Frontal Lisp, Lateral Lisp, Distorted R

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Frontal Lisp,Lateral Lisp, Distorted RPam Marshalla, MA, CCC-SLP, Speech-Language PathologistMorning:LispsAfternoon:Distorted R 2012-20131Speech Improvement vs. Speech Pathology A century ago SLP started by doing speech improvement. Example: Child says “Thee my thoo?” instead of “See my shoe?”Example: Child says “It’s a wed wabbit!” instead of “It’s a red rabbit.” Speech Improvement: Speech improvement is the process ofcorrecting word productions. Anyone can do speech improvement.Anyone can tell a child: “Say, “Shhhhoe” or “Say, “Rrrrrrred.” Engagingin speech improvement is how we started out. We began as “teacherswith an interest in speech.” But anyone can do that today: Parents,teachers, teach aids, speech aids, grandmothers, nannies, babysitters.Anyone can provide lessons in speech improvement. Speech-Language Pathology: The speech-language pathologist’s jobis to go much deeper than the process of simple speech improvement.Our job is to engage in the diagnosis and remediation of articulation andphonological deficits. Our job includes showing others how to do speechimprovement. But that is secondary to what we really do. Today we aregoing to talk about what we really do.Meet and Greet21

Articulation TherapyVan Riper, C. (1939)Speech Correction.Charlie Van Riper is the one who said that we can’t justhave clients repeat words as a way to improve speech.The work has to revolve around phonemes. He said tostart by seeing if the child can imitate your phoneme. If hecan, then move on to the syllable, the word, and so forth.The key is correct imitation of the pPhraseTomato soupSentenceI ate a bowl oftomato soup.LEVELSAMPLEParagraphI like tomato soup and Iwanted to eat it. But it felt cold.I put the soup in the microwave to heat it up. Then it gotvery hot and I had to wait for itto cool. The tomato soupwarmed me up.ConversationLevel I– Talk about S.Level 2– Talk about soup. 2012-20133Phonetic Placement MethodWhat if a client cannot imitate a phoneme correctly?Van Riper said that if a client cannot imitate aphoneme correctly within a few minutes, wemust do more. He said we must resort to theold-time phonetic placement methods.“For centuries, speech correctionists have used diagrams,applicators, and instruments to ensure appropriate tongue,jaw, and lip placement “These phonetic placement methods are indispensabletools in the speech correctionist's kit “Every available device should be used to make the studentunderstand clearly what positions of tongue, jaw, and lipsare to be assumed.”Van Riper (1954) Speech Correction, p236-8 2012-201342

The Reason for Our TroublesA Misleading Classic View of Tongue Lingua-velarTh, ThT, D, N, L, S, ZSh, Zh, Ch, J, YK, G, Ng, RThis sagittal view causes misunderstandings abouttongue positions for phoneme productions because it is amidline view only. We need to understand what the wholetongue is doing in order to teach our clients what to do. 2012-20135ModernElectropalatometryDeveloped bySamuel FletcherBrigham Young UniversityPhotos fromLogometrix 2012-201363

UltrasoundTechnology 2012-2013T and DReal Tongue PositioningS and ZBasicHorseshoe ShapePalate7MolarsCh and JTwophasesSh and ZhAnterior View 2012-201384

We haveknown thisfor a verylong timeDetail fromBorden and Busse(1925)Speech Correction.New York: Crofts. 2012-20139Movement PerspectiveAll movements are made with an interplay of mobility andstability. Stability allows for advanced and accurate mobility.TSSMMM M MProximal stabilityCore strength 2012-2013S StabilityM Mobility105

Production of TNormal adult speaker usingmodern day electropalatographyStart2134567813101122Start of closureLateral bracing129141516171819202129303132Maximum Contact23242526272833EndReleaseGibbon, F. (1999) Undifferentiated lingual gestures in childrenwith articulation/phonologicaldisorders.JSLHR, 42, p. 382-397. pammarshalla.com2012-201311Correct Sibilant ProductionCorrect sibilant production requires thatthe tongue stabilizes at the back lateralmargins, and then simultaneously liftson both sides from back-to-front in astripping action.S and ZSh and Zh 2012-2013Ch and JTwo phases126

Evidence: Experience through the last centurySamuel Fletcher (1992)“Articulation: A Physiological Approach”(Creator of modern electropalatography)Elizabeth Nemoy & Sara Davis (1937)“The Correction of Defective ConsonantSounds” (Best pre-Van Riper book)Noam Chomsky & M. Halle (1968)“The Sound Patterns of English”(First phonology book; They used x-ray analysis)Anchors of the TongueFulcrums of Tongue MovementLateral Lingual StabilityE Position(Can’t get a phoneme? Start with E.)Neutral Position; Position for /l/(I wish they had called it “StartingPosition”)Sara Rosenfeld-Johnson (2001)“Oral-Motor Exercises for Speech Clarity”Back-Lateral Side Spread(A basic OM skill)Leo Kofler (1887) “Art of Breathing:As the basis of tone-production for singers,elocutionist, etc.” (Written before the IPA)To fix a lisp, first teach “Thatcramming of the sides ofthe tongue against the molars”(A modern-day “oral-motor” book)Pam Marshalla Shoulders of the Tongue Starting Position(Various publications Back Lateral MarginsTongue StabilityZones of Stabilitybeginning in 1982) Points of Stability13Tongue Position: Mature vs. Frontal LispSay “sixty” correctly many times in a row and note yourtongue anchors. Now alternate between correct and frontallisp. Note the lack of appropriate back-lateral anchoring.Mature SpeechFrontal LispTongue is in.Tongue is stable.Tongue is anchored at theback-lateral margins.Tongue is out.Tongue is unstable.Tongue is not anchored at theback lateral margins.Frontal Lisp: The tongue is not anchored appropriately.The jaw also is out of position as we shall see next. 2012-2013147

Jaw Positionfor Sibilants and VowelsMelville Bell (1849)“The Principles of Elocution”The jaw is always high on the consonants.The jaw lowers for the vowels. Beet Bit Bate Bet BatSibilants But Boot Book Boat Bought Box“Normal Range” of jaw movement in speech: From S to Ah 2012-201315Jaw and Frontal LispOld information that has been ignored: Approximately99% of frontal lisps related to jaw lowering“Of some 800 cases [with frontal lisps] who passed underour observation we found only three who used theopening formed by the abnormal teeth [i.e., the anterioropen bite] for protruding the tongue. All other caseslowered the jaw to make room.”Froeschels E. and Jellinek, A. (1941) Practice of Voice and SpeechTherapy. Boston: Expression. p. 162-163. 2012-2013168

OralStabilityvs.OralInstabilityWhich child is stabilizing correctly?Five signs of oral instability: jaw is too .The tongue is too far .The lips are .The cheeks are .Muscle tone is .Where isthis child’stonguestabilized? 2012-201317Tongue Position in the Lateral LispFrom Gibbon (1999): One subject who was making a lateral /s/. 2012-2013189

Assessing Direction of AirflowAirUse a straw to test thedirection of air flow.Hold the straw on theoutside of the teeth asthe client produces eachindividual sibilant.AirAirflow will amplify at thepoint where it is escaping.Move the straw from leftto right across the teethto determine where air isescaping. 2012-201319Jaw Problems Also Cause LispingStructural ProblemsFunctional ProblemsMaxilla smallMa ndiblelargeJawThis is a problem of bone structure.The tongue is situated correctly in relationto the mandible, but too far forward inrelation to the maxilla.The solution for this is to reduce the sizeof the mandible, and/or to increase thesize of the maxilla; or to teachcompensation for the structural deficit.shifting forwardThis is a problem of jawmovement (jaw instability).The tongue is carried forward as thejaw protrudes too far forward.The solution for this is to stabilizethe jaw in an appropriate positionthat is more posterior. 2012-20132010

Jaw Lateralization Also Causes LispingThe mandible shifts to one side orthe other; or it shifts back-andforth from one side to the other.This is a problem ofjaw movement.The tongue is in the right positionrelative to the jaw.Upper teethLower teethThe solution is to stabilize the jawin its appropriate position atmidline. 2012-201321Assessing Jaw PositionA thin probe placed against the jaw in various positionshelps us assess patterns of jaw movement during speech.Place the item to help see or “read” jaw position. 2012-20132211

Deeper Assessment of Jaw PositionHow do we tell if the jaw is pushing forward orif the jaw is just too large for the maxilla? the client bite on a probe with his molars on one side.See if you can adjust the jaw gently back into place with your hand.Touch the molar area and say, “Bite back here.”Refer to dentist/orthodontist. 2012-201323Review The tongue moves in three dimensions. It functions like abowl that is anchored in the back and held up by the jaw. The frontal and lateral lisps are caused by problems in oneor more of these areas: Bowling, anchoring, or being heldup by the jaw. These are not phonological problems. Theyare phonetic problems that result from problems in mouthmovement. These are problems in oral-motor skill. Therapy for the lisps is mechanical, not linguistic. Theseclients need to learn how to bowl the tongue, how toanchor the tongue in the back, and how to hold the tongueup with the jaw.24 2012-201312

TechniquesTraditional books contain a randomassortment of ideas for phonetic placementthat are presented as simple laundry lists.We are going to organize these ideas andput them together with our newest ideas.1. Start with T, S, and Z.2. Teach jaw position if necessary.3. Teach tongue anchoring if necessary.4. Use the anchors to teach Sh, Zh, Ch, J.5. Create the groove: Traditional methods.6. Create the groove: Modern methods.7. Refining the groove for S and Z.8. Dealing with hyper-nasality on the sibilants.25 2012-20131Start with T, S, and ZTMany clients can start right here.Most therapists use T to teach S,and most artic books discuss it–Procedure: Have the client say T and attend to theup-down tip movement. Then have him keep the tipdown to make the S.SAssociation Method: Using one phoneme to teachanother (Van Riper, 1939). This method only works ifthe client is producing T correctly in the first place.Why does it work? Both T and S use the basic horseshoe shape. Both T and S require back-lateral tongue stability. Both T and S require a high stable jaw position. The only difference between T and S is in the tip. 2012-2013Straw2613

Straw MethodHelp the client establish a midline sound and help him learnto make the groove more narrow with straws.Organize“Blow air into a straw held just in front ofyour strawsthe space between the upper two medialby diameter.incisors” (Elizabeth Bosley, 1981, p. 66).Wide-to-narrow straws help narrow the feeStirrerStrawUse wide onesto get the airstream goingdown midline.Use graduallysmaller strawsto narrow thechannel.27 2012-2013Dental Floss MethodFrom: Vaughn, G. R., & Clark, R. M. (1979).Speech Facilitation. Springfield: Charles C.Thomas.Tie 5-10 “sewer’s knots” on the end of apiece of dental floss. Place floss between theupper central incisors.Draw the string out so the knot sits rightbehind the central incisors, at the alveolarridge.Use to teach small midline airflow.Homework: Use tongue-tip to fiddle withknot during a 30-minute TV program(Popcorn Principle). 2012-20132814

Dental Pick MethodEeeDental pick: Used just like dentalfloss, but much faster and easier tohandle.“T-T-T”GUMDental pickPick is placed between the upper central incisors.Pick sits between alveolus and tongue-tip. 2012-201329The BumblebeeSoundUse S to teach ZEverything we have said about T and Salso applies to D and Z.WordZoo: Dzzz---oooPhraseMad zebra: Ma---dz---ebraSentenceI rode a mad zebra.I rode a ma---dz---ebra. 2012-2013ZZEee“D-D-D”Or we cansimply addvoice to S.3015

2Teach Jaw Position (If necessary)Some clients cannot produce a correct sound, and some cannotcarryover their skills out of the therapy room, because their jawis perpetually slipping out of position. Stabilizing the jaw can bethe key to success for them.Van Riper: “Tooth props of varioussizes will help the student to assume aproper dental opening” (1947, P. 186). Bite down on thin tool with molars. Tug slightly on tool to build awareness ofthe “Up Position.” Practice sound with tool in place. Carryover: Fade use of the tool over timeby training the ear to monitor productions.31 2012-2013Adjust Rx forDental ProblemsAnterior Dental BarrierThe anterior teeth create a barrieragainst which the midline air streamstrikes. Integrity of barrier is neededfor accurate frication.312 2012-20133216

Making Rx PlansOnly general recommendations can be made.Each case must be evaluated on its ownmerit. It helps to have two SLP’s looking atthe client to make a decision.SituationPlan of Action1Normally missing teeth2Overbite, under bite, crossbite, anterior open bite3Missing teeth, crooked teeth,diastema, etc.4Clefts, Fistulas, Tumors, etc.5Palatal expanders,rakes, cribs, etc.Start therapy after teeth come in.Then re-screen and treat if necessary.OPTIONS1. Start therapy after braces are goneor after surgery is complete2. Or start therapy and teachcompensation.3. Or dismiss the client from therapy.4. Or combine all three options in areasonable sequence 2012-201333Examples to considerCaseSLP recommendationMale 15 years. Frontal lisp. Nodevelopmental problems. Very higharched palate, narrow maxilla. Tonguecannot fit against palate well. Has beento orthodontist. Parents aren’t sure ifbraces are necessary.Sibilants are as good as they canget given dental/palatal structure.Refer for orthodontic treatmentnow. Postpone therapy until afterpalate widens and palatalexpander removed.Male 9 years. Muscular dystrophy. Lowcognitive skills. Severe malocclusion,missing and twisted teeth, severediastema. Lateral sibilants emerging.Child will not receive orthodontia.Teach a gross Sh for all sibilantsif stimulable from E. Overemphasize Long E to stabilizetongue at back lateral marginsand work on jaw stability.Begin therapy to eliminate thumbsucking habit, establish correctoral rest and swallow. Teachcompensated S. Refer to34orthodontia. 2012-2013Female 12 years. Frontal lisp, anterioropen bite, thumbsucking habit, reverseswallow. Very intelligent. No medicalproblems.17

3Anchor the Tongue (If necessary)Get the tongue to stay inside the mouth byanchoring it at the back-lateral margins.Long ELong E pulls and keeps the tongue inside themouth. It puts the tongue in a wide stabile positionin the back, with the sides high.“Smile on the inside of the mouth.”Sample activitiesSay E. Maintain E position while counting to 10,practicing words, reading aloud, conversing Practice diminutives: Doggie, Kitty, Mommy,Daddy, Baby, Birdie, Horsie, Piggie, Mousie 2012-2013Increase Awarenessof the Sides of the Tongue35Bite down on bothsides simultaneouslyBasic Motor PrincipleTactile stimulation increasesbody part awareness.Brush the sidesof the tongueToothbrushToothetteNuk 2012-20133618

4Use the anchors toteach Sh, Zh, Ch, JUse E to teach ShThe Quiet SoundEShWe don’thave tostart with S“Ask the child to round his lips, and raise the tongue,and shut the teeth, as he whispers a prolonged ee”Van Riper (1947) Speech Correction, p191. 2012-201337Organizing Van Riper’s StepsWe can organize Van Riper like this:E and Sh Bite on a coffee stirrer with molars. Make a wide smile and say E. Pant through this position. Round the lips while continuing to pant. Fine tune the sound (adjust the jaw).Key to success: The client has to be able to hold firm toeach position while he adds the next change in position.This has been called Successive Approximations. 2012-20133819

Smile Wide for a Better Tongue Spread“In case of the lateral slisp have the child retractthe lips sharply ”Retracting the lips broadly causes thetongue to retract and widen in the backMildred Berry and Jon Eisenson(1956) Speech Disorders:Principles and Practices ofTherapy.Basic Motor Principle: Movementsoverflow from one body part to another.AssociatedReactionTherefore, exaggerate E when using it toestablish stability and the groove. 2012-201339Baby StepsTake your time from the initial sound to syllables and words.EPant whileholding ERound the lips whileholding E and pantingOShowEPant whileholding ERound the lips whileholding E and pantingESheEPant whileholding ERound the lips whileholding E and pantingIShyEPant whileholding ERound the lips whileholding E and pantingAhShopTake these into sentences: “I E-Pant-Round-op at the mall.” 2012-20134020

Use Shto teach ZhThe Engine SoundEShZhMake Sh and then turn the voice on. 2012-201341Use Sh to Teach ChSTEPS1. Shhhh-----Prolong Sh and lift the tip to stop the air.2. Shhh-----Lift tip-----Shhh.3. Shhh---Lift tip---Shhh---Lift tip---Shhh Lift tip Choo-chooSound4. Go faster and faster. “Keep the air going.”Key- Don’t release the T. Just “shut the door.” Spell it out.Use Ch to teach JSTEPSMake Ch and add voiceJumping Sound 2012-20134221

Review Most therapists start by using T to teach S. Then theyuse S to teach Z. This will work if the tongue and jaware appropriately stabilized in the back. Some clients need to learn how to stabilize the jaw. Some clients need to learn how to stabilize the tongueat its shoulders in order to keep it inside the mouth. E position is the basic position of tongue stability. E position also can be shaped into Sh, Zh, Ch, and Jthrough the process of successive approximations. Working in “Baby Steps” is the best way to assure thatthe client will learn self-control over time. 2012-2013543Create the Basic Groove:Traditional MethodsMany ideas to create the central groove for the sibilants havebeen devised by many therapists throughout the centuries.These methods are represented widely in old textbooks.Most therapists create methods like these on their own.None of them have been researched in formal ways.LogueVan RiperStinchfieldBerryEisensonThe following slides demonstrate a variety of approaches. (5a–5h) 2012-20134422

5a. Draw the GrooveTraditional therapists oftenhelped clients develop aconcept of the midline channelsimply by drawing a line downthe midline of the tongue.Example: “Use a tongue depressor and trace a linethrough the center of his tongue to give the client the ideaof a trough” ""Secord et al (2007) Eliciting Sounds, p38"Have you tried this? Does it work? Does it work all the time? 2012-2013455b. Engage in “Tongue Exercises”Traditional therapists alsorecommended generic “tonguegymnastics” or “tongue exercises” tostimulate the groove. Unfortunately,they didn’t really say how to do this.Example: “Have the child go through some brisk tongueexercises with special stress paid to the grooving of thetongue”Van Riper (1947) Speech Correction, p190Do you think that engaging a client in non-speech oral-motor exercises(NS-OME) like this will facilitate production of your target phoneme? 2012-20134623

5c. Use a Stick"Traditional therapists often laid a“stick” down the center of the tongue,and they taught their clients to curl thesides of the tongue up around it.Example: “Groove the tongue along the median raphe witha slender orange stick, and ask the child to curl his tonguearound the stick” ""Berry and Eisenson, 1956, p148 "An orange stick is a manicuring tool made of wood.They are made of plastic now. What else could be used? 2012-2013475d. Use a SpoonVan Riper used a spoon to teachthe tongue to groove.Example: “With mouth open wide andtongue relaxed, place bowl of spoon onfront third of tongue. Ask child to firstsqueeze the sides of the spoon withoutlifting, then to squeeze and lift. Afterthis is successful, pretend that you areusing an imaginary spoon and repeat.Repeat this but with teeth together”Van Riper (1947) Speech Correction, p. 172 2012-2013Can you follow whatVan Riper is saying?Do you think all yourclient’s could follow it?4824

5e. Use Visual ImageryTraditional therapists oftenused the imagery of “hillsand valleys” to describe thehigh sides and low middleof the tongue’s trough.This is an old idea that has been passed down from onegeneration of SLP’s to another throughout the centurieswith no known original reference.What other imagery could be used? 2012-2013495f. Ask for Voluntary CuppingTraditional therapists knew thatthe groove was a modificationof simple tongue cupping, andthey asked for voluntary controlof this position. Example: “Protrude the tongue and try to cup the edges.Retract the tongue inside the mouth attempting to maintainsome semblance of this shaping”Bosley (1981) Techniques for Articulatory Disorders, p67.Do you think all your clients could do this? Why or why not? 2012-20135025

5g. Use the Upper Side TeethTraditional therapists usedthe upper side teeth toteach voluntary lifting ofthe sides of the tongue.Example: “[Ask] the child to raise the whole tongue and‘paste’ the sides against the molar and premolar teeth,leaving only the tip of the tongue free”Berry and Eisenson (1956) Speech Disorders, p148Can you see any problems with this? What will themiddle of the tongue do when the sides lift? 2012-2013515h. Push Up the Sides of the TongueYoung and Hawk were thedevelopers of the motokinesthetic method (1955).This was first sensory-motorspeech training system.They recommended lifting the sides of the tongue with atongue depressor. This is passive movement stimulation onthe part of the client. (Pam calls this assisting movement.)Have you ever tried this?Can you see any problems with it? 2012-20135226

6Create the Basic Groove:Modern ConceptsToday we also know how weight encourages musclecontraction, we know how the skin can be stimulated tofacilitate awareness and control of the muscles, and we knowthe role reflexes play in motor development.Modern therapists can use these concepts to create evenmore methods for developing the basic central groove pattern.a. Resistanceb. Tactile Stimulationc. Reflexes 2012-20136a. Resistance53Butterfly PositionBasic Motor PrinciplePressure applied against thedirection of movement causesmuscles to work harder.Bite down on bothsides of tongue“Counter pressure” Bosley (1981)Techniques for Articulatory Disorders. This process requires full controlon the part of the client. But if he can do it, it will create abig beautiful groove. Resistance is the most powerfuland direct technique of all.Push sides up againstupper molars as jaw lowers 2012-20135427

Therapists can supply the resistanceIf the client cannot figure out how to push the sides up againsthis teeth, we may have to provide the resistance ourselves.Press down on the sides of the tongue as the client pushes up.Apply pressure downwardDentalFlossHandleClient presses sidesof tongue upward“If the elevation is difficult, have him work on lifting the sidesof the tongue against resistance.” Hanson, 1983, Articulation, p 22855 2012-2013Clients can supply their own resistanceClient presses down on the sides of his own tongue with hisown fingers. Then he pushes those parts of the tongue upward.This procedure allows him to feel the movement with both histongue and his fingers.Fingers push DOWN while sides of tongue push UP. 2012-20135628

6b. Tactile StimulationBasic MotorPrincipleTactile stimulationarouses the musclesunder the skin.Brush the sidesof the tongue“Brushing activates light work muscles”McDonald & Chance (1964) Cerebral Palsy. 2012-201357Use an object while saying “Long E”We also can use tactile stimulation to guide the sides of the tongue to theirstable positions. Some traditional therapists did this by using tonguedepressors and their own fingers. Today we can use many otherappropriate objects.ToothettesNuk brushesFingertipsDental FlossKnotsThis one isfree! 2012-2013Wads of gum5829

6c. Reflex StimulationAll the body’s appendages end in a grasping mechanism andeach of their movement patterns starts out as a reflex.Arms/HandsPalmer graspHead/TongueLingual graspLegs/FeetPlantar graspTongue bowl, Cup shape, Grasping pattern, Horseshoe shape,Hills and valley, Spoon-shape configuration, Trough, Central groove 2012-2013Tongue Bowl Reflex59TBRStimulus: Stroke down tongue’s midline.Response: Tongue flattens, widens,thins, and elevates its perimeter.“Primitive reflexes could provide a foundation for speecharticulation motor patterns The inborn patterns thus providea substrata for developing and refining controlled movementpatterns in mature body gestures”Fletcher (1992) Articulation: A Physiological Approach, p10, 14, 15“Touching or stroking a baby’s tongue elicits a spoon-shapedlingual configuration a similar posture could be elicited inadulthood by repeatedly touching, lightly stroking, or directinga stream of air across the tongue.”Fletcher, p10-11 2012-20136030

NS-OME One does not assume that simply because the client nowcan push the sides of the tongue up that he can make asibilant phoneme. That is the concept of the “non-speech oral-motorexercise” (NS-OME) or “non-speech oral-motortreatment” (NS-OMT). The NS-OME assumes that you engage the client in anoral-motor “exercise” and Poof! Phonemes correctthemselves as if by ctPhonemeProduction 2012-201361The Real ProcessAn excellent therapist realizes that onceany of these methods is used to help the client learn to liftthe sides of the tongue, that’s all you have. Now the clienthas to learn how to use that movement to make a phoneme.This occurs in baby steps–1. Teach the client to elevate the sides by usingresistance, tactile stimulation, or a reflex.2. Then transfer that skill to the teeth.3. Learn to hit and hold this Butterfly Position.4. Exhale through the position. What do you have?5. Now this has to be turned into a phoneme. Whichphoneme is the closest to this large channel?SZShZhChJ6. What has to change to make it that phoneme?6231

HomeworkFor “clumsy tongued individuals”Van Riper (1947) Speech Correction p132Daily Tooth Brushing Routine Brush the teeth, spit, and rinse. Brush tongue up-down midline 3 timesto activate the tongue bowl reflex. Brush tongue up-down sides 3 times toincrease awareness and tone on sides. Smile broadly for a 10-count toencourage tongue-widening. Butterfly for a 10-count to practice it. Perform the Hee-Haw exercise 3 times.(To be discussed in the afternoon)Brush 2012-201363Van Riper on “Clumsy tongued individuals”“Articulation cases are occasionally seen who could truly becalled the slow of tongue In modern speech correction, theemphasis on tongue exercises has almost disappeared. Yet forcertain of the clumsy tongued individuals with whom we work,modern forms of these exercises are very valuable.”Van Riper (1947) Speech Correction, p. 132“Many speech defectives need these exercises. Their tonguesdo not move with the speed and precision demanded by goodspeech. They can assume only the simplest tongue positions.Therefore, they raise the front or middle of the tongue instead ofthe back, and protrude it rather than lift it. It is difficult for themto curl the tip or groove the tongue. Tongue exercises are usefuland necessary for these cases.”p169 2012-20136432

Review Therapists have developed dozens of ways to create themidline groove. Most of these old-time methods requirevoluntary control on the part of the client. The groove has been created with “every availabledevice”–– tongue depressors, spoons, dental floss,dental picks, the teeth, visual imagery, and so forth. Modern methods to develop the groove are based onnew information about movement. They include weighttraining (resistance), tactile input to stimulate muscles,and the use of reflexes to stimulate the tongue bowlmovement pattern. Techniques are used to teach new movements, thenthese movements are used to teach the phoneme. 2012-2013765The “Long T Method”Given all the methods we already have described, what if theclient still cannot produce a correct sibilant?Abandon the acoustics of any of the sibilants and work on T.Go for a more gross motor pattern: T Air (aspiration)PROCEDURE– Produce T several times. Use tight and broad smiling. Check the air stream with straw. Instruction: “Blow more air” or“Make it longer.”CRITERIA– The jaw is high and midline. The tongue is behind the teeth. The tongue-tip touches thealveolus on T. The tongue grooves at midline.This doesn’t sound like S. It sounds like an aspirated T. 2012-20136633

The “Cornerstone Method” Use the Long T and build gradually morecomplex movement patterns around it. Work the Long T into the final positionbecause it sounds lik

with an interest in speech.” But anyone can do that today: Parents, teachers, teach aids, speech aids, grandmothers, nannies, babysitters. Anyone can provide lessons in speech improvement. Speech-Language Pathology: The speech-language pathologist’s job is to go much deeper than the process of simple speech improvement.

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Getting from ODCL to AutoCAD In this section, we will cover the code required to ensure that ObjectDCL.arx is loaded, load the project and then show the form. Open the lisp file that you associated to your ODCL project in your favorite lisp editor. For the purposes of this class, we will use the Visual Lisp IDE that comes with AutoCAD.

Mar 05, 2003 · namespaces. AutoLISP fundamentals are left for other books to cover as that topic has been aptly covered elsewhere already. This book will focus solely on the Visual LISP extensions to AutoLISP and the unique capabilities and features Visual LISP provides. For this book, you will need to have access

programming languages, and artificial intelligence courses and as a self-study guide for students, faculty members, and others learning Lisp independently. Draft versions of this book have also been used in Common Lisp courses, artificial intelligence courses, and for self-study. xiii

frontal suture, often associated with frontal sinus hypoplasia or agenesis. Metopic suture extends through the nasion to the bregma, in the midline across the frontal bone and often remain incomplete and usually fuses by around nine months after birth. (1,2) Rare

A large number of models describing specific parts of the body have been published but only a few of these models describe the response of the entire human body in impact conditions. Models simulating the response of car occupants have been published for lateral loading (Huang et al. 1994a, 1994b; Irwin 1994), frontal loading

9 Approximate Analysis of Rigid Frames 436 9.1 Gravity Load Method 438 9.2 Portal Method for Lateral Loads 458 9.3 Cantilever Method for Lateral Loads 473 9.4 Combined Gravity and Lateral Loads 490 Homework Problems 497 10 Approximate Lateral Displacements 514 10.1 Braced Frames—Story Drift Method 516

Influence of Purlins on Lateral-Torsional Buckling of Steel Girders with Corrugated . Wall thickness of a plate or shell Thickness of the flange of an I-beam Thickness of the web of an I-beam Deflection in the direction of the x-axis Lateral component of lateral

be made with the use of Gusher’s unique Jack Screw design: 1. LATERAL PARALLEL MISALIGNMENT is ad-justed by loosening four (4) Motor Screws, after which you loosen the Lateral Adjusting Screw (#58) on side of the Motor that has to be shifted and tighten the remaining Lateral Adjusting Screw until Lateral Parallel Align-ment is achieved.

Nov 05, 2016 · Nov 05, 2016 · Posterior-Lateral 1. RC Plica 2. Lateral Gutter Plica 3. Proximal Lateral Band 2. Posterior . PM Tip Spur / Fragmentation PM Trochlea OCL, LB Plica Trochlea Chondromalacia Posterior Osteophyte. 11/11/2016 2 Posterior-Lateral Impingement 1. Radius-capitellar Plica (Meniscus) . Full extension

The term ‘lateral thinking’ was coined by Edward de Bono in his book “New Think: The Use of Lateral Thinking” published in 1967. De Bono chose the term ‘lateral thinking’ to distinguish it from what is perhaps the traditional or conventional form – vertical thinking. De Bono said, “Lateral thinking

ARTIFICIAL INTELLIGENCE, STRATEGIC STABILITY AND NUCLEAR RISK vincent boulanin, lora saalman, petr topychkanov, fei su and moa peldán carlsson June 2020. STOCKHOLM INTERNATIONAL PEACE RESEARCH INSTITUTE SIPRI is an independent international institute dedicated to research into conflict, armaments, arms control and disarmament. Established in 1966, SIPRI provides data, analysis and .