended TSD full time. She began her college education at Gallaudet, but transferred to NTID after 3 semesters.  After her first year at NTID, she was admitted to the RIT Saunders College of Business and is majoring in Business Administration-Marketing.

Preferred Mode of Communication

American Sign Language; she does not use her speech at all for communication.

Speech Intelligibility

Student 6 presents with no usable speech upon entry into speech therapy.  She received the following speech intelligibility score:

NTID Write-Down Test: 2% = 1.0 (on a 1=low intelligibility to 5=high intelligibility scale)

Pre-therapy sentence samples:

1. Peter saw a hole in the tablecloth.

2. Someone heard a baby crying at home.

3. Mr. Black put an old table outdoors.

Voice (Qualitative)

NTID Voice Evaluation: Pitch level is much above optimal level with noticeable breaks of moderate to large magnitude, phonations are weak and breathy, loudness is below the appropriate intensity level and there is inadequate breath support for speaking. Vocal resonance includes a combination of hyper and hyponasality and there is moderate to severe laryngeal tension. With such low intelligibility, prosodic characteristics could not be judged.

Voice (Quantitative)

Using KayPENTAX Visi-Pitch IV:

Mean pitch sustained on /oo/ = 356 Hz, /ah/ = 246 Hz, /ee/ = 375 Hz

Habitual Pitch (counting 1-10) = 322 Hz.

Speech/Voice (Comprehensive)

The student's speech is unintelligible and she is unaided. She has a very limited phonologic repertoire, moderate to severe vocal tension and a very high pitch register. She shows some stimulability skills, but until therapy begins it is difficult to ascertain her potential to develop speaking skills for functional purposes.

Articulation

Fisher-Logemann Test of Articulation (words): 88% total error; 91% consonant error; of consonant errors there are 32 omissions and 18 distortions. Correct consonant sounds in some word position include /p, b, t, th, w/. Twelve of the sixteen vowels are incorrect.

Pre-therapy word samples:

1) pin 2) paper 3) soap 4) box 5) baby 6) bib 7) water 8) flower 9) man 10) hammer

Language

Student 6 has completed all her English requirements and has college-level reading and writing skills.

Therapy Goals and Objectives

Long Term

• To build a phonetic repertoire

• To reduce pitch level

• To improve intelligibility for functional communication

Short term - 1st ten weeks of therapy

• To enhance awareness of English phonology including manner and placement features of consonants and vowels

• To explore potential for improving respiratory support for speaking, reducing vocal tension and lowering pitch level to 285 Hz on vowels, consonant-vowels and consonant-vowel-consonant words

• To explore her potential for producing consonants and vowels

• To explore her potential for using speech for a set of functional words

Short term - 2nd ten weeks of therapy

• Reinforce articulation accuracy for front and back vowels in words and 2 word phrases

• Improve articulation and co-articulation for bilabials /p, b, m/, fricatives /f, th, s, sh/, and tip-dentals /t, d, l, n/ in single and bisyllabic words and two-word phrases

• Monitor and reinforce pitch level at no higher than 275 Hz for words and phrases

• Improve intelligibility for a set of functional words and phrases

• Highlight and reinforce basic English pronunciation rules

Therapy Progress

1st ten weeks - primarily diagnostic instruction

• This student was a quick learner.  She absorbed all the information presented on English phonology.  She enjoyed using the website, Phonetics: The Sounds of English

http://www.uiowa.edu/~acadtech/phonetics/ to reinforce the concepts she was learning.

•  Relaxation exercises were used to address laryngeal tension and her pitch.  She was shown how to relax her neck, shoulders and articulators.  She practiced diaphragmatic breathing and then phonated vowels.  Use of the software, RealTime Pitch, on KayPENTAX Visi-Pitch IV was helpful in reducing her pitch and providing visual feedback regarding her pitch level.  Target lines were set up on the computer at 280 Hz, so she could see when she was successful at lowering her pitch.  During this training, she indicated that she was focusing on the tactile feedback she was receiving regarding her pitch level.  After several weeks using RealTime, she was able to lower her pitch to 260 Hz for the mid to lower front and back vowels and lowered her habitual pitch to 295 Hz.  Her counting 1-10 was reduced by 25 Hz to 295 Hz.

•  She began to work on voiceless fricatives /f, s, sh/.  Short lists of CVC words with some two word phrases were practiced.

•  A functional list of ten words was also practiced and towards the end of the first ten weeks, she was beginning to achieve closer approximations for many of the words.

Formal tests at the end of ten weeks showed excellent gains.  On the Fisher-Logemann Test of Articulation (words), her total error score improved by 29%.  She reduced her omission errors from 32 to 12 and achieved fewer errors across all the sound categories.  On the NTID Write-Down Speech Intelligibility Test her new score of 36%, which converts to 2.3 on a 5-point scale, is a 34% improvement.

2nd ten weeks of therapy

•  Lists of CVC words with a few bisyllabic words were created for all the articulation targets.  Contrasting phonemes were emphasized.  She continued to respond well to verbal explanations regarding placement and manner characteristics and benefitted from watching the instructor's productions and the visual feedback she received from RealTime software.  She struggled with many of the sounds when trying to achieve the correct manner characteristics; however, she was very motivated and patient with herself and did not give up unless she was tired.  Other consonants that were not targeted also improved.  Less success was achieved with vowel productions.  She continues to neutralize her front vowel and diphthong productions.

•  She was able to lower her pitch to 245 Hz.

•  Intelligibility improved for her functional list, more words were added and she began to use her voice more spontaneously in therapy and with several friends using single words and short phrases.

Formal tests again showed improvement.  On the Fisher-Logemann Test of Articulation (words), the total error score was 52%.  There were only 7 omissions and fewer severe distortions.  On the NTID Speech Intelligibility Test, the new score of 70% converts to 3.4, which is a 68% improvement over 20 weeks.  This new score indicates better than semi-intelligible speech for read sentences.  A lower pitch was used for the reading and it was evident that she made improvements in reducing tension and in using her air more efficiently for speech.

Post-therapy word samples:

1) pin 2) paper 3) soap 4) box 5) baby 6) bib 7) water 8) flower 9) man 10) hammer

Post-therapy sentence samples:

1. A little boy ran after a white cat.

2. Paul saw a little mouse under a broom.

3. Three boys played at school yesterday morning.

Prognosis

Prognosis for continuing to attain intelligible speech for functional purposes is good after 40 hours of instruction. Improvements were noted in articulation, pitch and respiratory support. Student 6 is looking into purchasing new hearing aids for the coming academic year, which may also affect her gains. Significant improvement has been made because the student is highly motivated and she is able to benefit from verbal instructions, computer-aided feedback, visual modeling and tactile feedback. She also developed more self-confidence in her ability to make changes in her speech.  Student 6 will be continuing in therapy to reinforce the changes she has made and to explore additional improvements particularly with the possibility of acquiring new hearing aids.

Other Pertinent Information

When this student began speech therapy, she was extremely shy about vocalizing, even in front of the instructor and was unsure about her decision to work on her speech.