for Speech-Language Pathologists & Audiologists
March 17, 2008 – Vol. 18 – Issue 11 – Page 10
By Stephen Sacks, MA, CCC-SLP

It is not unusual to have students entering school with severe phonological disorders. I’ve had more than one kindergartener and first-grader who presented the following pattern of phonological processes: fronting, stopping, consonant cluster reduction, final consonant deletion, deaffrication, and gliding/vowelization for /r/. These students sound like they are speaking another language and are highly unintelligible.

The good news is that with effective remediation they can be easily understood in a short period of time. I primarily use a software program called SATPAC, which I developed. The program allows speech-language pathologists to develop lists of nonsense words targeting certain sounds or phonological processes. They also can delete from the lists any sounds that interfere with the target sound or are not in a student’s repertoire.

Consider the case of a student who presents with fronting (t/k, d/g); stopping (t/sh, s, d/z, b/v, p/f, t, d/th); consonant cluster reduction (p/pl, p/sp); final consonant deletion (kni/knife, da/that); deaffrication (t/ch, d/j); and gliding/vowelization for /r/ (wud/rug, dee-e/deer). I would develop two series of lists. The first involves remediating fronting and final consonant deletion using the nonsense word OKKOP; and the second involves remediating stopping, cluster reduction and final consonant deletion using the nonsense word EESNEEP.

The first step is to establish the target sound. For the /k/ I begin with the facilitating context of OK or OKKO, whichever is easier. The mouth is wide open, and the tongue is back, encouraging correct /k/ production. I then add the final /p/ to work on the final consonant deletion process. Systematic practice involves a series of nine lists, with each becoming progressively more difficult.

Next is a CVCV series of four lists. Interfering sounds can be added, and the student practices contrasting the /t,d,k,g/ sounds. Examples of this from list 4 might be TEEKO, KADI, GOOKA, DEEKEE and TAGO. Although the complexity approach would suggest that the /g/ should be the target instead of /k/,1 I’ve never had a student unable to quickly transfer to correct cognate usage. I choose /k/ as the target, as I find it is typically easier to say than /g/.

For the second series of lists, I establish EES, EESNEE and finally EESNEEP. I use facilitating contexts with the EE, encouraging correct /s/ production followed by the continuant /n/ and again followed by EE with all sounds in the lingua-alveolar position. As with OKKOP, I print out a series of nine lists, with each list progressively more difficult.

Examples of the first five words from list 1 are EESNEEP, EESNIB, EESNAEM, EESNET and EESNAD. The student simultaneously is practicing correct usage of the /s/ sound, using s-clusters, and using the final consonants that are in his repertoire.

Learning theory suggests that skills should be learned at the level that students can perform them quickly and accurately.2 I use a metronome and frequently begin at a rate of 100 beats per minute (BPM). As skill develops, we work up to a slow conversational rate of 140 BPM. The student must be at 80 percent accuracy at each level before moving to the next list.

I recommend using both series of lists together to work on all these phonological processes at the same time. Using this method systematically addresses the student’s phonological processes and leads to intelligibility quickly and efficiently.

References
1.McReynolds, L.V., Jetzke, E. (1986) Articulation generalization of voice-voiceless sounds in hearing-impaired children. Journal of Speech and Hearing Disorders, 51: 348-55.

2.Marzano, R.J., Pickering, D.J., Pollack, J.E. (2001) Classroom Instruction That Works. Alexandria, VA: ASCD.

Stephen Sacks works for Fresno Unified School District and is the co-owner of SATPAC Speech LLC in Fresno, CA. He can be contacted at steve@satpac.com.

Stephen Sacks has been a speech-language pathologist in the schools for 25 years. He can be contacted at steve@satpac.com.

Article on Advance website

Copyright å©2005 Merion Publications 2900 Horizon Drive, King of Prussia, PA 19406 ‰Û¢ 800-355-5627 Publishers of ADVANCE Newsmagazines www.advanceweb.com

This article was published by for Speech-Language Pathologists & Audiologists
March 17, 2008 – Page 10

for Speech-Language Pathologists & Audiologists
February 7, 2005 – Vol. 15 – Issue 6 – Page 10
By Stephen Sacks, MA, CCC-SLP

As school speech-language pathologists, we have been faced with a dilemma these past few years. With the emphasis on literacy and the expectation that we will work with students who have phonemic awareness deficits, as well as reading and writing problems, caseload management has become a nightmare.

The idea that we will not work with traditional areas such as articulation, fluency and voice when students are showing academic proficiency has become a controversial issue in our field. This has left teachers raising their eyebrows, as if to ask, “If you don’t remediate their speech problems, who will?”

Lindsey Jessup, MA, CCC-SLP, DIS coordinator in the Fresno Unified School District, in Fresno, CA, has developed an innovative approach to deal with this problem. Students who would benefit from speech therapy but do not have severe deficits are seen on an informal basis for short-term therapy. This model can be used for other deficit areas as well.

“No Child Left Behind [NCLB] allows us to provide intervention before students are referred to special education,” stated Jessup. “This meets the three-tiered intervention model of NCLB.”

Elin Oppliger, MA, CCC-SLP, has used this approach in several different areas in the Fresno schools.

“I have worked with groups of students using the Visualizing/Verbalizing Program to improve language expression as well as the LiPS [Lindamood Phoneme Sequencing] Program to improve phonemic awareness,” said Oppliger.1,2 “My teachers really appreciate the extra help that their students get in those areas.”

This approach also works with older single-sound articulation students for problems such as lateral lisps and /r/, she said. “This short-term therapy sometimes is just the extra push these students need to remediate their deficits.”

Additionally, preschool, kindergarten and first-grade students have received oral-motor work to develop correct movements, typically for /s/ and /r/ problems. The goal is to develop correct oral-motor skills leading to correct speech development so students will not need therapy when they reach third grade.

I have found this model to be liberating in terms of paperwork reduction and an effective way to do therapy. Last year, I had two students who were particularly memorable: a third-grader with a frontal lisp and a second-grader with a lateral lisp.

The third-grader’s mother was taking English classes at the school, so she sat in on the sessions. After five weekly sessions the student had completely remediated her problem and was using correct /s/ sounds in conversational speech.

The dramatic success of this student was attributed to 10 minutes of correct daily practice of the prerequisite oral-motor skills for /s/.3 The Systematic Articulation Training Program Accessing Computers (SATPAC) Program then was used to develop systematic motor memory patterns for the /s/ sound using nonsense CVCCVC combinations.4 Finally, the SATPAC transfer phase was used to move to real phrases, sentences and contrasting sentences.

It was a different story for the second-grader with a lateral lisp. After two months of weekly sessions, there was no consistency of responses. One week he would seem to develop the appropriate prerequisite oral-motor skills, and the next week they would be gone.

The student was placed into therapy with an individual education plan (IEP). He had sessions twice a week and was able to progress with lots of repetitions. He was dismissed from therapy after a year.

This model of therapy allowed me to make appropriate decisions for these two students because I had the freedom to work with them and determine what they would need.

Like Oppliger, I also am exploring oral-motor therapy with younger students in kindergarten and first grade for /r/ and /s/ sounds.5 Parents are sitting in on the sessions and watching the skill being taught. They return periodically for the next step. While it is too early to say whether this approach will keep students out of speech therapy in the future, the preliminary results are encouraging.

This model employed by the Fresno Unified School District is a win-win situation for all involved. Speech-language pathologists can do therapy without horrendous amounts of paperwork and keep their caseload numbers at manageable levels. Teachers see their students receiving help, and parents are pleased by the progress their children show in the areas of speech, language and literacy.

References
1. Bell, N. (1991). Visualizing and Verbalizing for Language Comprehension and Thinking. San Luis Obispo, CA: Gander Publishing.

2. Lindamood, P., Lindamood, P. (1998). Lindamood Phoneme Sequencing (LiPS) Program for Reading, Spelling and Speech. Austin, TX: Pro-Ed.

3. Sacks, S. (2004). Multimodality approach to remediating /s/ sound, ADVANCE, 14 (26): 11.

4. Sacks, S., Shine, R. (2004). SATPAC (Systematic Articulation Training Program Accessing Computers). Fresno, CA: SATPAC Speech LLC.

5. Sacks, S. (2003). Multimodality approach to articulation, ADVANCE, 13 (43): 9.
Stephen Sacks has been a speech-language pathologist in the schools for 25 years. He can be contacted at steve@satpac.com. Lindsey Jessup can be contacted at Lindseyspeech@aol.com.

Article on Advance website

Copyright å©2005 Merion Publications 2900 Horizon Drive, King of Prussia, PA 19406 – 800-355-5627 Publishers of ADVANCE Newsmagazines www.advanceweb.com

This article was published by for Speech-Language Pathologists & Audiologists
February 07, 2005 – Page 10

for Speech-Language Pathologists & Audiologists
October 27, 2003 – Vol. 13 – Issue 43 – Page 9
By Stephen Sacks, MA, CCC-SLP

Working on the /r/ sound for years with minimal progress frustrates students and therapists, clogs up caseloads, and takes valuable time away from children with more severe deficits. Having spent the last 23 years as a speech-language pathologist in the schools, I have developed an effective system that utilizes a multimodality approach to integrate auditory, visual and tactile-kinesthetic-proprioceptive feedback.

I begin by asking students to say “EER.” Invariably, the response is “EEO” (“O” as in “bought”). Usually, they are not stimulable and do not have a facilitating context. They typically drop the jaw and round the lips. These are significant indicators because an important goal of saying “EER” correctly is to differentiate the tongue movement from the lips and jaw. Generally, when EER is said correctly, only the tongue moves while the lips and jaw are stationary.

I begin using the visual modality right away, modeling correct and incorrect tongue placement. I demonstrate the correct EER, mimic the student’s EER, and ask the student to tell me what is different between the two. I tell the student to watch my tongue, particularly the sides, to see what is different. Usually, they can see and describe that the sides of my tongue stay up on my top teeth while theirs drop down.

We work on getting the tongue pulled back and wide by doing “tongue push-ups.” Using a mirror and flashlight, the student opens the mouth wide, pulls the tongue back as far as possible into a ball, and then closes halfway and says “EE,” pushing up on the top teeth with the sides of the tongue. If the student has difficulty pulling the tongue back, touching the side of the tongue near the back with an applicator stick usually works.

If the student is still unsuccessful, oral-motor techniques, such as sipping pudding through a straw or blowing horns as described by Sara Rosenfeld-Johnson, MS, CCC-SLP, of Sara R. Johnson Oral-Motor Speech & Language Associates, in Tucson, AZ, will do the trick.1-2 The sides of the tongue should be pushed up against the back molars. These steps are all visible to the student.

A frequent problem is the inability of students to grade the jaw appropriately and stop halfway open. For these students we practice jaw grading, using a scale of one to four. One has the teeth closed in a normal bite, two has the teeth slightly open, three has the mouth open halfway, and four has the mouth all the way open. We practice different sequences until the student can stop easily at each number. The mirror and flashlight then are taken away, and the exercise is repeated using proprioceptive feedback.

After they can competently move their jaw into the four positions without visual feedback, students are ready to attempt EER. They keep the mouth halfway open and say, “EE, EE, EER.” If they still drop the sides of the tongue on EER, which is usually the case, I use a tongue depressor to assist them. Placing one hand behind their neck for stability, I place the stick laterally under their tongue. I tell them to keep their bottom lip in a tight smile and keep their mouth still. When they say “EE, EE,” the stick stays still. When they say “EER,” I push up and back under the tongue. The student will say a correct EER approximately 80 percent of the time.

Students often feel they have to pull the tongue way back to get the correct /r/ sound, while the reality is the opposite. It is just a slight backward movement with the stick primarily assisting the sides to stay up on the top teeth. Perhaps 20 to 50 repetitions are needed before the student can take the stick and do this exercise independently. I allow for visual feedback, if needed, using a mirror and flashlight, which I hold.

At this point it becomes very individualized. Some students can proceed without the stick, while others need to use it for a week or two before moving on. Once they begin to show consistent success, only EER is said. Many repetitions are very important. I have my students do sets of 50 to 100 and daily practice of 50 to 100 at home. Tactile-kinesthetic feedback is important as the mirror and flashlight are removed. I ask students to close their eyes occasionally and feel what they are doing as they make the correct /r/ sound.

Once the student can say EER, the most frequent mistake is not keeping the mid-tongue area high enough. As a result, a clear /r/ sound does not come out. Using a mirror and flashlight for visual feedback, place an applicator stick tip midline where the hard and soft palates meet. Instruct the student to touch the point of the stick with the mid-tongue area and say EER. Most often the student will not get the tongue high enough to touch, but the attempt to keep the tongue higher results in a successful /r/ sound.

While this progress is happening, I focus on more consistent responses through mirroring their responses. Every time they make an incorrect EER sound, I give them immediate auditory feedback. Eventually, they listen more closely to their responses and will self-correct.

When students are making consistent EER sounds, I find a facilitating context using coarticulation and eventually proceed into the Systematic Articulation Training Program Accessing Computers (SATPAC).3 This program establishes a CVCCVC nonsense word through seven steps that are progressively more difficult and then uses nine lists of CVCCVC nonsense words and contrasting sentences to generalize correct /r/ production in every phonetic context. Finally, the sound is transferred into phrases, sentences and real activities.

References
1. Rosenfeld-Johnson, S., Manning, D. (1999). Using simple tools in oral-motor therapy. Part I: Straws. ADVANCE, 9 (16): 20-21

2. Rosenfeld-Johnson, S., Manning, D. (1999). Using simple tools in oral-motor therapy. Part II: Horns. ADVANCE, 9 (22): 20-21

3. Sacks, S., Shine, R. (2002). SATPAC Version 3.0, SATPAC Speech LLC 2000-2002

For more information contact Stephen Sacks at info@satpac.com or https://satpac.com/

Copyright å©2004 Merion Publications 2900 Horizon Drive, King of Prussia, PA 19406 ‰Û¢ 800-355-5627 Publishers of ADVANCE Newsmagazines www.advanceweb.com

This article was published by for Speech-Language Pathologists & Audiologists
October 27, 2003 – Page 9

for Speech-Language Pathologists & Audiologists
February 11, 2002 – Page 11
By Stephen Sacks, MA, CCC-SLP
Students are making rapid progress in articulation therapy with a unique computerized program in the Fresno Unified School District (FUSD) in Fresno, CA. All speech-language pathologists have the SATPAC (Systematic Articulation Treatment Program Accessing Computers) program on their laptop computers and take it with them as they travel to their different school sites.

SATPAC, which has been in the works since 1994, was released last year.

“It’s been a tremendous time saver.” said Chae Gagnebin “I can print out lists for each student’s exact needs whenever I need them.”

I was one of the developers of SATPAC, having been inspired during a 1994 conference presentation by Richard Shine, EdD, of East Carolina University in Greenville, NC. Based on the work of Eugene McDonald and the McDonald Deep Test of Articulation, Dr. Shine had developed a series of lists, that moved from facilitating contexts to normal production.

For example, using the word “beetseek” for a frontal lisp, the /t/ assists in correct /s/ production at the syllable juncture. The other sounds also work together to aid in making the correct production. The /s/ sound is established, generalized and transferred all with the use of lists in the program. Sounds not within the student’s repertoire can be excluded as well as sounds which interfere with the target (e.g., /th/).

I was very impressed by Dr. Shine’s system and the FUSD Speech Department made a commitment to use this list system to remediate articulation problems. However, it soon became clear that it was not practical. It took up to two hours to handwrite the lists for one student. Due to high caseloads and little time, the project was abandoned.

With the collaboration of Bob Alei, a computer program developer, a home version of SATPAC was created.

The turning point in developing a functional program for widespread use came in 1995 when new student transferred to the school. He was 8 years old, had been in speech since he was 4 and was totally unintelligible. He had almost all the major phonological processes: he stopped, fronted, glided and deleted initial and final consonants . After 30 sessions using the SATPAC program, he was highly intelligible and used all sounds in conversational speech except for /th/, which hadn’t been targeted.

During the next five years, the SATPAC program continued to develop and evolve. In 2000 speech-language pathologists at FUSD began using it. The reaction among therapists who use the program has been positive.

Specialist Carl D’Souza noticed that the program’s rhythmic nature and rapid rate using a metronome while saying the bisyllable led to more time on task with increased focus. Words from lists are modeled for the student and then repeated.

“Having the kids say the words from the computer is motivating for them, too” he said. “It is not unusual to get 200 correct responses during a therapy session.”

“Because SATPAC is systematic and stresses coarticulation from the earliest phases, students meet their goals very quickly. My dismissal rate has increased significantly since implementing SATPAC.”

The FUSD Speech/Language Administration also gives SATPAC high marks. Program Manager Kathleen Scott observed that students stay on task much better than with traditional articulation therapy, adding, “Through the use of SATPAC, I was able to see students make growth within a 25-minute period. “SATPAC is a real plus in our program,” agreed Lindsey Sutherland, Designated Instructional Services Coordinator at FUSD noted that, “It reduces overall time that students spend in therapy and that is significant with our large caseloads.”

Using traditional therapy materials in commercial programs has always been frustrating. One of my pet peeves using prepared materials is that there are always sounds in the words which the student cannot say or actually hinder correct productions. For example, there is a popular book that has 20 drawings per page. For a target sound of /k/ there are words like “cat,””coat,””kite,” etc. I have found that I have to avoid these words with a student who has the phonological process of fronting. However, with SATPAC I can make word lists without the /t,d/ sounds allowing the student the opportunity to focus solely on the target sound and develop the quick motor responses needed to say the sound correctly.

Procedurally, an appropriate CVCCVC word like “beetseek” is chosen to target the /s/ sound. The student must establish the word with 95% accuracy through 7 different lists. Then the sound is generalized through eight lists of 20 different words, each list moving farther and farther away from the facilitating context.

With the use of a metronome, students must say each syllable at 140 beats per minute before moving on to the next list. Practicing at a conversational rate is critical to success. If the practice is too slow, it doesn’t transfer. The metronome allows the therapist to know exactly at what rate the student can say the word.

When the student is near the end of the generalization phase, sentences are produced using varying prosodic stress. This simulates normal conversation where the emphasis in not necessarily on the targeted speech sound. For example, the student will say, “The boy bought a new beetseek,” “The boy bought a new beetseek,” “The boy bought a new beetseek,” etc. Success using the target sound in sentences with varying prosodic stress leads to faster transfer into conversational speech.

After target sounds are generalized, they are transferred into phrases and sentences. SATPAC comes with these materials and 100 target sounds in each list for each sound making it easy to baseline performance. The final portion of the program involves contrasting the target sound with various problem sounds. For example, for the student who used to front the /k,g/ sounds, sentences are given which include the /t, d, k, g/ sounds. Final transfer involves conversation and/or using classroom material to be read and discussed.

I recently met with McDonald to show him how his ideas and techniques had been expanded and applied to the computer. He stated that the program “‰Û_skillfully builds on my program of sensorimotor therapy. Its well-organized steps will be effective in remediating articulatory defects.”

What started as a one-year project turned into more than 5000 hours of work and six years of waiting. Through trial and error and feedback from speech-language pathologists using various evolving experimental versions, the current version of SATPAC was developed.

It’s thrilling to hear from other speech-language pathologists who are experiencing the same excitement I initially felt when I saw my students rapidly developing normal speech.

For more information contact Stephen Sacks at info@satpac.com or https://satpac.com/

Copyright å©2004 Merion Publications 2900 Horizon Drive, King of Prussia, PA 19406 ‰Û¢ 800-355-5627 Publishers of ADVANCE Newsmagazines www.advanceweb.com

This article was published by for Speech-Language Pathologists & Audiologists
February 11, 2002 – Page 11