Student 2 is a young adult female with a profound sensorineural hearing loss of unknown etiology. Despite an extensive history of speech instruction (age 4 through high school) she is unintelligible. Voice is characterized by severe tension with poor coordination of respiration and phonation. She reported first receiving hearing aids around the age of three to four, but stopped using amplification when ten years old. She resumed hearing aid use after enrolling in speech instruction at RIT/NTID. She is currently in her fifth ten-week quarter of instruction. At this point she is able to produce speech with a relaxed voice and has steadily expanded her phonetic repertoire, although rate and prosody continue to impede intelligibility. Computerized visual feedback equipment has been instrumental in facilitating instruction/learning.
Profound sensorineural loss bilaterally with no hearing responses beyond 750Hz for either ear
unknown
Birth/8 months of age
Student reported using aids from 3-4 years until the age of 10; no amplification from 10-18 years; currently wearing BTE on RE all the time
Attended individual speech therapy from four years of age through the end of her junior year in high school; did not work on voice
Mainstreamed in public school with support services (interpreter and note taker)
ASL with people who know sign language; writing, gestures, and speech when communicating with people unfamiliar with sign language
NTID Write-Down Test5: 8% (1.3 on a 1=low to 5=high scale). Rated as 1.0 in reading the Rainbow Passage (Fairbanks)2
NTID Voice Evaluation: Severe vocal tension which at times results in inability to sustain phonation; severe problem coordinating respiration and phonation; severe problem with prosody (blending and co-articulation); loudness was much below appropriate intensity levels.
Fisher-Logemann Test of Articulation Competence3: 84.34% total error; 85.07% consonant error; 81.25% vowel error. Of consonant errors, 46% were omissions, 37% were substitutions, and 17% were distortions. Fisher-Logemann Sentence Articulation Test3: 84% consonant error. Of consonant errors, 76% were omissions, 19% were substitutions, and 4% were distortions.
Written language sample, a retelling of the NTID Dormitory Picture Series: accurate description of the story depicted in the picture series; inconsistent grammatical errors involving determiners, prepositions, and noun-verb tense agreement which did not impede comprehensibility.
- To improve respiration for phonation.
- To eliminate vocal tension during speech.
- To expand her phonetic repertoire.
- To improve her functional communication skills with people who do not know sign language.
-
- 1st ten weeks of therapy (one hour per week)
- To improve respiration for phonation by using quick appropriate inhalations followed by controlled exhalations.
- To distinguish between a tense and relaxed voice production using tactile feedback.
- To explore the use of amplification for feedback.
- 2nd ten weeks of therapy (two hours per week)
- To stabilize relaxed voice during sustained phonation.
- To develop acceptable productions of vowels, including diphthongs.
- 3rd ten weeks of therapy (two hours per week)
- To expand phonetic repertoire [b, w, d, p] while maintaining relaxed phonation.
- To gradually increase length of utterances (3 syllables) while maintaining relaxed voice.
- 4th ten weeks of therapy (two hours per week)
- To continue to expand phonetic repertoire [l, f, t, s] with relaxed phonation.
- To continue to increase length of utterance while maintaining relaxed phonation (4-5 syllables).
- 5th ten weeks of therapy (two hours per week)
- To gradually increase length of utterances (3 syllables) while maintaining relaxed voice.
- To increase use of speech and voice outside of speech instruction.
Student 2 is currently in her 5th ten-week quarter of instruction. The "Training Program for Correction of Tense Voice Production" (Spector [Brown], P., et.al. (1979) Description and evaluation of a training program to reduce vocal tension in adult deaf speakers. The Volta Review, 81, 81-90) has been used quarterly as a guide for developing relaxed phonation and expanding phonetic repertoire. The results of the first 4 quarters of instruction are summarized below.
Feedback:
Since Student 2 was unaided during the first quarter of instruction, visual feedback was used to augment tactile awareness of tense vs. relaxed phonation. The Real-Time Pitch program on the Kay Computerized Speech Lab (CSL) was utilized because it provided a trace pattern during relaxed phonation that was markedly distinct from the pattern during tense voice. The Real-Time Spectrogram program on the CSL was also used because it facilitated correct phoneme production. At the start of the 2nd quarter of instruction Student 2 started using a hearing aid which introduced auditory feedback, but she expressed the need to continue using the CSL for reinforcement of voice and articulation.
Voice:
Qualitative judgments indicate that this student is able to produce a relaxed voice production in controlled speaking situations (single words, 2 to 3-word utterances, etc.) and has developed a functional phonetic repertoire. However, rate of speech is far too slow for effective communication and she still has not mastered prosodic features of blending, co-articulation, stress, and inflection. (Pre and post recordings of this student's speech and voice are included on this site.)
Articulation:
Steady gains have been accomplished. At the end of the 4th quarter of instruction her Fisher-Logemann Test results were as follows: 56.72% consonant error (28.35% improvement); 31.25% vowel error (50% improvement); 51.81% total error (32.53% improvement). Of the consonant errors, 34% were omissions, 42% were substitutions, and 24% were distortions (9 distortions: 2 severe and 7 mild). Compared to the error patterns on the intake exam, Student 2 has made significant gains. The highest percent of errors on the intake evaluation were omissions. Recent testing revealed substitutions were most prevalent. On closer examination most of these errors were cognate substitutions which often do not impact on functional intelligibility.
Speech Intelligibility: NTID Write-Down scores have slowly improved:
Intake score: 1.3
- 1st quarter post: 1.8
- 2nd quarter post: 2.0
- 3rd quarter post: 2.2
- 4th quarter post: 2.9
This indicates that over the course of instruction, speech intelligibility has improved from unintelligible (1.3) to semi-intelligible (2.9) on read sentences with experienced listeners. However, Student 2's speech is not intelligible to naive listeners in unstructured situations.
Speech samples following 4th 10-week quarter of instruction:
Intake score: 1.3
'On first base'
'A dish fell'
'We bought fish'
'Fill a bowl'
Achieving functional speech intelligibility with relaxed phonation is possible but the prognosis remains guarded. Although Student 2 has made steady gains (reducing vocal tension and improving phoneme production), she does not consistently use speech outside of instruction. She is dependent on visual feedback (CSL) and without it, she is not consistently able to maintain relaxed phonation. She has reported using voice with some friends and classmates on a limited basis (one or two-word utterances) and has been reinforced by experiencing some success. She is currently in her 5th quarter of speech instruction and wants to remain enrolled. If she continues to make this slow and steady improvement and increases her use of speech in her daily life, limited functional intelligibility is a realistic goal.