(a) true; (b) true; (c) false; (d) false; (e) true

A submucous cleft palate typically involves three deformities: a bifid uvula, a notched posterior hard palate and muscular diastasis of the velum. The majority of individuals with this type of cleft are asymptomatic, although approximately 15% can have velopharyngeal insufficiency (Hopper et al., Reference Hopper, Cutting, Grayson and Thorne2007).

Intellectual disability is often a feature of the syndromes in which cleft palate occurs, e.g. velocardiofacial syndrome (De Smedt et al., Reference De Cuypere, Van Hemelrijck, Michel, Carael, Heylens, Rubens, Hoebeke and Monstney2007). The presence of intellectual disability poses a further compromise to speech acquisition and language development in children who have syndromic clefts of the palate, and is thus of concern to speech-language pathologists.

The two factors which are central to this debate are (1) the benefit of achieving normal velopharyngeal function to optimise speech development against (2) the potential disadvantage of impaired facial growth secondary to early surgical trauma (Hopper et al., Reference Hopper, Cutting, Grayson and Thorne2007).

parts (a), (d) and (e)

parts (a), (c) and (e)

To achieve the articulation of oral plosives, an active articulator (e.g. the tongue) rises and seals firmly against a passive articulator (e.g. the alveolar ridge), completely obstructing the oral airflow. Air pressure then builds up behind this obstruction. However, this build-up of air pressure is only possible when there is complete closure of the velopharyngeal port and air cannot escape through any other means. This situation does not obtain in children with cleft palate. The presence of a short, immobile velum permits intra-oral air to escape through the velopharyngeal port. Also, fistulae can develop in the palate following surgery, and these may also permit the loss of air into the nasal cavities. To avoid this loss of air pressure, children with cleft palate often shift the articulation of oral plosives to the glottis. The glottis is often the only place of articulation in the vocal tract where complete closure of the airstream and build-up of air pressure can be achieved.

The toddlers with cleft palate in this study are selecting to produce words which begin with sonorants as these consonant sounds are easier for them to produce than obstruents.

(4) Three reasons why children with cleft palate are at risk of language delay:

1. (i) lengthy periods of hospitalisation – children with cleft palate may have many other medical complications that require hospital treatment. This is particularly the case in children with syndromic cleft palate. If children are hospitalised for weeks or even months after birth, they are not receiving normal language stimulation and are thus at risk of language delay.

2. (ii) intellectual disability – intellectual disability is present in many of the syndromes in which cleft palate is a feature. Language acquisition is compromised in children with intellectual disability.

3. (iii) speech disorder and hearing loss – impaired speech and hearing have an adverse effect on language acquisition.

(a) false; (b) true; (c) true; (d) false; (e) true

Rachel was born 11 weeks prematurely. Low gestational age is more frequent among newborns with oral clefts than in newborns with no cleft (Wyszynski and Wu, Reference Wyszynski and Wu2002).

Rachel has an isolated cleft of the palate. This type of cleft is more commonly found in girls. So Rachel's cleft type is consistent with the findings of studies of sex differences in clefting.

(a) true; (b) false; (c) false; (d) true; (e) true

Children with cleft palate are at an increased risk of hyperfunctional voice disorders. This is because they misuse their vocal folds in an effort to close the velopharyngeal port or to compensate for poor velopharyngeal closure.

A pharyngoplasty achieves reduction in the velopharyngeal port with no disruption of the velum. It is a surgical procedure for the correction of velopharyngeal incompetence. It is most suitable for patients who have poor medial excursion of the lateral pharyngeal walls and a short anteroposterior component of velar competency (Hopper et al., Reference Hopper, Cutting, Grayson and Thorne2007).

Phonotactic structures: ‘glasses’ CCVCVC; ‘string’ CCCVC; ‘matches’ CVCVC. Rachel is able to replicate these phonotactic structures in her spoken productions. Rachel clearly has sufficient phonological knowledge to ensure that each segment in the adult target form is marked in some way, even if that way involves the use of segments that are phonetically distant from those of the target form.

(2) Rachel signals a contrast between the alveolar nasal /n/ and the alveolar plosives /t/ and /d/ through the use of a uvular nasal /ɴ/ and glottal plosive /ʔ/, respectively. This can be seen in the word-initial segments of the following examples:

• ‘nose’ [ɴəʊҫ͋]

• ‘teaspoon’ [ˈʔiҫ͋ᵬuɴ]

• ‘dog’ [ɁɒɁʰ]

(3) The contrast between the velar nasal /ŋ/ and the velar plosives /k/ and /g/ is also signalled by the use of a uvular nasal /ɴ/ and glottal plosive /ʔ/, respectively. This can be seen in the word-final segments in ‘ring’ and ‘dog’ and the word-initial segment in ‘cat’:

• ‘ring’ [ʊɪɴ]

• ‘dog’ [ɁɒɁʰ]

• ‘cat’ [ɁæɁʰ]

In the same way that Rachel uses the glottal plosive /ʔ/ to realise alveolar and velar plosives, she also uses the glottal plosive to realise the voiceless bilabial plosive /p/. This can be seen in the word-initial segment in ‘pen’ [ʔeɴ]. On occasion, Rachel provides her listeners with an additional visual clue as to the target bilabial segment that she is attempting to produce. She achieves this through the coarticulation of a bilabial closure as can be seen in word-initial and word-medial positions in ‘paper’ [ˈp͡ʔeɪp͡ʔə].

Apart from glottal stops, bilabial segments are realised as follows in Rachel's speech: [m, ᵬ, ʘ, p̃ʰ]. With the exception of [ʘ], what these sounds have in common is that they all involve some degree of nasal airflow. The realisation which is particularly unusual is [ʘ] (and [͡ʔʘ]) for /p/. Here, Rachel is using a velaric airstream mechanism to mimic the voiceless bilabial plosive. Because this is a late-appearing feature of Rachel's speech, it is thought that this has arisen as a result of speech therapy which is directed at replacing the glottal stop with /p/.

The approximants /j/ and /w/ are correctly realised in Rachel's speech, e.g. ‘yes’ [jɛʔ] and ‘why’ [waı]. It has already been stated that stops are realised word initially by the glottal plosive [ʔ]. Alveolar fricatives /s/ and /z/ and the postalveolar fricative /ʃ/ are consistently realised in word-initial position as [ç͋], e.g. ‘shop’ [ҫ͋jɒp̃ʰ]. So Rachel does have an effective articulatory strategy for signalling a contrast between stop, fricative and approximant sounds.

The stop–affricate contrast is realised in word-initial position by [ʔ] and [ʔj], respectively. Rachel separately marks the stop and fricative elements in an affricate, e.g. ‘chair’ [ʔjɛə] and ‘jam’ [ʔjæm]. Moreover, she displays remarkable consistency in that the stop element in affricates is replaced by the glottal stop in the same way that individual stops are glottalised. Once again, although Rachel's productions are phonetically distant from the target in each case, she is nevertheless able to signal a contrast between stops and affricates.

Rachel's alveolar and postalveolar fricatives are consistently realised as [ç͋], e.g. ‘Sue’ [ç͋u] and ‘shoe’ [ç̫͋u]. So Rachel has not succeeded in consistently signalling an alveolar–postalveolar contrast in her production of fricatives following therapy. However, her post-therapy production is still an improvement on her pre-therapy production in two ways. First, she has succeeded in bringing forward the place of fricative articulation from earlier pharyngeal realisations. Second, Rachel sometimes labialises postalveolar fricatives to signal a contrast between them and alveolar fricatives.

The voicing contrast is marked for the bilabial plosives /p/ and /b/. However, there is no voicing contrast observed for the alveolar plosives /t/ and /d/ or the velar plosives /k/ and /g/. The word-initial phoneme in the productions of ‘tea’, ‘dig’, ‘key’ and ‘go’ is the glottal stop [ʔ]. Rachel variously signals a voicing contrast between /f/ and /v/. On some occasions, she uses the approximant [ʋ] for /v/ (e.g. ‘cover’ [ˈʔʊʋə]). On other occasions, a voicing distinction is marked by differing forces of articulation, with /v/ realised as the strong articulation [f͈] (e.g. ‘a van’ [ə ˈf͈æɴ]) in contrast with the weakly articulated [f͉] (e.g. ‘laughing’ [ˈæf͉ɪɴ]).

part (d)

(a) The fact that Louise had to have transtympanic drains fitted at 11 and 18 months and then again at 2 years suggests the presence of an otological abnormality; (b) conductive hearing loss; (c) The placement of transtympanic drains serves to ventilate the middle ear. This prevents the build-up of mucus in the middle ear, which can impede the vibration of the ear ossicles, known as the malleus, incus and stapes.

The measurement of otoacoustic emissions can be used to test for the presence of sensorineural hearing loss. The presence of these emissions in Louise's case suggests that the outer hair cells of the cochlea are intact and functioning normally.

Yes, Louise's middle ear defect is related to her palatal abnormality. The presence of a submucous cleft palate suggests a defect of the palatal muscles. It is the contraction of the tensor veli palatini muscles which causes the Eustachian tube to open, permitting ventilation of the middle ear.

Yes, Louise has a generalised hypotonia which could cause a speech disorder of neurogenic aetiology.

Kabuki make-up syndrome is caused by mutations of the MLL2 gene. This gene codifies for an enzyme that regulates embryogenesis and tissue development. This explains the multiple congenital anomalies in the syndrome: abnormal facial features; skeletal anomalies; dermatoglyphic abnormalities; intellectual disability; and postnatal growth deficiency.

(a) Reynell Developmental Language Scales; (b) GRBAS scale; (c) McCarthy Developmental Scales

During this procedure, a flexible nasolaryngoscope is passed along the nasal passages. It allows the otorhinolaryngologist to directly observe the anatomy of the nasal passages, pharynx and larynx as well as visualise aspects of laryngeal function.

The perceptual attribute is pitch.

It is important for the depicted objects and actions to be part of Louise's vocabulary. If these depicted items are not within her vocabulary, Louise's failure to name them may be related more to vocabulary limitations than to any failure of speech production.

part (b)

kiss the doll: comprehension of action–object semantic relation; beside: comprehension of spatial preposition; smallest: comprehension of terms relating to the size of objects

This particular passive sentence poses difficulty for Louise because it describes an implausible event in the world. Louise can clearly comprehend passive sentences when they describe plausible world events.

part (c)

will come (not produced: future tense); cups (produced: regular plural noun); mice (not produced: irregular plural noun); dog (produced: singular noun); gone (not produced: past participle); she (produced: personal pronoun); run (produced: infinitive form); walks (not produced: third-person singular verb); John likes oranges and Mary likes apples (not produced: compound sentence involving coordination)

parts (d) and (e)

The hypernasality and nasal emission in Louise's speech is most likely to be related to the presence of a submucous cleft palate. However, given that Louise also exhibits some hypotonia, the involvement of neurological factors cannot be discounted in this articulatory deviance.

(2) (a) Frication; (b) Stopping; (c) Fronting; (d) Backing

• ‘kruis’: frication; ‘kop’: fronting

(3) Progressive assimilation: /siˠɑRɛt/ → /sizɑRɛt/

• Regressive assimilation: /fits/ → /sis/

• Metathesis: /ˠitər/ → /Ritə/

• Syllable deletion: /wɔlkən/ → /wɔk/

• Final consonant deletion: /jɔŋən/ → /ɔŋə/

Word initial /kr/ in ‘tap’ and ‘cross’: /kr/ undergoes cluster reduction in ‘tap’ and frication in ‘cross’

Word medial /rst/ in ‘sausages’ and ‘brush’: /rst/ is reduced to /s/ in ‘sausages’ and to /t/ in ‘brush’

Final syllable /ən/ in ‘clouds’ and ‘boy’: /ən/ is deleted in ‘clouds’ and reduced to /ə/ in ‘boy’

Word initial /k/ in ‘head’ and ‘clock’: /k/ undergoes fronting in ‘head’ and frication in ‘clock’

In short, there is considerable variability in Louise's speech production with one and the same target being differently realised on separate occasions.

‘worsten’ /wəs/ – cluster reduction and syllable deletion

‘wolken’ /wɔk/ – cluster reduction and syllable deletion

‘jongen’ /ɔŋə/ – initial and final consonant deletion

parts (b) and (c)

There is some basis for the inclusion of a treatment based on principles of motor learning of the type used to treat apraxia of speech. Louise displays high variability in the production of sound distortions which is a feature of apraxia of speech. Also, the presence of a slight general hypotonia suggests that there may be a neurogenic aetiology to Louise's speech production difficulties. A neurogenic aetiology is posited to exist in apraxia of speech.

A phonological treatment that could be used with Louise is the Cycles Phonological Remediation Approach (Hodson, Reference Hodson2010). This is a prominent intervention for the treatment of severe speech sound disorders in preschool and school-age children. Evidence of its efficacy is provided in a study by Rudolph and Wendt (Reference Rudolph and Wendt2014). In an investigation of three children with moderate–severe to severe speech sound disorders, Rudolph and Wendt found that two of these children exhibited statistically and clinically significant gains by the end of the intervention phase and at follow-up. There were significant gains at follow-up in the third child. Across all phases of the study, phonologically known targets showed greater generalisation than unknown target patterns.

Kummer (Reference Kummer2008) states that blowing and sucking exercises should never be used in the treatment of VPD as they are not effective.

The diagnosis of general developmental delay is not appropriate in Louise's case as she displays normal cognitive functioning. The diagnosis of specific language impairment (SLI) is not appropriate either as Louise exhibits features which preclude a diagnosis of SLI. These features include episodes of otitis media, neurological dysfunction in the form of slight general hypotonia and craniofacial anomalies in the form of a submucous cleft palate.

(a) infectious; (b) traumatic; (c) genetic; (d) genetic; (e) infectious

(a) articulation; (b) prosody; (c) phonation; (d) articulation and resonation; (e) respiration

language disorder; dysphagia; oral apraxia

(a) true; (b) false; (c) true; (d) false; (e) true

(a) improves or remains static; (b) deteriorates; (c) remains static; (d) remains static; (e) improves

High-tech communication board: a computerised device that offers speech generation and eye-tracking as well as memory storage of commonly used phrases; Low-tech communication board: a book that allows a user to point to letters and words

Four factors: (i) presence of sensory impairment (e.g. vision); (ii) presence of cognitive impairment; (iii) user's literacy level; and (iv) presence of physical disability (e.g. hemiplegia)

There is evidence that CB's attitude is similar to that of most AAC users with cerebral palsy. In a study of the perspectives of five AAC users with cerebral palsy, Chung et al. (Reference Chung, Behrmann, Bannan and Thorp2012) reported that all of the participants preferred to use their natural speech if possible, and thought that their AAC device was not a replacement for speech.

CB's neurological damage occurs in the upper motor neurones.

One of the effects of spasticity on the larynx is hyperadduction of the vocal folds. A strained–strangled voice occurs when subglottic air is forced through a narrow, tightly constricted larynx in which the vocal folds are excessively adducted.

Because CB is unintelligible in conversation, her communication partner is forced to make repeated requests for clarification. Clarification sequences typically proceed by means of a series of yes–no questions (e.g. ‘Do you mean X?’), which puts CB in the role of always responding to the utterances of others. This role is a passive one, from which CB expects only to respond to others and not to initiate communication herself.

parts (a), (c) and (e)

The range and timing of palatal elevation are aberrant in spastic dysarthria, with the result that the velum is unable to make contact with the pharyngeal wall. Hypernasal speech results from the escape of air into the nasal cavities.

birth anoxia

Wit et al. found that the fundamental frequency range of children with perinatal-onset spastic dysarthria was lower than that of children with normal speech. This accounts for the reduced pitch of children with spastic dysarthria.

(a) true; (b) true; (c) false; (d) false; (e) true

The target sounds are all voiceless consonants. Voiceless consonants have been chosen in order to address the tendency of children with cerebral palsy to voice voiceless consonants. Four of the five target consonants are fricative sounds. Fricatives and affricates pose the greatest articulatory difficulty for children with dysarthria and are a significant source of unintelligibility in their speech production.

In a traditional articulation hierarchy, the production of a target sound progresses through a number of stages. The production of the target sound is first attempted in isolation or in simple syllables, followed by single words, phrases, sentences and finally conversational speech. Progression from one level to the next level in the hierarchy is dependent on the client achieving a certain level of accuracy in sound production which, in the case of CB's treatment, is an accuracy level of 80%.

The assumption which underlies this aim is that improvements in oromotor functions such as tongue elevation and lip pursing will lead to improvements in speech sound production. Evidence in support of this assumption is somewhat tenuous. In a review of theoretical and experimental work in motor speech disorders, Weismer (Reference Weismer2006) concluded that support for the view that oromotor, non-verbal tasks could be used to improve speech production processes was ‘weak at best’, and that frequent appeal to oromotor, non-verbal tasks is ‘misguided’.

parts (b) and (c)

(5) Two principles of motor learning: (i) there should be multiple opportunities for the practice of the desired motor movement; (ii) appropriate feedback should be provided regarding the nature of the movement. The implementation of principle (i) in CB's treatment took the form of speech drills in phonetic placement therapy. The implementation of principle (ii) in CB's treatment took the form of visual feedback, the use of an animated character during sEMG-facilitated biofeedback relaxation therapy.

The finding that both treatments failed to bring about improvement in sentence- or paragraph-level intelligibility is consistent with the evidence base on the efficacy of SLT interventions available to individuals with developmental dysarthria. In a wide-ranging review of research published up to April 2009, Pennington et al. (Reference Pennington and Bishop2009) found no firm evidence of the effectiveness of SLT interventions which aimed to improve the speech of children with dysarthria acquired before 3 years of age.

There is no evidence that CB's functioning or psychological well-being were enhanced by the treatments she received in this study. CB's self-perception of her speech impairment remained unchanged following intervention. She still had moderate concern about her speech disorder following treatment.

Tongue protrusion and lip pursing are both non-speech postures. The fact that these non-speech postures improved in CB when her overall intelligibility did not increase supports the view taken by Weismer (Reference Weismer2006) that oromotor, non-verbal tasks do not enhance speech production processes.

Alternate motion rates can be assessed by means of DDK tasks. It is not entirely unexpected that these rates did not decrease significantly following PPT, as phonetic placement therapy aims for accuracy in labial and lingual placement and is not concerned to target the rate of articulatory movements.

During PPT, CB progressed as far as the single-word level in the articulation hierarchy. It was also at the single-word level that there was a significant increase in CB's intelligibility at the end of the study. If PPT had been extended and CB had been able to progress to more advanced levels in the articulation hierarchy, then improvements in her intelligibility beyond the single-word level might have been possible.

The absence of neuromuscular deficits sets CAS apart from developmental dysarthria.

To establish the prevalence and incidence of a disorder, it is necessary first to be able to identify the disorder. There has not been widespread clinical consensus on the features of DAS. In the absence of this consensus, it has not been possible to identify all cases of the disorder, with the result that investigators cannot study the epidemiology of DAS.

part (c)

If a speaker with DAS is unable to coordinate the onset of voicing with the positioning of the articulators for the production of a certain speech sound (e.g. /b/), the result may be the devoicing of the sound in question (i.e. /p/).

By reducing their rate of speech, speakers with DAS are able to increase their intelligibility. Speech rate reduction is a compensatory strategy on the part of these speakers.

Both influenza and chickenpox can have neural complications such as encephalitis. Encephalitis could have adverse implications for Zachary's postnatal neurodevelopment.

Zachary developed middle ear infections when he was 3 years old. These infections could put him at risk of conductive hearing loss.

parts (b) and (e)

The following non-speech, oral movements suggest the presence of oral dyspraxia: (i) inability to purse or spread lips on command; (ii) inability to protrude tongue and perform lateral tongue movements; and (iii) inability to use tongue tip to lick upper and lower lips.

A comprehensive multidisciplinary evaluation should examine the following three areas: (i) Zachary's cognitive or intellectual skills; (ii) Zachary's motor skills including oral motor skills; and (iii) Zachary's hearing and other sensory organs.

Zachary displayed some incoordination in running and in placing blocks in a wooden frame. This behaviour suggests that he may have a generalised dyspraxia in addition to an apraxia of speech.

Hypotonia is a reduction of the skeletal muscle tone which is marked by a diminished resistance to passive stretching. Hypotonia can be a feature of developmental dysarthria.

The Vineland Adaptive Behavior Scales may be used to diagnose autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD). There is no evidence to suggest that Zachary has either ASD or ADHD.

perceptual and motor skills

Zachary had to use analysis and synthesis skills in order to work out what blocks needed to be brought together to fit into the wooden frame.

The 8th percentile means that 92% of Zachary's peers would score above him on the same test, with only 8% scoring below him. The 14th percentile means that 86% of Zachary's peers would score above him on the same test, with only 14% scoring below him.

Normally developing children can produce 10 words at a mean age of 15.1 months (Nelson, Reference Nelson1973). Zachary has fewer than 10 words at 4 years of age (48 months). He thus has a very severe developmental delay in terms of this language milestone.

To say that Zachary's speech displays frequent homonymous forms means that he repeatedly uses the same spoken form of a number of different lexical items. For example, the child who says [tu] for the words ‘shoe’, ‘two’, ‘chew’, ‘stew’ and ‘Sue’ is using homonymous forms.

Zachary was unable to perform non-speech, oral movements such as (i) puffing his cheeks; (ii) lateralising and elevating his tongue inside his mouth; and (iii) pushing the examiner's finger when it was placed against his cheek.

With such poor expressive speech skills, Zachary is a suitable candidate for an intervention based on augmentative and alternative communication.

Therapies for sound production disorders in children typically emphasise working on sounds that are stimulable, i.e. children must be capable of imitating target sounds in isolation and in nonsense syllables before they are addressed in therapy. However, the new intervention that Powell (Reference Powell1996) undertook emphasises working on unknown aspects of phonology. So this new treatment approach incorporates stimulability, rather than demanding that it be present before certain sounds are addressed in therapy.

Zachary's earlier treatment involved just two, 30-minute sessions per week. This is a low-intensity therapy which is likely to have contributed to the limited success of this intervention. In support of this view, Campbell (Reference Campbell, Caruso and Strand1999: 394) states that ‘children with apraxia of speech [require] 81% more individual treatment sessions than children with severe phonologic disorders in order to achieve a similar functional outcome’. Campbell claims that while phonologically disordered children need an average of 29 individual, 45-minute treatment sessions for parents to increase their ratings of their children's speech from having less than half of their speech understood by an unfamiliar listener to having about three-quarters understood, children with apraxia of speech require an average of 151 individual sessions to achieve a similar level of parental estimated speech intelligibility.

Feedback in new intervention: successful imitations of sounds and/or syllables are acknowledged by the clinician. Although we cannot say for sure, it seems likely that this acknowledgement takes the form of verbal feedback. Visual feedback is also effective in interventions for DAS. For example, electropalatography (EPG) may be used to deliver visual feedback on tongue–palate contacts during articulation.

The stimulus items that are used for the stabilisation of inconsistently used sounds in goal 2 are selected with a view to facilitating Zachary's vocabulary development. In goal 3, the design of activities addresses language goals. In goal 4, the maintenance of previously taught sounds is achieved by means of a language stimulation activity. It is in this goal that we see language stimulation assuming priority over speech targets.

(a) true; (b) false; (c) true; (d) false; (e) false

(a) false; (b) true; (c) false; (d) false; (e) true

Swallowing and speech are the two factors consistently reported by clients who undergo glossectomy to be most significant to their quality of life (e.g. Fang et al., Reference Fang, Shi, Zhang, Li, Liu and Sun2013).

parts (b) and (c)

Following total glossectomy, a bulky flap can achieve propulsion of a bolus into the pharynx during swallowing. However, a large, bulky flap may lack the range and speed of movement that is needed for speech production.

Incidence rates of oral cavity cancer are highest in countries where there is widespread use of tobacco, and are in decline in countries where tobacco use has peaked (Simard et al., Reference Simard, Torre and Jemal2014).

(a) otolaryngologist; (b) speech-language pathologist; (c) radiation oncologist; (d) prosthodontist; (e) oral surgeon

A gastrostomy tube, or G-tube, provides access for long-term enteral nutrition in patients who are unable to eat. The tube is inserted through the skin into the stomach. Different types of tube exist for this purpose (Juern and Verhaalen, Reference Juern and Verhaalen2014). Patients who have a glossectomy are candidates for a gastrostomy tube. This is because their nutritional needs cannot be safely met by means of oral feeding for a period of time after surgery.

These substitutions have a compensatory quality. In the absence of the ability to achieve full closure of the pulmonary airstream at the alveolar ridge, these speakers with glossectomy achieve closure at the glottis and lips instead. Hence, the use of the glottal stop [ʔ] and bilabial stop [p], respectively, for /t/.

On account of their tongue defect, these speakers with glossectomy are not able to achieve the full closure that is needed to produce the alveolar and velar plosives /d/, /k/ and /g/. Instead, they approximate these places of articulation by producing alveolar and velar fricatives, respectively. The voicing of the target velar plosives /k/ and /g/ is strictly observed in the use of the voiceless and voiced velar fricatives [x] and [ɣ], respectively. However, this is not the case in the production of /d/ where the voiceless alveolar fricative [s] is used in place of the voiced alveolar plosive.

According to Barry and Timmermann (Reference Barry and Timmermann1985), post-operative lingual mobility is more related to speech acceptability than the amount of tongue mass remaining after surgery.

GS is a white male who was diagnosed with oral squamous cell carcinoma (OSCC) when he was 61 years old. The age, ethnicity and sex of this subject are typical of clients who receive a diagnosis of OSCC. In a study of incidence trends of OSCC in the United States, Chaturvedi et al. (Reference Chaturvedi, Engels, Anderson and Gillison2008) reported that the mean age at diagnosis was 61.0 years in HPV-related OSCC and 63.8 years in HPV-unrelated OSCC. Weatherspoon et al. (Reference Weatherspoon, Chattopadhyay, Boroumand and Garcia2015) reported that white males displayed the highest incidence rate of all race/ethnicity–gender groups in a study of oral cancer cases diagnosed in the United States between 2000 and 2010.

1. (a) false; (b) false; (c) true; (d) false;

2. (e) false; of 1,113 cases of tongue cancer examined by Krishnatreya et al. (Reference Krishnatreya, Nandy, Rahman, Sharma, Das, Kataki, Das and Das2015), 846 (76.1%) occurred at the base of the tongue and 267 (23.9%) occurred on oral tongue.

There is a high probability that GS resumed oral feeding after total glossectomy. In the absence of additional surgical procedures such as laryngectomy, there is a high probability that oral feeding can be resumed. Rigby and Hayden (Reference Rigby and Hayden2014) reported that after total glossectomy with laryngeal preservation, gastric tube dependency ranges from 30% to 44%.

A local flap is a tissue flap that is lifted close to the defect but retains its original blood supply.

The fact that GS had already complied with two years of speech therapy by the time of this study shows that he has a high level of personal motivation. This will have contributed to his good speech outcome.

It is uncertain for two reasons that listeners would rate GS's speech to be more unintelligible if they had seen a video-recording as well as heard an audio-recording: (i) the articulatory adjustments that GS makes to signal differences between bilabial and alveolar plosives may be detectable on a close-up video analysis but fail to be detected under natural conditions; and (ii) even if listeners did detect these adjustments, they may not be able to attribute any significance to them in terms of their perception of plosive sounds. On account of (i) and (ii), there may be no significant gain in terms of GS's intelligibility by listeners having access to visual information from a video-recording of GS's speech.

GS is using bilabial protrusion, jaw protrusion and jaw lowering as compensatory articulations. Within his anatomical and physiological limitations, GS is using his spared oral structures, specifically his lips and jaw, to alter the configuration of his vocal tract during the articulation of plosive sounds.

Like GS, some of Barry and Timmermann's subjects used the bilabial plosive /p/ in place of /t/. However, these subjects performed other substitutions which were not used by GS. The glottal stop also took the place of /t/. Furthermore, these subjects used alveolar and velar fricatives on account of their attempts to approximate the contact needed to produce alveolar and velar plosives. This pattern was not observed in GS.

GS underwent a total glossectomy while Barry and Timmermann's subjects had a partial glossectomy. The preservation of tongue tissue in a partial glossectomy means that there is greater lingual mobility for articulation. Accordingly, Barry and Timmermann's subjects were able to approximate alveolar and velar plosive articulations even if they were unable to achieve full closure. This approximation was not possible for GS who had a total glossectomy and a flap repair. Because the latter had limited mobility, GS had little option but to substitute alveolar and velar plosives with bilabial stops.

Not all compensatory articulations that are naturally developed by clients who have a glossectomy are effective in terms of improving intelligibility. Some may even be counterproductive to this aim. To the extent that clients can develop maladaptive patterns of articulation following surgery, the supervision of a speech-language pathologist is required to ensure maximally effective use of post-surgical anatomy.

Electromyography was performed to confirm the results of video analysis, and specifically the finding that GS protruded his lips more during the articulation of /t, d/ than the articulation of /p, b/. By selecting vowels for use in CV monosyllables that are neutral for lip position, the investigator was ensuring that any lip activity detected during EMG could be attributed to the consonant sound alone in these syllables.

parts (a), (c) and (e)

The epiglottis is active during the production of vowels. It serves to constrict the pharynx during the production of low vowels.

The finding that listeners could not discriminate between GS's production of bilabial and alveolar plosives – all were perceived as bilabial plosives – is unsurprising given that there is no acoustic distinction between these plosives.

The movement of GS's grafted flap, jaw, pharynx and epiglottis altered the configuration of the vocal tract sufficiently that GS was able to discriminate acoustically between high and low vowels, even if not alveolar and bilabial plosives.

parts (b) and (d)

(a) neoplastic and iatrogenic; (b) infectious; (c) traumatic; (d) iatrogenic; (e) neoplastic and iatrogenic

multiple sclerosis: mixed ataxic-spastic dysarthria

Parkinson's disease: hypokinetic dysarthria

motor neurone disease: mixed flaccid-spastic dysarthria

(a) resonation; (b) articulation; (c) respiration; (d) phonation; (e) prosody

When assessing the suitability of an alternative communication system for a client, speech-language pathologists need to consider: (i) the presence of any physical disability; (ii) the presence of any cognitive deficits; and (iii) the presence of any sensory impairments.

AB had a type of CVA called an intracerebral haemorrhage. AB's high blood pressure (hypertension) caused one or more arteries within his brain to rupture. This released blood into the brain tissue. This blood forms a clot or haematoma which compresses the surrounding brain tissue, leading to raised intracranial pressure.

spastic weakness: damage to the upper motor neurones

flaccid weakness: damage to the lower motor neurones

parts (a), (c) and (d)

AB's palate was atrophied and foreshortened following his CVA. This would have compromised velopharyngeal closure. AB's wife reported that he had nasal speech prior to his CVA. VPI may thus also have been a feature of AB's premorbid communication.

Most of the motor nuclei of the cranial nerves in the brainstem receive bilateral upper motor neurone innervation. Accordingly, in the presence of unilateral cortico-bulbar lesions, there will still be some innervation to the cranial nerve nuclei and the speech musculature will continue to function adequately. Bilateral cortico-bulbar lesions are required to eliminate innervation to the cranial nerve nuclei altogether, resulting in a significant dysarthria.

parts (a), (c) and (e)

AB's uneconomical use of air is evident in (i) inadequate vocal fold adduction, resulting in loss of air through the glottis and a breathy voice, and (ii) inadequate velopharyngeal closure, resulting in loss of air through the velopharyngeal port and hypernasal speech.

(a) perceptual assessment; (b) physiological assessment; (c) acoustic assessment; (d) physiological assessment; (e) perceptual assessment

AB's articulation of plosive sounds is compromised in two ways: (i) AB's velopharyngeal incompetence makes it difficult for him to achieve the build-up of intra-oral air pressure that is needed to produce plosives; and (ii) the limited range of AB's articulatory movements means that the full closure which is needed to produce plosives is replaced by a fricative stricture.

AB is unable to vary the pitch (fundamental frequency) and loudness (intensity) of his voice. These phonatory disturbances create prosodic anomalies, as control of pitch and loudness is essential for the use of stress and intonation in speech.

part (a)

Spasticity compromises the range, speed and force of articulatory movements.

The articulator in which there is combined flaccid and spastic involvement is the soft palate (velum). The effect of spasticity on the palate is a tendency towards downward movement. The effect of flaccidity on the palate is to render it too weak to achieve elevation. An appropriate prosthetic intervention in this case is the use of a palatal lift device.

The same lower motor neurones, namely, the vagus nerves (CN X), innervate both the laryngeal muscles and the levator veli palatini. The lower motor neurone involvement of the palate bilaterally is thus a strong basis for the suggestion that AB's phonatory abnormalities are related to a flaccid condition of the vocal folds.

Indirect laryngoscopy is a technique used to examine the larynx. In mirror laryngoscopy, the examining physician uses gauze to hold the end of the client's tongue while a laryngeal mirror is positioned just below the back of the soft palate as the patient says ‘ee’. In patients where this procedure elicits a strong gag reflex, fibreoptic laryngoscopy may be a more appropriate technique. A flexible endoscope is passed transnasally into a position above the larynx. Insertion of the scope may be made more tolerable by the use of a local anaesthetic spray.

parts (a), (b) and (d)

Speakers with dysarthria are usually assessed by familiar listeners such as spouses and carers to have a greater level of speech intelligibility than that determined by unfamiliar listeners. Accordingly, both familiar and unfamiliar listeners should be involved in an assessment of the intelligibility of the speaker with dysarthria. Scripted tasks (e.g. reading passages) and unscripted tasks (e.g. conversation) should both be used in an assessment of intelligibility. Target words are known by the listener in the former tasks but not in the latter tasks, with the result that speech production during scripted tasks is likely to be judged to be more intelligible than during unscripted tasks. If only scripted tasks are used in an assessment of intelligibility, it is likely that the client's intelligibility level could be overestimated.

Under the reflex section of the FDA-2, one might expect to record the presence of pathological reflexes (e.g. sucking reflex). Under the jaw section, one might expect to record any deviation of the jaw to one side or problems with tongue–jaw coordination.

AB's social and occupational functioning will be adversely affected by his dysarthria. His level of unintelligibility is likely to restrict his communication to such a degree that he withdraws from a range of social interactions. Also, AB suffered his CVA at 39 years of age, an age when most adults are still economically active. Although we are not told what AB's employment was prior to his stroke, his level of unintelligibility is likely to preclude a return to the workplace. The combination of social withdrawal and unemployment is likely to put AB at risk of depression and other psychological problems, thus reducing yet further AB's quality of life.

body structure and function

In an autosomal recessive disorder, the gene which gives rise to a disorder is found on the autosomes, i.e. the chromosomes which are not the sex chromosomes. In a recessive disorder, both alleles of the gene must be disease alleles in order for the disorder to be expressed or manifested in an individual.

part (b)

In the well-managed client with Wilson's disease, dysarthria is likely to improve over time.

part (b)

(a) prosody; (b) resonation; (c) prosody; (d) articulation; (e) prosody

(1) Three features of R's history:

1. (a) presence of neurological signs

2. (b) presence of psychiatric disturbance

3. (c) presence of Wilson's disease in a biological relative

R's psychiatric problems directly contributed to his poor compliance with his drug and dietary regimen. These same psychiatric problems are likely to have an adverse impact on R's ability to comply with assessment and intervention in speech-language pathology.

There are two indications that R is at risk of aspiration pneumonia. He displays drooling and dysphagia which suggest that his swallowing mechanism is compromised to at least some degree. There is likely to be inhalation of oropharyngeal secretions in this case.

Written messages and sign language were of limited effectiveness for R because he would also experience poor manual motor control as a result of Wilson's disease.

social functioning

part (e)

R's speech skills and impairments will vary with changes in his underlying pathology (Wilson's disease). It is, therefore, important that therapy is sensitive to these changes, and is adjusted to reflect them and their impact on speech production.

parts (a), (c), (d) and (e)

R's psychiatric problems may have contributed to (i) his refusal to consider augmentative and alternative communication in therapy, and (ii) his difficulties in monitoring and evaluating his productions.

The behaviour in question is R's use of gestural communication. This behaviour is described as ‘maladaptive’ because R's gestures were unsuccessful and confusing and, thus, had little communicative value.

part (e)

By slowing his speech rate, R has more time in which to make the transitions between speech sounds and to assume the articulatory positions that are needed to produce target sounds.

Blowing exercises are one traditional therapy technique which is used to improve hypernasal speech. It is the conclusion of a Cochrane systematic review that there is currently no good-quality evidence to support or refute the use of such techniques in the management of dysarthria (Sellars et al., Reference Sellars, Hughes and Langhorne2005).

A palatal lift is a rigid, acrylic appliance which is created by a prosthodontist. It consists of a retainer that covers the hard palate and fastens to the maxillary teeth. There is a lift portion that extends along the oral surface of the soft palate. This portion raises the soft palate posteriorly and superiorly so that it does not have as far as normal to travel in order to close the velopharyngeal port.

The two approaches that were used to ensure generalisation of speech skills beyond the clinic were (i) emphasis on R's monitoring and evaluation of his intelligibility in a range of non-clinical settings, and (ii) the provision of feedback from R's wife and his other communicative partners.

By the end of therapy, R's articulation of individual speech sounds made a relatively minor contribution to his overall intelligibility. This is demonstrated by the fact that even as R's intelligibility was judged to have improved significantly by 1985, his production of consonants and phonemes was still judged to be deviant (imprecise consonants and prolonged phonemes were first- and second-ranked, respectively, in an assessment of deviant speech features in 1985).

Reductions in R's intelligibility during the 10-year period of his intervention could be accounted for by (i) R's failure to alter his daily schedule in order to avoid the speech-aggravating effects of fatigue, and (ii) R's failure to comply with the medical regimen that was needed to manage his underlying neurological disorder.

On account of its extended duration, R's intervention raises pressing questions about its cost-effectiveness. The considerable expenditure that is incurred in this case can be supported by the gains that have been achieved in R's occupational functioning, societal participation and psychological well-being. In terms of occupational functioning, R is in full-time employment by the end of therapy. Not only has this resulted in him no longer requiring disability compensation under social security, but he now has the economic means to support his wife and son. In terms of societal participation, R has been able to assume social roles which were previously denied to him by his severe speech disorder. He is now a husband and father. R's range of communicative partners will also have increased with improvements in communication. With these partners comes an expansion of R's social relationships to others. In terms of psychological well-being, R has been vulnerable to psychiatric disturbance on account of his neurological disorder. The psychological benefits that accrue from his improvements in communication might mitigate the effects of conditions such as depression.

The duration of therapy in R's case posed challenges in terms of monitoring speech progress. One challenge is that several different clinicians assessed R's speech production over the course of 10 years. Unless efforts are made to ensure each clinician is working to the same discriminatory standard, the measurement of speech performance will not be reliable. A second challenge is that speech progress can only be properly documented if exactly the same speaking tasks are used at each point of assessment. If different tasks are used to assess a client's speech, what appears to be an improvement in speech function may simply be a reflection of the different levels of difficulty that attend tasks.

This decision reveals that therapy must be tailored to the needs of individual clients. The use of augmentative or alternative communication, even if effective in R's case, would not have been judged by him to be a satisfactory outcome of therapy. However, in another client with R's same level of speech unintelligibility, the use of AAC may be judged to be acceptable. A speech intervention would not be pursued in this case.

parts (b) and (d)

Three causes of AOS: traumatic brain injury; cerebral infections (e.g. encephalitis); brain tumours.

parts (c) and (e)

Botha et al. (Reference Botha, Duffy, Strand, Machulda, Whitwell and Josephs2014) found that bilateral atrophy of the prefrontal cortex anterior to the premotor area and supplementary motor area was associated with non-verbal oral apraxia. This neuroanatomical area is in close proximity to the premotor area which has been implicated in AOS. This proximity explains why oral apraxia is very common in clients with progressive AOS.

static AOS: cerebrovascular accident

progressive AOS: neurodegenerative disease (e.g. frontotemporal dementia)

part (d)

A right hemiplegia has the following implications for SLT assessment and intervention: (i) a client will be unable to produce written responses on assessments like the Boston Diagnostic Aphasia Examination (at least not with the preferred hand); (ii) a client will find it difficult to manipulate objects during an assessment like the Token Test; (iii) if a client needs to use an augmentative or alternative form of communication, a right hemiplegia will limit the type of communication system that can be used, e.g. signing and the use of natural gesture will be compromised.

parts (b), (d) and (e)

The lower part of the primary motor cortex does have implications for motor speech production. It contains the part of the motor strip that controls movements of the organs of speech production (e.g. articulators, larynx). If this neuroanatomical area is damaged, a motor speech disorder such as dysarthria may result.

part (c)

This client does appear to have apraxia of phonation. The evidence in support of this is: (i) the client exhibited minimal vocalisation in the two-week period following the start of speech-language intervention; (ii) when he started producing automatic verbal responses to tasks, his speech remained aphonic; (iii) at five weeks post-stroke, he had substantial difficulty initiating speech. Problems with the initiation of phonation may account for this difficulty.

(a) true; (b) true; (c) false; (d) false; (e) true

The client's naming is influenced by the frequency (high/low) of the target, the class (open/closed) of the target, and the concreteness or abstractness of the target. We are not given specific information about how these variables influenced the client's naming. He may, for example, find it easier to name a word of high frequency (‘dog’) over a word of low frequency (‘albatross’), a word from an open class like noun (‘house’) over a word from a closed class like preposition (‘with’), and a concrete word (‘table’) over an abstract word (‘trust’).

By the end of the fourth week post-stroke the client was able to produce automatic verbal responses. This is significant in terms of AOS symptomatology, as automatic speech production is known to be easier than volitional speech production in clients with AOS.

The presence of verbal paraphasias indicates that the client exhibits semantic deficits during naming. In a verbal paraphasia, a client produces a word that is semantically related to the target word.

1. (a) ‘hurt hisself’ (uses [s] in place of /m/)

2. (b) ‘it's cookie jar’ (omits ‘a’)

3. (c) ‘fo fo folling’ (unsuccessfully attempts to correct first vowel in ‘falling’)

4. (d) ‘She's overflowing the sink’ (rather than ‘The sink is overflowing’)

5. (e) ‘With her?’ (replicates intonation of examiner's question)

The client's expressive grammatical difficulties and numerous attempts to correct speech conspire to limit the fluency of his verbal output. This lack of fluency disrupts the intonation pattern and other prosodic features of the client's verbal output.

1. (a) Wernicke's aphasia – There is a severe impairment of auditory comprehension in this syndrome. However, the client's auditory comprehension of language is relatively good.

2. (b) conduction aphasia – There is a severe impairment of repetition in this syndrome. However, the client's repetition of words and phrases is relatively good.

3. (c) Broca's aphasia – There is a severe impairment of syntax (agrammatism) in this syndrome. However, the client does not exhibit agrammatic verbal output.

4. (d) anomic aphasia – There is a severe word-finding difficulty in this syndrome. However, the client's word-finding skills, as indicated by his naming performance, are relatively intact.

5. (e) global aphasia – There is severe impairment of expressive and receptive skills in this syndrome. However, the client's language difficulties are mild to moderate in severity.

1. (a) limb/hand praxis

2. (b) bucco-facial/respiratory praxis

3. (c) limb/hand praxis

4. (d) bucco-facial/respiratory praxis

5. (e) limb/hand praxis

Written confrontation naming is doubly compromised by a right hemiplegia and limb apraxia. The client's right hemiplegia will cause him to use his non-preferred hand to produce a written response, while his limb apraxia will make it difficult to programme the motor movements that are needed to control his hand.

Speech errors in AOS tend to increase in number as the length of words increases. Accordingly, there are likely to be more speech errors in multisyllabic words than in monosyllabic words.

word-initial position

Because the client engages in aphonic speech production, it is inevitable that he will produce a voiceless phoneme in place of a voiced cognate phoneme. Such an error is not a true substitution as such.

Schwa insertion is a common compensatory tactic among speakers with AOS who appear to use it to modify intra- and inter-syllabic consonant sequences (Miller et al., Reference Miller, Lowitt and O'Sullivan2006). It has been argued that by inserting a schwa, speakers with AOS can prolong transition times between consonants, thus enabling these speakers to attain articulatory targets (Miller, Reference Miller and Papathanasiou2000).

Speakers with AOS related to cortical lesions display more errors on affricates and fricatives than other manners of articulation, and produce more errors on consonant clusters than on singleton consonants (Ogar et al., Reference Ogar, Slama, Dronkers, Amici and Gorno-Tempini2005). However, the client in this study displayed similar percentages of errors across different phoneme groupings, e.g. consonant clusters, fricatives, nasals, etc.

(a) true; (b) false; (c) true; (d) true; (e) true

The client with FAS, who was studied by Tomasino et al. (Reference Tomasino, Marin, Maieron, Ius, Budai, Fabbro and Skrap2013), is not typical of FAS in general. This client did not display signs of dysarthria, apraxia of speech, or aphasia. However, Aronson (Reference Aronson1990) reported that 68% of patients with FAS had their accent embedded in, or following, dysarthria, aphasia, or apraxia of speech. Among Aronson's 13 Mayo Clinic patients, 62% had apraxia of speech as an antecedent to the perception of an accent.

Two examples of articulatory overshoot: (i) the production of velar fricatives as velar stops; (ii) the realisation of the glottal fricative as a glottal stop.

These errors are examples of articulatory undershoot, in which the speaker with FAS does not reach the plosive articulatory targets and produces fricatives in their place.

It is a general aim of communicators to give prominence to new information. This is achieved by placing pitch accents on new information. When speakers with FAS place pitch accents on given information, they are giving prominence to information that is already part of the shared or mutual knowledge of speaker and hearer.

Hearing loss with ‘sloping configuration’ means that TDF had greater difficulty hearing high frequency tones (on the right of an audiogram) than low frequency tones (on the left of an audiogram). It takes the form of a downward or sloping line on an audiogram.

TDF's first head injury occurred nine years before the onset of her speech problems. It is thus too distant in time to be a cause of TDF's speech problems. The second head trauma was minor in nature, and there was no evidence of it causing a lesion or other neurological damage. It, too, is unlikely to be a cause of TDF's speech problems.

A diagnosis of psychogenic dysphonia is only warranted when there is a perceptible vocal anomaly which arises on account of non-organic or psychological factors. However, in TDF's case, there was no perceptible vocal anomaly, according to the otorhinolaryngologist.

dysarthria

part (d)

part (b)

1. (a) production of automatised sequences such as days of the week

2. (b) word and sentence repetition

The telegraphic quality of TDF's expressive language – some articles, prepositions and auxiliaries are omitted – is similar to the symptom of agrammatism in aphasia. However, these omissions are not pervasive enough for TDF's expressive language to be described as agrammatic.

The absence of oral apraxia in TDF's case does not necessarily exclude apraxia of speech. It is possible for a client to have apraxia of speech in the absence of oral apraxia.

aphasia; dysarthria

stuttering

apraxia of speech

Monday – devoicing of voiced consonant; always – final consonant deletion; three – consonant cluster reduction; Hawaii – initial consonant deletion; talk – final consonant deletion

Scanning speech is the use of excessive and equal stress on all syllables. It is a term which has been used to describe a prominent characteristic of dysarthria in multiple sclerosis as well as of ataxic dysarthria in general.

Incorrect use of stress in sentences may disrupt TDF's ability to signal information status. In this way, instead of giving prominence to new information in utterances through the use of lexical stress, TDF may place stress on words which convey given information.

grammar

The variability in perceived accents in the listener experiments provides support for the view that FAS is a listener-bound epiphenomenon.

Prosody is largely mediated by neural networks in the right hemisphere (Bryan, Reference Bryan1989). Accordingly, one might expect the prosodic anomalies of FAS to be associated with right-hemisphere damage rather than left-hemisphere damage.

The listener experiments in this study used both scripted data (e.g. reading aloud) and unscripted data (e.g. conversation).

The fact that TDF's foreign accent resolved spontaneously within five months of onset suggests that her speech disorder was psychogenic in origin.

• idiopathic origin: part (e)

• structural anomaly: part (a)

• neurological impairment: part (c)

The prevalence of speech sound disorders varies between studies because there is a lack of clinical consensus on how to classify these disorders (Waring and Knight, Reference Waring and Knight2013). Because some prevalence studies examine all speech sound disorders, while other studies investigate one subgroup of speech sound disorders, the prevalence rates of these disorders can vary markedly between different investigations.

The comorbidity of these disorders tells us that there are commonalities in the genetic, neurobiological or other aetiology of these disorders. The reader is referred to Pennington and Bishop (Reference Pennington and Bishop2009) for further discussion.

The late eight phonemes are /ʃ, ʒ, l, r, s, z, ɵ, ð/ (Shriberg, Reference Shriberg1993).

cluster reduction: part (a)

palatal fronting: part (e)

gliding: part (c)

Jarrod's father had a speech disorder, for which he received speech therapy. Jarrod's maternal grandfather has a history of dyslexia. The aggregation of speech sound disorders and reading disability in Jarrod's family is not unique to his family. Lewis et al. (Reference Lewis, Shriberg, Freebairn, Hansen, Stein, Taylor and Iyengar2006) state that ‘[s]tudies of the familial aggregation of speech sound disorder have reported a higher percentage of family members affected by speech and language disorders in families of children with speech sound disorder than in control families’ (1295).

Jarrod is able to forge friendships with other children. He also has a range of interests. Hence, he does not exhibit the restricted interests and impairments of socialisation that are central to the behavioural phenotype of autism spectrum disorder.

The social difficulties reported by Jarrod's teacher are secondary to his communication problems. The social difficulties in autism spectrum disorder are a primary feature of the condition.

The fact that familiar listeners (i.e. Jarrod's mother and teacher) do not understand him outside of a known conversational context indicates that his phonological disorder is particularly severe.

non-verbal strategies: Jarrod uses gestures and drawing

metalinguistic device: Jarrod engages in message reformulation. This is a metalinguistic device, as Jarrod needs to make judgements about language in order to convey the same meaning using words that he can produce.

Jarrod did not exhibit feeding difficulties in the developmental period. This suggests that he has normal oromotor control.

These studies have revealed that speech sound disorder is most predictive of ADHD when combined with language impairment. McGrath et al. (Reference McGrath, Hutaff-Lee, Scott, Boada, Shriberg and Pennington2008) found that children aged 4–7 years with speech sound disorder and specific language impairment had higher rates of inattentive ADHD symptoms than those with speech sound disorder only. Lewis et al. (Reference Lewis, Short, Iyengar, Taylor, Freebairn, Tag, Avrich and Stein2012) reported that children with moderate-to-severe speech sound disorder had higher ratings of inattention and hyperactivity/impulsivity than children with no speech sound disorder. However, language impairment was more predictive of ADHD symptoms than the severity of speech sound disorder.

An allergy or upper respiratory tract infection can cause congestion and swelling of the Eustachian tube, nasopharynx and nasal mucosa. If the Eustachian tube isthmus (the narrowest portion) becomes obstructed, middle ear secretions can build up behind the obstruction. Bacterial and viral infection of these secretions can cause suppurative otitis media. To prevent this sequence of events, otorhinolaryngologists (ENT consultants in the UK) make a small incision in the tympanic membrane during a procedure known as a myringotomy. The middle ear is cleared of debris and a pressure equalising tube (grommet) is inserted in the membrane to create a temporary aperture. This tube keeps the middle ear ventilated and normally prevents a recurrence of otitis media. The ear drum naturally expels the tube after a period of time with the result that the procedure may need to be repeated (as happened in Jarrod's case).

1. (i) Jarrod's mother reported that he enjoys a number of activities. She also said that he has been willing to address the school at assembly even though he is not understood. Jarrod's teacher reported that he participates in classroom activities and group discussions.

2. (ii) Jarrod has been teased by other children about his speech difficulties.

3. (iii) Jarrod's teacher reported that he is sensitive about his communication problems and he has had reduced self-esteem which has improved as a result of his attendance at an Intensive Language Class.

Children with speech sound disorder have an increased risk of reading disability. Peterson et al. (Reference Peterson, Pennington, Shriberg and Boada2009) examined the literacy outcome of 86 children with histories of speech sound disorder. The study also included 37 control children with no histories of speech sound disorder. Reading disability was significantly more prevalent in the group of children with speech sound disorder (22.1%) than in the group of control children (5.4%).

1. (a) gliding; final consonant deletion

2. (b) initial consonant deletion; final consonant deletion

3. (c) cluster reduction; substitution of alveolar nasal by bilabial nasal; glottal stop replacement

4. (d) cluster reduction; glottal stop replacement

5. (e) substitution of bilabial nasal by velar nasal

part (d)

Poor non-word repetition suggests that Jarrod's phonological working memory is impaired.

Phonological awareness is impaired in children with reading difficulties. That phonological awareness is impaired in Jarrod is indicated by his performance on the Sutherland Phonological Awareness Test. Jarrod scored 18 on this assessment when the average score range for his age is 33–45.

(a) false; (b) true; (c) true; (d) false; (e) true

1. (a) ‘pig’ [beı]

2. (b) ‘television’ [tstʌ̰ʔædbedḛ~n̰]

3. (c) ‘legs’ [jeə̰]

4. (d) ‘goldfish’ [doʊbḛə̥]

5. (e) ‘house’ [hæʊ]

   Final consonant deletion affects syllable structure.

   The age at which these phonological processes are suppressed is indicated in brackets: prevocalic voicing (3;0 years); stopping of /v/ (3;6 years); gliding (5;0 years); fronting (3;6 years) and final consonant deletion (3;3 years). In other words, all these processes are normally suppressed by 7 years of age.

1. (a) ‘jam’ [ʤæ~m]

2. (b) ‘legs’ [jeə̰]

3. (c) ‘sock’ [j:ɒk]

4. (d) ‘foot’ [b̬ɒʔ]

5. (e) ‘zebra’ [jebwʌ:]

reduction of consonant cluster: ‘zebra’ [jegbʌ:]

deletion of consonant cluster: ‘legs’ [jeə̰]

(a) false; (b) true; (c) true; (d) false; (e) false

final consonant deletion: ‘pig’ [dḛ:]

gliding: ‘around’ [gʌwæ~ʊ̃]

Jarrod displays inconsistency in his production of ‘pig’ in the context of single words and connected speech.

The universal pattern of phonological acquisition (at least in terms of manner of articulation) can be represented as follows: stops > nasals > fricatives > affricates > liquids. The Turkish order of acquisition conforms to this pattern in that stops are acquired before nasals. However, the Turkish order of acquisition differs from this pattern in that affricates are acquired before fricatives.

(a) stopping; (b) affricate stopping; (c) consonant assimilation; (d) syllable-final consonant /ŋ/ deletion; (e) affrication

parts (b), (c) and (e)

The chronological ages at which suppression of these phonological processes occurs in Turkish are largely similar to the ages at which their suppression occurs in English. In English, reduplication (before 3 years), prevocalic voicing (3;0 years) and fronting (3;6 years) are suppressed early. The suppression of cluster reduction (4;0 years) and liquid deviation (5;0 years) occurs later.

Brosseau-Lapré and Rvachew (Reference Brosseau-Lapré and Rvachew2014)

It is important for a speech-language pathologist to know if D is monolingual or bilingual because there is some limited evidence that bilingual children are at an increased risk of speech sound disorder. In a systematic review of studies over a 50-year period, Hambly et al. (Reference Hambly, Wren, McLeod and Roulstone2013) found limited evidence to suggest that bilingual children develop speech at a slower rate than their monolingual peers. As well as differences in the rate of speech sound acquisition, this review also identified differences between monolingual and bilingual children in the patterns of their sound errors.

Three motor milestones: begins to sit without support (6 months); crawls (9 months); walks alone (18 months).

This description may be taken to exclude a condition like cleft lip and palate. More generally, it excludes any craniofacial disorder that compromises the structure of the oral cavity and articulators.

developmental dysarthria; developmental verbal dyspraxia (childhood apraxia of speech)

parts (a) and (c)

(a) fronting; (b) stopping, affrication, devoicing; (c) stopping; (d) fronting, stopping; (e) affrication

1. (a) [fugãw] → [tudãw] ‘oven’

2. (b) [igréʒa] → [idéʤa] ‘church’

3. (c) [aʒúda] → [atúda] ‘help’

4. (d) [azúleʒu] → [atúleʤu] ‘tile’

5. (e) [guardaʃúva] → [dadatúta] ‘umbrella’

cluster reduction: [igréʒa] → [idéʤa] ‘church’

[guardaʃúva] → [dadatúta] ‘umbrella’

(a) true; (b) false; (c) true; (d) false; (e) false

/ʃ/ and /ʒ/ are realised as [ʧ] and [ʤ], respectively. These realisations occur before the vowels [a] and [u] in syllable initial within word position.

/ʃ/ and /ʒ/ are differently realised in (8) to (10). These sounds are both realised as [t]. It is clear from these productions that /ʃ/ and /ʒ/ are realised as [t] in syllable initial word initial position.

This pattern of realisation is not maintained in (11) to (15). In these productions, /ʃ/ and /ʒ/ are both realised as [t].

In (11) to (15), /ʃ/ and /ʒ/ are realised as [t] because they occur in a stressed syllable. The general rule that captures the pattern of realisation of /ʃ/ and /ʒ/ across (1) to (15) can be stated as follows: /ʃ/ and /ʒ/ are realised as [ʧ] and [ʤ] unless they occur in syllable initial word initial position (in which case they are realised as [t]), and unless they occur in a stressed syllable (in which case they are realised as [t]). In other words, the [ʧ] and [ʤ] realisations are only found when /ʃ/ and /ʒ/ occur in syllable initial within word position and in an unstressed syllable.

In (16) to (21), there is velar fronting of /k/ and /g/ to [t] and [d], respectively. The fact that [t] and [d] in the single-word productions in (19) to (21) are not replaced by [ʧ] and [ʤ], as we would expect them to be based on the pattern identified in question 4, is an indication that velar fronting is a completely separate process in D's phonological system. So we end up with [atí] and not [aʧí] as we would expect, given that [t] is occurring in syllable initial within word position and in a stressed syllable.

An informal assessment procedure was used to assess D's phonology. D produced spontaneous descriptions of thematic pictures from which a sample of 210 words was obtained for analysis. The selection of an informal assessment procedure was almost certainly motivated by the lack of availability of formal phonological assessments in Brazilian Portuguese.

A reliable phonological assessment consistently gives the same results about a child's phonology when the test is administered under identical circumstances. A valid phonological assessment measures the specific phonological skills that it is designed to measure. A norm-referenced phonological assessment compares the phonological skills of a client to those of a representative sample of individuals of the same age and possibly same sex as the client. This representative sample is known as the normative group.

Two disadvantages in using informal procedures to assess phonology in multilingual children with speech sound disorder: (i) informal procedures are unlikely to test all sounds in a language in all word positions; (ii) informal procedures are not strictly replicable. Because these procedures do not employ the same set of stimuli on each occasion of use, informal procedures cannot be used to chart a child's progress in phonological therapy over time.

A phonological assessment developed for English might contain stimulus items which lie outside the cultural experience of children who are native speakers of other languages.

Puerto Rican Spanish and Mexican Spanish are two different dialects. In terms of assessment development, it is important to understand if there are different phonological norms and other processes at work in children who speak these dialects of Spanish.

The expression ‘diagnosis by exclusion’ means that SLI is a type of negative diagnosis that obtains when all causes of language disorder (e.g. hearing loss, intellectual disability) have been excluded in a particular case. Bishop (Reference Bishop2001: 369) states that ‘[w]here delayed or deviant language learning has no obvious cause, and where development is proceeding normally in other respects, the term ‘specific language impairment’ (SLI) is used. This is in part a diagnosis by exclusion (i.e. the child has language difficulties that are not associated with hearing loss, physical handicap, acquired brain damage, autistic disorder or more general learning difficulties), (italics added).

The variation in SLI prevalence across studies may be explained by the use of different diagnostic criteria. Where less restrictive criteria are used, the prevalence of SLI can be expected to increase.

1. (i) Child B uses a subject pronoun (albeit an incorrect one), while Child A is unable to use a subject pronoun at all (‘her’ is used instead of ‘she’).

2. (ii) Child B uses an auxiliary verb, which is omitted in Child A's utterance.

1. (a) object pronoun ‘her’ used in place of subject pronoun ‘she’

2. (b) omission of auxiliary verb ‘is’

3. (c) Two possibilities:

   1. (i) ‘She is building a block’: omission of auxiliary verb ‘is’ and indefinite article ‘a’

   2. (ii) ‘She has a building block’: omission of lexical verb ‘has’ and indefinite article ‘a’

4. (d) omission of auxiliary verb ‘did’

5. (e) omission of auxiliary verb ‘is’

   • grammatical morpheme: progressive -ing

(a) false; (b) false; (c) true; (d) true; (e) false

Two conditions which can be excluded as a cause of DF's language problems: (i) hearing loss (DF passed hearing screenings); and (ii) intellectual disability (DF scored within normal limits on the Leiter-R).

It is important to understand socioeconomic status and maternal education in this case as studies have found a relationship between these factors and a child's language ability. In a longitudinal study of 1,910 infants recruited at 8 months in Melbourne, Australia, Reilly et al. (Reference Reilly, Wake, Ukoumunne, Bavin, Prior, Cini, Conway, Eadie and Bretherton2010) found that low maternal education levels and socioeconomic status predicted adverse language outcomes at 4 years.

(a) morphology; (b) syntax; (c) syntax; (d) morphology; (e) syntax

The SPELT-3 is particularly suited to an assessment of children with SLI, because it is a sensitive measure of expressive morphosyntax which is impaired in these children.

This finding can be explained by the fact that children with expressive SLI have intact receptive vocabulary: ‘Findings from studies employing status assessment measures indicate that children with expressive SLI demonstrate good receptive vocabulary’ (Evans and MacWhinney, Reference Evans and MacWhinney1999: 118).

Children with SLI have limitations in cognitive skills known as executive functions (Im-Bolter et al., Reference Im-Bolter, Johnson and Pascual-Leone2006; Roello et al., Reference Roello, Ferretti, Colonnello and Levi2015).

(1) Three morphosyntactic deficits:

• narrative 1: ‘I get to hold’ (use of present tense ‘get’ instead of past tense ‘got’)

• narrative 2: ‘He going to jump’ (omission of auxiliary ‘is’)

• narrative 2: ‘I know the frog going to jump’ (omission of auxiliary ‘is’)

To produce an autobiographical memory narrative, a narrator must have a mental representation of a past event. Such a representation is not needed when producing a storybook narrative, as the events in the story are visually represented for the narrator. The former type of narrative is thus more cognitively challenging for the narrator than the latter type of narrative. This explains why DF produces an uninformative narrative about his camping holiday, and a more informative narrative based on the wordless picture book.

In the storybook narrative, DF's mother utters ‘look at that’. DF reveals his understanding of the deictic function of this demonstrative pronoun by producing an utterance which identifies the referent of ‘that’ (the frog). Then DF utters ‘He going to jump into that’. His use of the demonstrative pronoun to refer to a feature of the picture confirms that he also has mastery of the deictic function of this expression.

mental state language: remember (mother); think (mother); know (DF)

In order to comprehend and produce mental state language, DF must have theory of mind skills (i.e. the ability to attribute mental states both to his own mind and to the minds of others).

(5) Four question types:

1. (i) yes–no questions (e.g. ‘Do you think the frog is going to jump on his face?’)

2. (ii) wh-questions (e.g. ‘what's he looking for?’)

3. (iii) tag questions (e.g. ‘that's not going to be good, is it?’)

4. (iv) prosodic questions (e.g. ‘He's looking for a frog?’)

DF's mother produces the following utterance at the end of the autobiographical memory narrative: ‘And you got to hold the black walkie talkie’. This response serves to reinforce DF's utterance, while simultaneously correcting his incorrect use of the present tense verb ‘get’.

Two strategies: (i) affirmation of DF's utterance followed by a question (e.g. ‘Yeah, what's he looking for?’); (ii) expansion of DF's single-phrase response (‘A frog’) into a grammatical sentence (‘He's looking for a frog?’).

For the strategies identified in response to question (2), strategy (i) is intended to encourage DF to expand his narrative, while strategy (ii) is used to provide DF with a linguistic model that will facilitate his development of expressive syntax.

(a) false; (b) false; (c) true; (d) true; (e) true

There are no examples of phonological recasts in the narratives between DF and his mother. However, DF's mother does use a lexical recast when she produces the utterance ‘And you got to hold the black walkie talkie’ at the end of narrative 1.

If DF's poor expressive language skills mean that he cannot make himself understood to his peers, it is likely that he will attempt to initiate interaction through a range of non-verbal means. Some of these means might include taking a toy from a child or forcefully intruding into the play of others. These clumsy attempts at initiating interaction with others may lead to conflict between DF and his peers, conflict which DF will be unable to negotiate on account of his poor expressive language skills. These poor social encounters with others, which are set in motion by DF's impaired expressive language skills, are likely to result in a reduced ability on DF's part to forge social relationships with others.

Strong expressive and receptive language skills are vital to successful classroom participation. Children like DF who have impaired expressive language may feel inhibited in responding to a teacher's questions in class or may fail to ask for assistance with tasks. This behaviour may be misinterpreted as social withdrawal or a lack of interest on the part of the child. If receptive language is impaired, a child may be unable to follow a teacher's instructions in class. This behaviour may be misinterpreted as defiant behaviour which might incur penalties and sanctions. In each case, poor classroom participation is a consequence of impaired language skills.

Reduced academic attainment is likely to mediate the relationship between specific language impairment and poor vocational outcomes.

parts (b) and (d)

The clinical value of findings from impact and outcome studies is the role that these findings can play in improving language services to individuals with SLI. Specifically, clinicians can use findings of adverse, long-term impacts of SLI to support the case for early language interventions to preschool children with SLI. If these interventions are delivered at an intensity which can produce significant language gains, it may be possible to mitigate many of the serious, lifelong consequences of SLI.

Tony has been exposed to a bilingual language environment during his development. Although Tony's parents have always spoken English to him, this does not preclude their use of Twi when talking to each other.

parts (b) and (d)

part (b)

Five behaviours which are consistent with a diagnosis of autism spectrum disorder are: poor social skills (Tony had poor eye contact and did not relate to children or adults); use of echolalia; recitation of pop songs and nursery rhymes; inability to initiate conversation and respond in conversation; and a lack of imaginative play.

Motor development – Tony has the motor skills to dress and toilet himself.

The lack of pointing to indicate or request things, and the failure to bring objects to show to another person suggest that Tony may have impaired theory of mind.

Tony's verbal comprehension score on the Reynell places him below the 1-year level. His receptive vocabulary exceeds 80 words, which is the level expected of typically developing children by 12 months of age (Fenson et al., Reference Fenson, Dale, Reznick, Bates, Thal and Pethick1994). So, there is no discrepancy between Tony's receptive language level on the Reynell and as measured by his receptive vocabulary.

Given a lack of positive results from an electroencephalogram (EEG), a diagnosis of Landau–Kleffner syndrome (LKS) now appears increasingly unlikely. This is because there is a close relationship between aphasia and abnormal EEG activity in LKS.

parts (a), (c) and (e)

part (b)

part (b)

Mechanical reading ability is the ability to read written language without processing it for meaning. Tony's excellent articulatory (phonological) memory supports this ability.

In order to use ellipsis appropriately, Tony must be aware that he can elide certain phrases and constructions which his hearer will be able to fill in. In order to do this, Tony must be sure that his hearer has these phrases and constructions as part of his discourse representation. That is, Tony must have an understanding of his hearer's discourse knowledge.

use of pronoun reversal (e.g. ‘you’ for ‘I’)

We are told in unit 13.2 that Tony has good visual memory – he could recall 4/5 objects. And we are told in unit 13.3 that he has excellent auditory (phonological) memory. So it appears unlikely that reduced auditory–visual memory capacities explain Tony's difficulties in dealing with the multiple conceptual demands of the RDLS. Of course, this still leaves open the possibility that reduced semantic memory may play a role.

part (d)

Tony's inability to cope with situation change is consistent with ASD symptoms.

Humour, banter and teasing all involve the use of non-literal language. If Tony does not understand this language, he is at risk of being upset by the playful teasing of his peers.

Tony's inability to spontaneously change or add anything to a set of acting instructions suggests a lack of cognitive flexibility on his part.

Pragmatists and theorists draw upon a script or schema. This is a body of knowledge of the actors, entities and events that we associate with certain scenarios. For example, a restaurant script leads us to expect to find waiters, menus and tables and different food courses within this particular scenario.

1. (a) Extract 1: ‘Hi Ken’

2. (b) Extract 2: ‘Daddy cut your hair’

3. (c) Extract 6: ‘Tony is sick’

4. (d) Extract 2: ‘Daddy cut your hair’

5. (e) Extract 6: ‘Judy talk mummy’

Ellipsis: Extract 5: ‘[Alex is] playing with a bus’

Pronoun for self-reference: Extract 6: ‘Can I talk to mummy?’

1. (a) Extract 2: ‘Daddy cut your hair’

2. (b) Extract 4: ‘Flowers’

3. (c) Extract 4: ‘Wind it up…jump inside’

4. (d) Extract 6: ‘Judy talk mummy’

5. (e) Extract 6: ‘Can I talk to mummy?’

In extract 7, Tony is able to identify that Carl is frightened. This suggests he has a reasonably intact affective ToM capacity.

Tony does not appear to understand questions that interrogate the consequences of actions (e.g. What would happen to your teeth if you were always eating lots of sweets?) and the cause of events and actions (e.g. Why [is Carl crying]?).

parts (a), (c) and (d)

conductive hearing loss

The achievement of motor milestones (e.g. crawling, walking) was normal.

The fact that both of Lena's brothers have severe developmental language disorders suggests that genetic factors may play a significant role in the aetiology of her own language disorder.

part (a) phonology

part (d) semantic paraphasia. Where Lena fails to repeat a target word, she uses a word that has a semantic relationship to one of the target words (e.g. chair is related to ‘lamp’; water is related to ‘swimming’).

(2) Lena can produce the following consonant clusters:

• /kl/ word initial (‘clothes’)

• /br/ word initial (‘braids’)

• /bl/ word initial (‘black’)

• /ŋk/ word final (‘pink’)

Lena has greater expressive than receptive lexical semantic deficits. This is evidenced by the fact that she struggles to produce words belonging to certain semantic categories (e.g. food, clothes), but can classify pictures of objects correctly.

Phonology: Lena uses visual feedback to help her discriminate phonemes. Syntax: Lena's participation in tasks that required the comprehension of grammatical constructions was poor in the absence of visual support.

Sentence connectors confer coherence on narratives by linking their constituent sentences in time, space, causality, consequence and a number of other relations. Examples include ‘Paul went to the show. Afterwards, he briefly visited his parents’ (time) and ‘The performance was terrible. So we left the theatre early’ (consequence).

Exchange 1: (d) consequence

Exchange 2: (a) causation

The script which appears to dominate Lena's responses is that of a set of directives or instructions issued by a parent or teacher, e.g. ‘you may go out’; ‘you may not run’.

The three respects in which Lena's response in exchange 2 is problematic are (1) omission of the inflectional suffix in ‘she go[es]’; (2) omission of the inflectional suffix in ‘ask[s]’; and (3) incorrect use of the preposition ‘with’.

It is less likely that a lack of sentence connectors accounts for Lena's narrative production difficulties at 6;6 years than at 5;6 years. This is because sentence connectors are beginning to emerge at 6;6 years. Also, Lena's specific narrative difficulties include the omission of story events and their narration in an illogical order, neither of which is related to the use (or otherwise) of sentence connectors.

Visual (and possibly tactile) cues appear to facilitate naming for Lena, in that she is able to produce the names of clothes that she is wearing, but is unable to produce the names of clothes which are not present in the situation.

circumlocution; Lena produces old wagon bike for ‘wheelchair’.

Lena's own experience serves as a familiar script. She superimposes this script on narratives because she does not understand the events and relationships between actors in those narratives.

(3) (a) locked for ‘hasp’

1. (b) strainer for ‘funnel’

2. (c) heather for ‘fern’

3. (d) the kings for ‘pyramid’

Lena can make appropriate use of cohesion during the production of narratives. For example, in the following utterance she uses a personal pronoun and a possessive determiner to refer to her cats: ‘My Misse and Murre they could climb up the tree in their sharp claws’.

Lena's comprehension of language is good on the Token Test but poor during connected discourse (e.g. narrative, conversation). This is typical of the child with a diagnosis of semantic-pragmatic disorder or pragmatic language impairment.

(a) true; (b) false; (c) false; (d) true; (e) false

Topicalisation occurs in ‘Flowers…on the apple trees I think are beautiful to see’. Lena's language problems mean she needs extra time to produce and comprehend utterances. The topic–comment structure of this utterance might assist Lena by giving her the extra time she needs to plan what she wants to say about the topic of the utterance.

Lena displays problems with world knowledge during this exchange when (1) she thinks that autumn follows spring and (2) she appears not to know that there are leaves on the ground in autumn.

There are two referential anomalies in the utterance ‘everybody went out and played and she throw snowballs on the wall and it was red’. There are no clearly identified referents for either pronoun.

1. (a) ‘Winter and then spring then autumn and then spring…usually many days are passing’: In this utterance, Lena responds correctly to the question ‘What season comes after autumn?’ but then proceeds to convey information that has not been requested by the examiner.

2. (b) ‘At day nursery when was winter then everybody went out and played and she throw snowballs on the wall and it was red’: In this utterance, Lena has returned to the topic of winter, even though the examiner has indicated a termination of this topic by asking what it is like in spring.

3. (c) ‘What sort of pen is this?’: When Lena poses this question, it marks an abrupt change of topic.

4. (d) ‘What is it like in the winter?’ and ‘what season is it when it is like this outside?’: When these wh-interrogatives are posed to Lena, there is a pause before she is able to produce a response. In each case, the pause suggests Lena needs time to decode the question and plan its response.

5. (e) ‘she throw snowballs on the wall and it was red’: Lena uses pronouns such as ‘she’ and ‘it’ when it is clear the examiner does not have the requisite knowledge to establish their referents. This suggests that Lena has limited awareness of the examiner's knowledge state.

parts (a), (b) and (e)

1. (a) Reading problems occur in the presence of intellectual disability.

2. (b) Reading and spelling problems are caused by a neurological injury.

3. (c) Reading and spelling problems occur in the presence of a sensory deficit (hearing loss).

4. (d) Reading problems are related to the onset of epilepsy.

5. (e) Reading problems occur in the presence of intellectual disability.

Occupational, social and psychological functioning are all adversely affected in adulthood in individuals with developmental dyslexia (de Beer et al., Reference De Beer, Engels, Heerkens and van der Klink2014).

parts (a), (c) and (e)

Comorbid conditions in developmental dyslexia can reveal common underlying aetiologies between dyslexia and disorders such as ADHD at the cognitive and genetic levels.

On the assumption that JR's business involves carpentry and joinery, he has pursued skilled, manual work. Adults with developmental dyslexia tend to pursue non-professional careers where the literacy demands are low.

JR's intellectual functioning is in the normal range.

Although there is little specific information given, it is clear from JR's pursuit of a non-academic route – carpentry and joinery at a technical college – that he experienced limited academic success at school.

absence of a head injury and a neurological disorder

There is familial aggregation of reading and spelling problems. Such aggregation supports a genetic aetiology of dyslexia.

JR's performance on the Raven's Progressive Matrices indicates that he has average non-verbal intelligence.

JR was able to name 33 of 36 objects correctly on a naming test. This performance does not indicate the presence of anomia.

1. (a) JR is able to use the facts that the woman is wearing a sleeveless dress and that the window is open to infer that it must be a sunny day.

2. (b) JR uses the word ‘mishap’ to describe the children's behaviour. While ‘mishap’ conveys the sense of them having an unfortunate accident, it does not convey the fact that they are misbehaving when their mother is not watching them. ‘Mischief’ conveys the latter behaviour more appropriately.

3. (c) The picture displays the words ‘cookie jar’. However, JR uses the word ‘cake’.

4. (d) JR is able to use the mother's eye gaze to infer that she does not know that the sink is overflowing.

5. (e) JR is able to use his script knowledge of kitchens to draw the inference that a cooker should be present.

JR's semantic memory is intact as evidenced by his ability to generate the names of a considerable number of animals and things in one minute. JR's phonological memory is not intact as evidenced by his difficulty in producing words which begin with the letters ‘f’ and ‘s’ in one minute.

In normal subjects, forward digit span is traditionally considered to be 7 with an approximate standard deviation of 2. In other words, correctly repeating 5–9 digits forward is considered to be normal (Scott, Reference Scott, Schoenberg and Scott2011). JR's forward digit span of 5 thus falls within the normal range for verbal working memory.

pivot – visual paralexia

grotesque – neologism

fascinate – morphological paralexia

systematic – visual paralexia

metamorphosis – neologism

(2) There are three forms of evidence that JR is unable to use a phonological reading route:

1. (i) JR was only able to read four unfamiliar, low-frequency words on a regular word test, in which words can only be read by applying grapheme-to-sound rules.

2. (ii) JR has considerable difficulty reading non-words, which are not in the semantic system and must be read by applying grapheme-to-sound rules.

3. (iii) JR was unable to read words when they were presented in typewritten letters in lower case and in the reverse order. A sequential analytic method, in which individual graphemes are identified along with their corresponding phonemes, is needed to read these words. The fact that JR was unable to employ this method is further evidence that he has problems with the phonological reading route.

Irregular words like ache and psalm cannot be read correctly via the application of grapheme-to-sound rules, and must be read via the semantic system. JR was able to read seven such words correctly. This shows that his semantic reading route is relatively intact.

JR is using whole-word recognition to read high-frequency regular words, thus avoiding use of the impaired phonological reading route (grapheme-to-sound rules). Owing to their lack of familiarity for JR, low-frequency regular words cannot be read by whole-word recognition. Instead, these words must be read via the impaired phonological route.

part (b)

JR's reading age on the Schonell is 12 years 6 months. However, his spelling age is 10 years 2 months. His spelling performance is therefore worse than his reading performance.

cuisine: phonologically valid

menace: vowel error

leopard: phonologically valid

ritual: phonologically valid

health: omission of letter

JR's relatively strong performance on the spelling of regular words suggests that his phonological route for spelling is intact to a large extent. This is not consistent with what we know about JR's reading skills, where the phonological route was impaired.

JR's spelling of regular words suggested that the phonological spelling route was relatively intact. However, if this were the case, then JR would have been expected to achieve a better performance on the spelling of non-words – JR spelled only 52% of these correctly. The wider conclusion that we can draw from these findings is that the phonological spelling route is working to some degree even if it is not completely intact.

Like the phonological spelling route, the graphemic spelling route is functioning with reduced efficiency in JR. This is suggested by the fact that JR achieved 47% accuracy on the spelling of irregular words, the spelling of which takes place by means of the graphemic spelling route.

JB sat at 15 months, walked at 26 months and used phrases at 3 years. However, normally developing children are able to sit without support for long periods of time between 6 to 9 months, are able to walk while holding an adult's hand between 6 to 9 months, and are able to produce two-word utterances between 18 to 24 months. So JB's motor and language development is markedly delayed.

Aspiration pneumonia suggests that JB may have a swallowing disorder (dysphagia). This should be a concern for the speech-language pathologist who assesses JB.

conductive hearing loss; JB has small, underdeveloped, low-set ears which suggests that his otological development may not be normal.

part (c)

part (d)

One of the functions of the corpus callosum is to integrate visual inputs to one cerebral hemisphere with the motor outputs of the other cerebral hemisphere (Berlucchi et al., Reference Berlucchi, Aglioti, Marzi and Tassinari1995). This permits fast visuomotor integration to occur. However, in individuals like JB who have a congenital defect of the corpus callosum, this integration proceeds more slowly along extracallosal pathways.

Walking and moving one's arms are gross motor skills. Writing and drawing are fine motor skills.

It is stated in unit 16.1 that JB is ambidextrous. This suggests that he may have bilateral representation of language.

The pragmatic interpretation of utterances draws heavily on visual and other non-linguistic information. For example, to establish the referent of the deictic expression you in the utterance ‘Do you want more coffee?’, a hearer has to know who is present in the physical context. Similarly, a hearer might use a speaker's facial expression to establish that the utterance ‘What a delightful child!’ is produced with sarcastic intent. In a client with agenesis of the corpus callosum, this visual information may not be successfully integrated with linguistic information, leading to impairments of pragmatic interpretation.

JB's excellent personal-social skills indicate that a diagnosis of autism spectrum disorder would not be appropriate in his case. In fact, his personal-social skills exceed his chronological age on the Denver Developmental Screening.

At 34 months, JB's receptive language skills exhibit a delay of 14 months. In other words, JB at 34 months has the receptive language skills of a child of 20 months of age. Sentences with an agent–action–object structure are understood by normally developing children for the first time between 24 and 36 months of age. So it is highly unlikely that JB will be able to comprehend a sentence like ‘The mummy feeds the baby’ at 34 months.

At 34 months, JB's expressive language skills exhibit a delay of 14 months. In other words, JB at 34 months has the expressive language skills of a child of 20 months of age. The relational terms more and no appear in the two-word utterances of normally developing children for the first time between 18 and 24 months of age. So JB may well be able to produce utterances such as ‘more juice’ at 34 months.

parts (b), (d) and (e)

parts (a) and (d)

JB's language problems place him at risk of social devalue when he does not have the requisite language skills to forge social relationships with his peers. If JB's language problems at 34 months are still present when he enters formal education, he will also experience a lack of academic achievement, as he will not have the language skills he needs to access the curriculum.

JB is producing distorted speech sounds and his speech displays mild hypernasality. These difficulties point to the presence of a mild dysarthria.

JB compensates for his poor language skills by (a) touching his listeners to gain their attention, and (b) using gesture to augment his limited verbal output.

When making a request to push the equipment cart around the room one more time, JB uses ‘please’. This indicates a relatively well-developed sense of politeness constraints in conversation.

(4) Three linguistic immaturities:

• JB omits the preposition in ‘I sleep [in] uncle bed’

• JB omits the possessive determiner in ‘I sleep [my] uncle bed’

• JB omits the genitive (ʼs) in ‘uncle bed’ and ‘uncle room’

JB omits function words like prepositions (in), possessive determiners (my) and conjunctions (and). Alongside the retention of content words such as nouns (uncle) and verbs (go), this confers a telegraphic quality on JB's expressive language.

semantic memory

JB's expressive language contains many pauses and fillers. Also, during his naming of objects such as watch and match, JB produces circumlocutions. Both features suggest that JB has a word-finding difficulty.

(3) Immature linguistic forms:

• JB omits the inflectional suffix –es (‘Puppy dog go bite’)

• JB uses an onomatopoeic form (‘It go woof woof’)

• JB uses an incorrect subject pronoun (‘They go pee-pee’)

JB tells the examiner in his first turn that he has a doggie. Yet, it is a presupposition of the examiner's utterance in her first turn that she already knows that JB has a dog. JB appears to be unaware of this presupposition of the examiner's utterance.

JB is able to produce the names of six animals during a verbal fluency task. Additionally, even as he fails to name a chicken and a shovel correctly, he produces words that are semantically related to these targets (‘duck’ and ‘rake’, respectively). Both features suggest that JB has relatively intact knowledge of the semantic categories of words.

Apgar scores are based on five functions in the neonate: breathing effort; heart rate; muscle tone; reflexes; and skin colour. Each of these functions is scored 0, 1 or 2. The 1-minute score determines how well the baby tolerated the birthing process. The score at 5 minutes indicates how well the baby is doing outside the womb. The total Apgar score ranges from 1 to 10, with scores of 7, 8 or 9 considered to be normal.

The boy's height and weight at 3 years of age are such that less than 3% of children of the same age will have a height and weight below him, while 97% will have a height and weight above him.

The philtrum is the groove that runs from the top of the upper lip to the nose. The columella connects the apex of the nose to the philtrum of the upper lip.

part (b)

A ToRCH assay was undertaken and was normal. This result excludes a number of neonatal infections including the following: toxoplasmosis, rubella, cytomegalovirus, herpes simplex and HIV.

The boy is able to use his stronger non-verbal cognitive capacities to facilitate communication. He does this by using mimicry and gestures to compensate for his poor expressive language skills.

1. (b) The car is in the garage (spatial preposition)

2. (d) The book is on the table (spatial preposition)

3. (e) The girl sleeps during the day (temporal preposition)

The boy does not understand colour words like red and yellow.

As the boy attempts to repeat longer sentences – that is, sentences which are grammatically complex – his production of speech sounds deteriorates. This reveals a trade-off between grammar or syntax on the one hand and phonology on the other hand.

The boy is likely to omit the Italian equivalents of the inflectional suffixes –s (in ‘boys’) and –ing (in ‘running’).

The GRBAS scale was used to undertake a perceptual assessment of the boy's voice quality.

parts (a), (b) and (e)

The function of the boy's velopharyngeal port is somewhat compromised. The palate displays hypomobility and is poorly coordinated with other articulatory movements, resulting in moderate nasal emission on pressure sounds such as plosives.

The boy is able to produce all seven Italian vowels correctly. The production of vowels is invariably distorted in childhood apraxia of speech.

As pressure sounds, fricatives may be compromised by the palatal abnormality which results in moderate nasal emission on all pressure sounds. Also, the boy's production of fricatives may be further compromised by his open bite malocclusion.

(1) Three advantages of a multidisciplinary approach to intervention:

1. (a) Speech and language skills are often affected by other aspects of function and development (e.g. hearing, motor development). An intervention that neglects these aspects is likely to have to have an adverse impact on the gains in speech and language that are possible.

2. (b) The input of other medical and health professionals can explain a client's regression in treatment or failure to make progress when such progress should be possible. Factors like depression can impact negatively on a client's progress in treatment and are most successfully identified and managed by the team's clinical psychologist.

3. (c) It may not be possible to remediate speech and language skills in the absence of prior work on a client's cognitive problems or behavioural issues. Only a multidisciplinary team can decide what problems and issues are a barrier to progress in speech and language and, as such, must be prioritised within intervention.

executive functions

part (e)

parts (c) and (e)

Consonant harmony is a process whereby consonants which are not string adjacent assimilate to one another, usually in place features. There are different types of consonant harmony including velar harmony (e.g. [gɔg] for ‘dog’) and labial harmony (e.g. [bɛ:p] for ‘bed’). By around 3 years 9 months, consonant harmony is usually eliminated from the speech of typically developing children.

The boy's improved speech and language skills may also be attributed to maturation in areas such as neurodevelopment.

Work on this boy's oromotor skills may have contributed to the disappearance of nasal emission in his speech. However, his developing phonological knowledge may also have contributed to its disappearance.

drawing and writing

A short attention span and receptive language difficulties compromised an early assessment of the boy's intellectual functioning. By the end of intervention, attention span and receptive language had improved, and were unlikely to compromise an assessment of intellectual functioning in consequence.

Literacy skills, namely reading and writing, are particularly important in terms of achieving access to the school curriculum.

The prevalence of an illness or condition is the number of individuals who have the condition at any moment. The incidence of a condition is the number of new cases in a period of time, usually one year.

The incidence of ASD is increasing because of better case ascertainment. That is, clinicians are becoming more skilled in recognising the symptoms of ASD and diagnosing the disorder.

Comorbid conditions in ASD are of relevance to speech-language pathologists because many of them (e.g. ADHD, intellectual disability) have implications for communication apart from ASD.

1. (a) subject relative clause (complex syntax)

2. (b) idiom (figurative utterance)

3. (c) object relative clause (complex syntax)

4. (d) metaphor (figurative utterance)

5. (e) idiom (figurative utterance)

Normally developing children follow the gaze of adults because they believe them to be intentional agents who entertain mental states about people and things in the world. Moreover, children can only learn words when they are presented as part of an intentional act of naming by adults – simply hearing a word in the presence of an object is not sufficient for word learning to occur. Children with ASD do not attribute intentional significance to the gaze of others, with the result that their word learning is compromised.

Mary did not engage in spontaneous play, preferring instead to perseveratively waggle objects.

Mary displayed a lack of interest in her peers and elder sibling.

part (d)

parts (a) and (e)

Mary has a mild intellectual disability.

The topic of the mini-olympics is clearly familiar to Mary who is able to discuss it with ease (lines 3 to 6). Moreover, she is given the opportunity to do so by two open-ended questions from the researcher (lines 1 and 2). Mary's extended response to that question mentions badminton with Amy which the researcher then attempts to topicalise through the use of a question in line 7. Mary takes this topic in a different direction in line 11 when she begins to talk about the advocacy group where a card was signed for Amy's birthday. Amy provides thematic continuity with the prior topic of badminton. In line 17, the researcher introduces an ancillary topic by asking about Amy's age. It is only in line 29 that the researcher returns to the topic of Amy's birthday. The reintroduction of this topic is indicated by the researcher's use of the discourse marker ‘so’ at the beginning of line 29.

1. (a) personal reference – line 18: ‘she was twenty nine’ (‘she’ refers to Amy)

2. (b) demonstrative reference – line 1: ‘what happens at those then’ (‘those’ refers to mini-olympics)

3. (c) ellipsis – line 8: ‘yes she does […]’ (‘play badminton’ is elided)

4. (d) conjunctions – lines 13–14: ‘Amy was cutting her cake…and we sang’ (‘and’ is a conjunction)

5. (e) lexical reiteration – lines 12–15: ‘we signed a birthday card for Amy…Amy was cutting her cake cutting her birthday cake…and we all sang happy birthday to Amy’ (repetition of ‘birthday’, ‘cake’ and ‘cutting’)

In extract 2, Mary's ability to contribute to the topic of discussion between lines 17 and 32 sharply declines. This is manifested in her use of a series of brief, low component turns such as ‘just a joke’ (line 18) and ‘she was just saying it’ (line 24). While Mary has difficulty maintaining the topic at this point, the researcher manages to maintain it through the use of four question turns such as ‘why did she say that’ (line 17) and ‘why did she make a joke like that’ (line 22).

(4) Between lines 11 and 15 in extract 2, Mary uses direct reported speech on two occasions:

• ‘she (Gloria) says to me “what's that?”’

• ‘she (Gloria) says to Amy “what's that? Is that a cake or is that a piece of…or is it a rabbit?”’

Of course, Mary's use of ‘rabbit’ in the second instance of direct reported speech is the source of the researcher's misunderstanding from line 17 onwards. However, this does not detract in any way from Mary's effort to use direct reported speech as a means of animating her account of Amy's birthday cake for the researcher.

In extract 3, Mary makes extensive use of repetition to maintain the topic of housework. This includes repetition of lexemes such as ‘lounge room’ and ‘downstairs’ (and their variants ‘dining room’ and ‘stairs’), as well as repetition of syntactic structures such as ‘I hoovered’ with a range of direct objects. Repetition is also a feature of the other extracts. For example, in extract 2 there is extensive repetition of relative clauses introduced by ‘that’ between lines 33 and 38: ‘that we bought with Kirsty’ (lines 33 to 34); ‘that we bought with Kirsty Barker’ (line 35); ‘that we had it after tea last night’ (line 38).

After a pause of 1.37 seconds, the researcher legitimately feels entitled to develop the topic of conversation by asking Mary a question (‘what colour?’). However, it seems that Mary is still processing her earlier utterance at line 1, which she appears to view as being incomplete. Mary's overlap in line 4 is designed to achieve the completion of that utterance.

The overlap in extract 2 arises because Mary appears to view her response (‘I just do sometimes’) to the researcher's question in line 3 as informationally inadequate, and wants to convey more information to the researcher about her reasons for not wanting to go swimming. In extract 1, the overlap occurs because Mary is simply continuing an earlier turn, while in extract 2 Mary is dissatisfied with an earlier response and wishes to expand upon it.

That slowed cognitive processing may explain the overlaps in extracts 1 and 2 is supported by two features of these exchanges. First, both overlaps relate to Mary's prior utterances which she still seems to be processing at the point at which processing should be complete. Second, both overlaps are preceded by lengthy pauses which the researcher legitimately interprets to mean that she can ask Mary questions. Even after these pauses have elapsed, Mary can still be seen to be processing her earlier utterances, suggesting that her cognitive processing is slowed.

In extract 3, Mary's overlap appears to pre-empt what the researcher is about to utter. If anything, this suggests a degree of cognitive anticipation on Mary's part. In this case, an explanation of Mary's overlaps based on slowed cognitive processing does not appear valid.

In extract 4, the researcher uses overlapped talk to indicate a revised understanding of Mary's message based on further information which Mary has provided. The purpose of the researcher's overlapped talk is thus quite different from the purposes that are served by Mary's overlapped talk.

In extract 1, the first of Mary's long pauses appears to be on account of lexical retrieval problems. That Mary is having difficulty retrieving the word ‘event’ is suggested by her prolongation of the vowel on ‘the’ and her use of the filler ‘errr’. In conjunction with the pause of 3.66 seconds, these features buy Mary additional processing time in which to retrieve the word ‘event’. Having retrieved the word ‘event’, Mary's second long pause in this extract appears to be related to the further planning of her utterance. Mary appears to need time to plan what it is she wants to say about the event.

The first pause of 3.28 seconds is a grammatical pause as it occurs at a grammatical boundary between two clauses: ‘they went to the speak up advocacy group’ and ‘we signed a birthday card for Amy’. The second pause of 2.9 seconds is a non-grammatical pause as it occurs in the middle of a verb phrase: ‘Amy was (2.9) cutting her cake’.

(3) Three features which suggest that pauses are related to a word search:

• Prolongation of sound in ‘ss-ʼ

• Use of filler ‘errrr’

• Use of word (‘apple’) that is semantically related to the target word (‘fruit’)

Mary's sound prolongation and use of the filler ‘errrr’ give her additional processing time in which to conduct a word search. The retrieval of a word that is semantically related to the target word suggests that Mary is conducting a lexical search during which other activated words are produced.

The first of the researcher's questions in extract 4 concerns the name of a British prime minister. Politics is an area of particular interest for Mary, so we can assume she has an extensive store of knowledge in this area. The long pause of seven seconds reflects the time that is needed by Mary to search this extensive store of knowledge before she is able to produce an answer. The second of the researcher's questions concerns an aspect of English literature, about which Mary appears to have little knowledge. Because her knowledge store is small or even non-existent, Mary does not need to conduct an extensive search in order to produce the response ‘I don't know’. The pause that precedes this response is shorter as a result.

The pause of 2.15 seconds in extract 5 appears to be used for dramatic effect by Mary and is not related to cognitive processing constraints. This pause serves to foreground the name ‘Elly Grey’. Mary builds the suspense further by telling the researcher ‘guess what’. She then goes on to repeat the name and narrate what Elly Grey did.

parts (b) and (d)

parts (a), (d) and (e)

(3) Three neurological deficits:

• Hemiparesis – a child with weakness or paralysis in one side of the body will be unable to use a manual signing system or manipulate symbols on a computer keyboard.

• Visual field deficit – a child with a visual field deficit may not be able to scan pictures on a communication board or computer screen.

• Intellectual or cognitive disability – a child with low IQ or cognitive deficits may be unable to learn how to use certain AAC systems. Such a child may fail to understand what symbols may be taken to represent or how to use computer technology or a communication board.

part (e)

Mariotti et al.'s client only had mildly impaired language skills even though the language-dominant left hemisphere was removed. The boy studied by Vargha-Khadem et al. displayed considerable language gains by the non-dominant right hemisphere following left hemidecortication.

The trigeminal nerve is cranial nerve (CN) V. It provides motor innervation to the muscles that control the mandible, the tensor veli palatini muscle of the velum and the tensor tympani muscle of the middle ear. CN V also mediates sensation from the head, jaw, face, some of the sinuses and tactile sensation from the anterior two thirds of the tongue.

The plum-coloured cortex and the dense purple arachnoid are significant in that they reveal the presence of vascular anomalies in both these structures.

parts (a), (c) and (e)

If a hemispherectomy is performed early, cerebral specialisation will not have taken place. It is likely that the right hemisphere will be able to assume many of the functions of the excised left hemisphere.

part (c)

CA's spastic hemiplegia might limit her ability to undertake the manual expression subtest of the ITPA, as she will struggle to produce certain gestures. Visual field deficits in children with SWS might compromise picture identification in a vocabulary comprehension test such as the PPVT.

use of the inflectional suffix –s (dogs)

part (d)

1. (a) passive negative

2. (b) active affirmative

3. (c) active negative

4. (d) passive affirmative

5. (e) passive negative

1. (a) parts 2 and 4

2. (b) parts 3 and 5

There is no evidence of a dissociation of auditory and visual modalities in CA's comprehension of language. This is because auditory reception and visual reception are developed to similar, albeit delayed levels.

(a) false; (b) true; (c) true; (d) false; (e) false

CA can comprehend sentences when normal subject–verb–object (SVO) word order occurs. SVO word order occurs in active sentences. However, in passive sentences SVO word order is reversed, explaining CA's poorer comprehension performance on these sentences.

The fact that CA's performance on the Token Test deteriorates markedly in part 5, when the syntactic complexity of the test items is increased, suggests that syntactic complexity plays a more decisive role than informational load for CA on this test.

part (d)

1. (a) ‘she knocked on the door’ (pronoun should be ‘he’)

2. (b) ‘she said, “um- hello-” No- he said, “who's there?”’

3. (c) CA states that the grandmother answered the door before she asked ‘Who's there?’

4. (d) ‘she put on all her clothes and everything like that’

5. (e) ‘And then the wolf said, “who is it?”’

CA fails to relate that Little Red Riding Hood thought her grandmother sounded funny and she wondered if she had a cold. This story element involves an exercise in mind-reading on CA's part – CA must be able to attribute mental states to Little Red Riding Hood in order to understand what she was thinking and wondering about her grandmother. The omission of this story element might suggest that CA has some difficulties in theory of mind.

In her narration, CA states that the bears went to Baby Bear's room after Goldilocks has already been discovered in Baby Bear's bed. This misrepresentation suggests that CA does not fully comprehend the temporal meaning of ‘and then’ – that one event (the visit to Baby Bear's bed) must precede another event (the discovery of Goldilocks in the bed).

Upon discovery by the bears, Goldilocks’ affective mental state is one of fear. However, CA does not succeed in representing this particular mental state. Instead, she characterises Goldilocks’ mental state as one of surprise and astonishment.

CA makes excessive use of ‘and then’ to link clauses and events in her stories. This type of conjunction expresses a temporal meaning and is more typical of the language of a child much younger than CA.

parts (b) and (d)

true

false

true

part (c)

viral encephalitis

DL's receptive aphasia may have compromised an assessment of his orientation. In order to assess orientation, an individual must be able to answer questions such as ‘What year is it?’ (orientation to time) and ‘Where are you?’ (orientation to place). These questions may not be understood by the client with receptive aphasia.

1. (a) Bacterial meningitis is not likely to be a cause of DL's neurological problems because his cerebrospinal fluid examination was normal.

2. (b) A metabolic disorder is not likely to be a cause of DL's neurological problems because his thyroid function tests and organ function tests were normal.

3. (c) Cerebrovascular disease is not likely to be a cause of DL's neurological problems because his vasculitis screen was normal.

Wernicke's area

DL's receptive aphasia appears to be mild. This is suggested by the fact that he was able to continue reading – he was able to understand written language – and by the family report that he was able to follow all but the most difficult discussions.

1. (a) attention

2. (b) language

3. (c) orientation

4. (d) recall

5. (e) language

Written language is superior to spoken language in DL's case.

parts (a) and (b)

parts (a), (c) and (e)

This behaviour is characterised as DL displaying inconsistent insight into his situation.

parts (a), (d) and (e)

Five features of fluent, jargon aphasia: fluent spontaneous speech; poor sentence repetition; impaired comprehension; lack of awareness of communication difficulties; impaired confrontation naming

(3) Three types of paraphasic error:

• Verbal (semantic) paraphasia in which there is a semantic relationship between the uttered and target words (e.g. ‘wife’ for husband)

• Literal (phonemic) paraphasia in which sounds are substituted, added or rearranged so that there is a sound resemblance between the uttered and target words (e.g. ‘stowcan’ for snowman)

• Neologistic paraphasia in which there is a preponderance of neologisms (‘new words’) in spoken output (e.g. ‘pargoney’ for park)

(4) Three changes in DL's communication skills with the onset of seizure activity:

• DL begins to use gesture to communicate

• DL starts to produce neologistic jargon

• DL's verbal comprehension markedly diminishes

Copying a drawing is a test of constructional praxis. Constructional praxis is a function of the right hemisphere. This skill remains intact as it is unaffected by DL's seizure activity in the left temporal lobe.

The dominant theme of DL's spontaneous language production is the loss of his language and cognitive skills.

DL makes repeated use of ‘I lost my concentration’ and ‘I'm just now concentrating’, which may be instances of verbal perseveration.

During picture description DL is able to monitor and repair his verbal output when he says ‘I don't know if I can figure out if he's a girl I mean a boy’.

(4) Pronoun anomalies during picture description:

• ‘she's claiming’ (does ‘she’ refer to the woman or the girl?)

• ‘he's asking him’ (there is only one male person in the picture, so ‘him’ lacks a referent)

• ‘he's a girl’ (‘he’ is the incorrect subject pronoun)

(5) DL is unlikely to have theory of mind deficits. That DL's theory of mind is intact is suggested by his extensive use of mental state language such as:

• ‘I don't understand them’

• ‘To interpret what he's doing’

• ‘I don't know’

• ‘I can figure out’

• ‘I mean a boy’

parts (c) and (d)

1. (a) swallowing

2. (b) communication

3. (c) motor

4. (d) communication

5. (e) sensory

Lip and tongue pressure transduction systems can be used to measure lip and tongue function in dysarthria.

1. (a) phonation

2. (b) resonation

3. (c) prosody

4. (d) articulation

5. (e) respiration

There is evidence that discourse deficits in children with TBI are related to cognitive deficits in executive function. For example, working memory has been shown to correlate with the ability of children with TBI to summarise the gist of a story and recall discourse content (Chapman et al., Reference Chapman, Gamino, Cook, Hanten, Li and Levin2006).

The brain, blood and cerebrospinal fluid inside the skull constitute a fixed space. In some cases of TBI, oedema and/or haemorrhage into this fixed space cause elevated intracranial pressure. Hemicraniectomy can reduce this pressure by allowing oedematous tissue to expand outside the neurocranium, thereby preventing fatal internal displacement of brain tissue and subsequent herniation. The procedure involves temporary removal of a large part of the skull which exposes the underlying cerebral hemisphere.

A subdural haematoma is a blood clot that develops between the surface of the brain and the dura mater, the tough, outermost membrane of the meninges. A clot of this type is usually caused by stretching and tearing of veins on the surface of the brain. An epidural (or extradural) haematoma occurs when a blood clot forms underneath the skull but on top of the dura mater. A clot of this type usually results from a tear in an artery that runs just under the skull called the middle meningeal artery. An epidural haematoma is typically associated with a skull fracture.

A right hemiplegia will compromise DG's communication skills in the following respects: (i) it will limit her ability to produce written language (assuming, of course, that DG uses her right hand for writing); and (ii) it will limit her ability to use natural gesture to communicate.

A right hemiplegia must be considered in the SLT management of DG in the following respects: (i) a language assessment that requires written responses must be performed using the non-preferred hand; and (ii) should an augmentative and alternative communication system be necessary, a system must be chosen that does not require the use of the paralysed arm.

parts (a), (c) and (e)

DG's language difficulties do not appear to be related to hearing loss. Even though DG was unable to comply with the requirements of pure-tone audiometry, there is evidence that she has adequate hearing for language comprehension. DG displayed adequate orienting responses to free-field pure tones. Also, she displayed normal responses to environmental sounds.

part (e)

parts (a) and (c)

DG does not have an oral apraxia. She was able to protrude, lateralise and elevate her tongue in imitation of the examiner.

DG's ability to visually match geometric objects, numbers, and pictures indicates that she has intact visual perceptual skills. These skills are mediated by the right cerebral hemisphere which is not damaged in DG.

The use of all language modalities might be advantageous as a principle of language intervention in general because: (i) clients can have impairments of auditory, written and signed language, with each requiring direct remediation; (ii) the combined use of auditory, written and signed language may facilitate clients in accessing the semantic system, where a single language modality may not suffice; and (iii) a period of therapy that involves all language modalities may reveal one to make a greater contribution to a client's overall communicative effectiveness than others.

fields

It is likely that DG will perform these activities well. This will provide the therapist with an opportunity to reinforce her correct responding with a view to maintaining this response rate in later activities.

regular words

DG needs to access her semantic system in order to match auditory stimuli to pictures and objects.

By the end of therapy, DG was able to match words with pictures or objects and match pictures or objects with words with 90% and 95% accuracy, respectively. DG could not perform these same tasks at the beginning of therapy. This indicates an improvement in word semantics.

DG's receptive language skills are superior to her expressive language skills. This same receptive–expressive gap is seen in normally developing children who display comprehension of aspects of language before they can produce them.

DG was able to write both regular words (e.g. ‘brush’) and irregular words (e.g. ‘comb’).

phonemic cuing

DG's case tends to disconfirm this statement. By 10 years of age, DG had clearly not reached the upper limit in her language recovery. Indeed, DG displayed evidence of considerable language gains at 10 years of age.

parts (a) and (b)

poor balance

parts (a), (b), (d) and (e)

parts (a), (b) and (d)

The cerebellum may also be compromised by trauma and infection.

(a) proverb; (b) idiom; (c) metaphor; (d) idiom; (e) metaphor

part (c)

(a) semantic; (b) pragmatic; (c) elaborative; (d) semantic; (e) elaborative

1. (a) lexical ambiguity:

   • ‘They sat down for a rest beside the bank’

   • (bank = side of river; financial building)

2. (b) structural ambiguity:

   • ‘Put the milk in the jug in the fridge’

   • (on one reading the jug is outside the fridge; on the other reading the jug is inside the fridge)

3. (c) lexical and structural ambiguity:

   • ‘I said I would file it last week’

   • (file = place document in filing cabinet; smooth surface of wood, etc.)

   • (on one reading the saying was done last week; on the other reading the filing was done last week)

promise (‘I will be at the party tonight’)

warning (‘The bull is in the field’)

request (‘Can you tell me the time?’)

(a) CELF-3; (b) PPVT-III; (c) CELF-3; (d) TOWK; (e) CELF-3

This characterisation is too simplistic because the results of the Test of Language Competence reveal that aspects of both receptive and expressive pragmatics are intact in this girl.

(a) hot–cold; (b) employer–employee; (c) ascend–descend; (d) absent–present

A routine language evaluation tends to examine structural language skills, which are intact in this girl. If such an evaluation does not include an assessment of language in more challenging contexts, then it is likely that this girl's language difficulties would go undetected. Such contexts might include an assessment of conversation and other forms of discourse (e.g. narrative production). These assessments are certainly more time-consuming to perform than structural language tests. However, they are also more revealing of the type of cognitive-language problems that this girl is displaying.

(a) false; (b) false; (c) false; (d) true; (e) false

The structural and functional brain changes that are associated with the administration of radiotherapy are likely to have made the single, biggest contribution to the decline in this girl's high-level language skills.

This case illustrates that it cannot be assumed that the language skills of children with cerebellar tumours remain static following surgery and radiotherapy. Accordingly, speech-language pathologists must commit to the long-term assessment of these skills, with consequent adjustment or resumption of therapy depending on the results of such assessment.

A girl of 11;9 years is approaching adolescence. This is a stage in life when social communication skills come under increasing demands as young people attempt to forge significant peer relationships and to negotiate conflict with their peers. The type of high-level language skills that are compromised in this girl will make a particularly important contribution to the development of strong social communication skills.

affective theory of mind

There is now considerable evidence that there are adverse, long-term psychosocial implications for children who develop brain tumours in areas such as suicide ideation, employment, independent living and dating/marital status (Brinkman et al., Reference Brinkman, Liptak, Delaney, Chordas, Muriel and Manley2013; Frange et al., Reference Frange, Alapetite, Gaboriaud, Bours, Zucker, Zerah, Brisse, Chevignard, Mosseri, Bouffet and Doz2009; Maddrey et al., Reference Maddrey, Bergeron, Lombardo, McDonald, Mulne, Barenberg and Bowers2005).

agrammatism and anomia

One of the CELF-3 subtests requires children to list as many words as possible within a given category in one minute (a test of category or verbal fluency). The girl in this case study displayed intact performance across all areas of the CELF-3. So it can be concluded that her verbal fluency is not impaired.

Differences in the linguistic performance of the girl in the case study and the other subjects reported in unit 22.5 may be accounted for by tumour type (e.g. ependymoma versus astrocytoma), tumour location (e.g. right or left cerebellar hemispheres) and language assessments (e.g. the Hundred Pictures Naming Test may not be as challenging as the tests used to assess naming in the subjects in unit 22.5).

Affective functioning was assessed through an examination of empathy in the Test of Problem Solving.

Children with cerebellar tumours must be treated as part of a multidisciplinary team. Speech-language pathologists must work closely with other professionals, particularly neuropsychologists, if the wide array of language and cognitive problems in these clients are to be addressed successfully.

parts (a), (c) and (e)

parts (a), (b) and (d)

Three structural changes: necrosis; atrophy; and calcification

The velopharyngeal port is malfunctioning to cause the client's hypernasal speech. A neurogenic aetiology is the basis of the client's velopharyngeal incompetence.

A palatal lift device has a posterior bulb structure which serves to elevate a weakened or paralysed soft palate (velum). The elevation achieved by the bulb structure reduces the degree of movement that the velum must perform in order to make contact with the nasopharyngeal wall, a movement which closes off the velopharyngeal port to pulmonary air. A palatal lift device was probably unsuccessful in this case because the client's velum was completely immobile as a result of her underlying neurological impairment.

vagus nerve; three branches: pharyngeal branch; exterior superior laryngeal nerve branch; recurrent nerve branch. The pharyngeal branch is compromised in this client so producing hypernasal speech.

part (c)

The Babinski reflex occurs in children up to 2 years old. When the sole of the foot is firmly stroked, the big toe moves upwards or towards the top surface of the foot and the other toes fan out. As children mature, the reflex disappears. Its presence in an adult is a sign of neurological damage, specifically within the pyramidal system.

The lenticular nucleus is a lens-shaped mass that consists of the putamen and globus pallidus. Along with the caudate nucleus, the putamen and globus pallidus form the basal ganglia, a set of nuclei which is located deep in the cerebral hemispheres. The basal ganglia is involved in the regulation of cortically initiated motor activity, cognition and emotion. The ventrolateral nucleus is a nucleus in the thalamus which is important in the regulation of volitional movements.

The cerebral ventricles are a series of interconnected, fluid-filled spaces that lie at the core of the forebrain and brainstem. The ventricles are filled with cerebrospinal fluid which percolates through the ventricular system and flows into the subarachnoid space (space between the meninges known as the arachnoid mater and pia mater) through perforations in the thin covering of the fourth ventricle.

parts (b), (d) and (e)

1. (d) pragmatics: the client is likely to have difficulty understanding figurative language such as metaphors and idioms

2. (e) discourse: the client is likely to have difficulty expressing causal relations between events during narrative production

The client has problems abstracting ‘general’ from ‘specific’ information. This cognitive skill is required in order to establish the gist of a story.

A score below the 10th percentile means that over 90% of adults would achieve a higher score than the client on the Rey Figure test.

parietal lobes

parts (b), (c) and (d)

Speech-language pathologists calculate diadochokinetic rates as a means of assessing an individual's ability to perform alternating articulatory movements. Typically, a client is timed as they produce rapid syllable repetitions such as /pə, tə, kə/.

(a) true; (b) false; (c) true; (d) false; (e) false

The client was observed to speak quickly, with noticeable breaks in fluency and short phrase length. All three features indicate that there is reduced respiratory support for speech.

The client displayed a marked reduction in the length of phonation. This is likely to be related to reduced respiratory support for speech production.

The client's repetition abilities were relatively well preserved. Combined with the lack of phonemic paraphasias during naming, this suggests that the phonological level of language is intact.

The naming errors are semantic paraphasias. The presence of these errors suggests that there is disruption to the lexical/semantic level of language. The severe impairment in word (category) fluency (<20th percentile) further suggests that the lexical/semantic level of language is disrupted.

These errors appear to be related to a visual–perceptual disorder in that the client has produced words that have a visual similarity to the target.

Semantic cues are unlikely to facilitate this client's naming given her evident difficulties at the lexical/semantic level of language.

The client is unlikely to be an informative communicator. Compared to normal subjects, she displays a reduction in both the efficiency of information transfer and the amount of information transferred.

part (b)

parts (b), (c) and (d)

The left superior temporal gyrus is the neuroanatomical location of Wernicke's area. A lesion of this area is not always associated with Wernicke's aphasia.

neologism (pargoney)

verbal paraphasia (‘run’ for ride)

There is an increased likelihood that RC may have right-hemisphere language dominance because she is left-handed. In healthy individuals, the incidence of right-hemisphere language dominance has been found to increase linearly with the degree of left-handedness, from 4% in strong right-handers to 15% in ambidextrous individuals and 27% in strong left-handers (Knecht et al., Reference Knecht, Dröger, Deppe, Bobe, Lohmann, Flöel, Ringelstein and Henningsen2000). However, brain imaging showed that RC has left-hemisphere language dominance. Two CT scans confirmed the presence of lesions in the left cerebral hemisphere as the cause of RC's language problems.

RC's lesions are found in the posterior portion of the first temporal gyrus and the anterior portion of the supramarginal gyrus. Neither of these lesions compromises the anterior temporal lobes, which we can assume to be intact in RC.

(3) Four linguistic impairments:

• use of neologistic jargon

• poor auditory comprehension

• poor repetition of language

• poor awareness and monitoring of communication problems

RC is unlikely to register verbal and non-verbal cues which indicate that she is not being understood by her conversational partner. These cues include requests for clarification (verbal cue) and puzzled facial expressions (non-verbal cue). In the absence of detection of these cues, RC is unable to correct her incomprehensible output.

RC may use rising pitch when making statements, with the result that they are understood by a listener to be questions.

(a) oral commands; (b) automatised sequences; (c) responsive naming; (d) complex ideational material; (e) reading comprehension of sentences

melodic line within the rating scale profile

The slightly better performance of RC on the picture-word match subtest than on other subtests suggests that the visual modality may be beneficially used during intervention. During this test, the examiner points to a picture without naming it, and asks the patient to find its name among four printed words.

phonological short-term memory

(5) Three distinctions:

• animate – inanimate (e.g. camel – comb; octopus – bed)

• high frequency – low frequency (e.g. house – sphinx; toothbrush – pelican)

• natural entity – artefact (e.g. volcano – dart; cactus – wheelchair)

In a picture categorisation task, a subject is given a number of pictures and is asked to group them according to categories like fruit, clothes and transport. This task is aimed at developing a subject's knowledge of semantic fields.

parts (a), (b) and (e)

The anterior temporal lobes can support comprehension of visually presented material (written words and pictures) in individuals with Wernicke's aphasia (Robson et al., Reference Robson, Zahn, Keidel, Binney, Sage and Lambon2014). This neuroanatomical area is intact in RC, who has lesions of the posterior portion of the first temporal gyrus and the anterior portion of the supramarginal gyrus.

(4) Three aspects of word knowledge:

• orthography, e.g. Are the words ‘boy’ and ‘boy’ the same or different?

• semantic field, e.g. Do ‘pants’ and ‘dress’ belong to the same category?

• grammatical class, e.g. Do ‘pen’ and ‘write’ belong to the same word class?

Increasing contextual and linguistic redundancy should improve RC's comprehension as there is additional linguistic and non-linguistic information that RC can use to establish the meaning of sentences.

RC was able to avail herself of contextual cues in natural conversation to aid her comprehension of language. These same cues are not available during language testing on the BDAE. The facilitation of these cues in natural conversation accounts for her improved comprehension in that situation even though RC's test scores did not reveal an improvement in auditory comprehension.

• ‘scissors’ /kʌtmæn/ (contains ‘cut’)

• ‘flower’ /blumpat/ (contains ‘bloom’)

• ‘pencil’ /pɛnres/ (contains ‘pen’)

• ‘drinking’ /kʌpʌp/ (contains ‘cup’)

• ‘cactus’ /prɪkəl/ (contains ‘prickle’)

In an active sentence like The man kicked the dog there is simple subject–verb–object word order. However, this word order is reversed (i.e. object–verb–subject) in a passive sentence like The dog was kicked by the man. The reversal of the SVO word order explains RC's greater difficulty in understanding passive voice sentences. A non-reversible passive sentence like The mouse was chased by the cat is usually more easily understood by an aphasic client than a reversible passive sentence like The lorry was followed by the van. This is because the misinterpretation of the roles of ‘cat’ and ‘mouse’ in the non-reversible passive sentence is rendered unlikely by real-world knowledge (i.e. it is usually cats who chase mice, and not the other way round). This is not the case for ‘lorry’ and ‘van’ in the reversible passive sentence.

Informational load and syntactic complexity are the two factors that explain RC's performance in the comprehension of instructions. As informational load (the number of words) and the syntactic complexity of instructions increase, RC's comprehension of instructions decreases. Of these two factors, syntactic complexity is the most influential one in terms of RC's comprehension. This is indicated by the fact that RC displayed better comprehension of a seven-word instruction that contains the coordinating conjunction ‘and’ than a six-word instruction that contains the preposition ‘with’.

Wh-interrogatives are more conceptually demanding than yes–no interrogatives. This is because they require the understanding of concepts such as a thing (What…?), a person (Who…?), a time (When…?) and a place (Where…?). The more conceptually demanding nature of wh-interrogatives probably explains RC's greater difficulty in understanding these questions over yes–no interrogatives.

parts (a), (b) and (d)

Visual information is analysed in the dominant parietal lobe, which is usually in the left hemisphere. The CT scan revealed that HW's ischaemic infarct extended to the left parietal lobe.

parts (a), (c) and (e)

poor sentence repetition

There is evidence that clients with aphasia experience elevated levels of psychological distress including depression and anxiety (Shehata et al., Reference Shehata, El Mistikawi, Risha and Hassan2014) and a reduction in their social relationships (Fotiadou et al., Reference Fotiadou, Northcott, Chatzidaki and Hilari2014). These psychosocial aspects are now addressed as part of the management of clients with aphasia.

HW's single-word and sentence-level comprehension is intact. Her comprehension of nouns and verbs is unproblematic. HW's performance on the TROG and the Token Test suggests that her comprehension of sentences is also effectively intact.

HW's inability to name items like pagoda and centaur on the Graded Naming Test is more likely to reflect a limitation in her premorbid vocabulary than any deficit in word-finding. This is because HW achieved 100% naming accuracy on the Boston Naming Test and her performance on the Graded Naming Test was comparable to that of normal controls.

part (c)

HW engages in circumlocution when she is unable to produce the names of these actions.

There is a possible visual basis to HW's error in that the face veil may have caused HW to recall an image of a soldier with his face covered for reasons of camouflage and protection. The left parietal lobe damage that was identified in unit 25.1 may contribute to this visual error.

At 15 months post-onset, HW achieved a percentile score of 100 on a verbal memory test (see unit 25.2). When first assessed, HW had a weak verbal memory. An improvement in verbal memory most likely accounts for HW's stronger word and sentence repetition skills at 15 months.

During sentence repetition, closed-class words are most compromised for HW. This can be seen in the sentence ‘In the classroom all children were talking aloud’, where the auxiliary verb (were) and the inflectional suffix (-ing) were omitted during HW's repetition. Additionally, HW replaces an adverb (aloud) with an adjective (loud).

Subject noun phrases are vulnerable to repetition (e.g. The old man the old man is begging for money). On one occasion, repetition finds HW correcting her verbal output. The correction takes the form of the inclusion of a definite article (Policeman the policeman fastens handcuffs).

1. (a) The teacher writes [a] word on the blackboard.

2. (b) Use of teapot for coffeepot

3. (c) The boy the boy drops a vase [and] cries.

4. (d) Ellipsis should be used in: The man is lying on the couch to [he is] smoking a pipe [he is] reading the newspaper.

5. (e) Use of vase for glass

(5) Circumlocutions occur in the following:

• use of fasten handcuffs for arrest

• use of has a boot on the hook for fishes a boot

(1) HW can comprehend:

1. (a) Prosodic questions: You also encounter problems when making a sentence?

2. (b) Requests for clarification: What do you mean, too fast?

3. (c) Yes–no interrogatives: Do you do that on purpose?

4. (d) Wh-interrogatives: Why don't you do that?

5. (e) Indirect speech acts: Can you tell me what are your problems? (a request)

(2) HW is able to establish the referents of the demonstrative pronouns in the following utterances:

• Why don't you do that? That refers to speak in correct sentences.

• And looking for words, is that difficult? That refers to looking for words.

• Do you do that on purpose? That refers to leave words out.

• That's why you talk in short sentences? That refers to difficulty looking for words.

• You do hear that? That refers to what you say wrongly.

(3) Mental state language in HW's expressive output:

• ‘difficult words er to think yes doesn't soon occur to me’

• ‘before the time I did know writing down’

• ‘I write down nothing remembers me’

The use of mental state language suggests that HW has an intact theory of mind capacity.

HW makes extensive use of filled pauses. This indicates that she is searching for words and wants to retain her turn while doing so.

1. (a) ‘I says wrongly’

2. (b) ‘Er I [am] too fast to talk’

3. (c) ‘I leave [the words/them] out’

4. (d) ‘to think yes [it] doesn't soon occur to me’

5. (e) ‘Er [I am] too fast to talk’

HW first tells the interviewer that she will not give presents at Christmas. She then goes on to say that she gives presents of 10 guilders to people at Christmas. HW first tells the interviewer that she sold her house in March. Later in the conversation, she tells the interviewer that she moved in March.

When the interviewer says ‘That is the oldest one, isn't it?’, HW understands that one is a substitute for child. Also, when HW says ‘Ah big one big one behind the house’, HW is using one as a substitute for garden. In other words, HW can understand substitution when it is used by the interviewer, and can use substitution in her own utterances.

HW uses direct reported speech (‘I want in the attic’) to relate to the interviewer a row between her children, Reinier and Renate, about occupancy of the bedroom in the attic.

(4) HW is able to engage in self-initiated and other-initiated repair of utterances:

• Self-initiated repair:

• ‘fifteen meters width seventeen no seven meters’

• Other-initiated repair:

• HW: Er room er ninety meters no

• INT: No, that seems very large

• HW: No nine meters all thresholds gone oh nice

This other-initiated repair also contains an element of self-initiated repair (see ‘no’ at the end of HW's first turn).

1. (a) ‘we [are] saving pennies’

2. (b) ‘In the pan tasty things snacks tasty’

3. (c) ‘Er three ground floor first [floor…] bedrooms two shower’

4. (d) ‘now tiles on [the] roof’

5. (e) ‘Reinier row about […] I want in the attic’

The lesion that causes Broca's aphasia affects the third frontal convolution of the left frontal lobe. This location is called Broca's area. The damage from a CVA often extends posteriorly to the most inferior part of the motor strip that controls voluntary movements of the right side of the body. Because of the organisation of the motor strip, the face and arm on the right are most likely to be affected by this extended damage.

Roy makes extensive use of filled pauses (…uh…) which reveal he is struggling to find certain words. Filled pauses help Roy to retain his turn as he searches for words.

Notwithstanding his severe expressive language problems, Roy can still communicate effectively as he retains the use of content words. These words, which include nouns and adverbs, convey most meaning to a listener.

In conversational situations, Roy is able to use a range of contextual cues to facilitate his comprehension of language. These same cues are reduced or absent altogether during language testing.

He uses mime to good effect when he mimes falling over.

parts (b), (c) and (d)

The boy runs: one-argument structure

Thematic role: the boy (agent)

The woman cooks the meal: two-argument structure

Thematic roles: the woman (agent); the meal (theme)

The man put the book on the shelf: three-argument structure

Thematic roles: the man (agent); the book (theme); the shelf (goal)

• teeth: an object that has a close semantic relation to the target verb

• scratching: an action that is related to the target action

• nails: an object that is related to the action distractor

The scene that is depicted in the cookie theft picture is intended to elicit a description that captures a specific moment in time. The subject who describes the individual events in the picture, such as the woman drying the plate and the boy climbing onto the stool, is doing so within a static frame. The subject who is describing events in a cartoon strip must capture the development of these events over time. The progressive character of this description sets the cartoon strip description task apart from the cookie theft picture description task.

Adults with aphasia may struggle with turn-taking and repair in conversation. These features may be overlooked if only tasks that elicit monological discourse are included within an assessment of language and communication.

semantic paraphasias

Jill gave the book to the woman contains the verb ‘give’ which has a three-argument structure. Roy was unable to produce any sentences on the TRIP which contained verbs with a three-argument structure.

(3) Three ways in which expressive language is compromised by agrammatism:

• omission of determiner ‘the’

• omission of auxiliary verb ‘is’

• omission of inflectional suffix ‘-ing’

This difference can be accounted for by the different test administration of the TRIP and the VAST. The TRIP provides a model of all target responses at the outset of the test, while the VAST only provides a single practice item at the beginning of each subtest. This is likely to have facilitated Roy's performance on the TRIP.

Roy cannot produce the verbs ‘cutting’ and ‘raking’, so he produces the nouns ‘scissors’ and ‘hoe’ to capture objects in the pictures instead.

Roy produces two consecutive discourse markers ‘so’ and ‘then’. These are followed by a standard storytelling phrase ‘all of a sudden’ and the noun ‘spell’. The use of level intonation between each of these elements indicates that there is more to come, with the falling intonation after ‘spell’ indicating the completion of Roy's turn. Through a combination of these linguistic units and prosody, Roy succeeds in relating an event in the ‘Cinderella’ story in the absence of any verb production.

Roy utters the name of an object (‘plate’) that is related to the verb (‘drying’) that he cannot produce. He then follows this noun with a complex mime.

Roy succeeds in constructing a relatively fluent unit by combining an adverb (‘actually’) with a first person pronoun and cognitive verb (‘I thought’). He then states the noun ‘dog’ to communicate his initial belief that it was the dog disappearing under the table, with the comment ‘but no’ to indicate that he was mistaken. Roy makes extensive use of subject pronouns and cognitive verbs (e.g. ‘you know’). Their ease of production for him confers fluency on his otherwise severely agrammatic output.

In extract D, Roy uses reported speech (‘quick, I know’) to convey the actions of the host in the situation. He follows this with symbolic noise (‘oooooh’) to convey the hostess's crying and then produces the verb ‘crying’ itself. He then uses further reported speech (‘never mind’) to convey the female guest's efforts to console the hostess.

part (b)

Roy uses a noun-initial strategy whereby he utters ‘racing’, ‘Newmarket’ and ‘Epsom’ first, followed by ‘anywhere’, indicating that he has attended racing in a large number of locations. The strategy of incrementally building his message continues when he states that he (‘but me’) has not attended Ascot (‘Ascot, no’). Di's contribution to the exchange can be described as one of facilitating her father's turn through the use of back-channel behaviours (‘yeah’, ‘mm’), then summarising his message, and finally giving him an opportunity to accept or reject her summary (‘you've never been have you’). After Roy accepts her summary, Di produces a final comment (‘perhaps you can go next year dad’).

Roy uses an adjective-initial strategy in this exchange whereby he begins with an adjective ‘interesting actually’. This stands as an evaluation of Di's job as a nursery nurse. He then justifies this evaluation by providing a reason through the use of the conjunction ‘because’. The reason ‘now me I think no, special’ is an admission that he (Roy) could not do Di's job as you have to be special to do it. Di's contribution to the exchange remains unchanged from extract A. She supports Roy in his turn through the use of back-channel behaviour. She then summarises what she believes his message to be, and provides him with an opportunity to accept or reject her summary (‘what working with children’). After Roy accepts her summary, Di produces a comment (‘not everyone can do it’).

1. (a) Roy states ‘two weeks’ (a noun phrase)

2. (b) Roy establishes that the referent of ‘it’ in ‘it'll be a good night’ is Di's birthday party.

3. (c) Roy comprehends Di's use of ‘this weekend’ (temporal deixis)

4. (d) Roy uses ‘I know’ (mental state language)

5. (e) Roy utters ‘two weeks innit’ (innit = isn't it?)

1. (a) false; (b) false; (c) true; (d) false; (e) true

1. (a) Roy describes past visits to racing at Newmarket and Epsom.

2. (b) Roy expresses his opinion that it takes someone special to be a nursery nurse.

3. (c) Roy confirms that Di's birthday party will take place in two weeks.

4. (d) Roy evaluates Di's job as ‘interesting’.

5. (e) Roy supports Di's conversational turns through the use of back-channel behaviour (see ‘yeah’ in extract C).

Most brain emboli are distributed in the territory of the MCA, which is the main and most direct branch of the internal carotid artery (Garcia et al., Reference Garcia, Ho, Pantoni, Barnett, Mohr, Stein and Yatsu1998: 46). This is why strokes of the MCA territory are so common. The poorer functional outcomes associated with MCA strokes arise because of the presence of aphasia and apraxia in left-sided MCA lesions, and neglect and agnosia in right-sided MCA lesions (Ng et al., Reference Ng, Stein, Ning and Black-Schaffer2007). These conditions make a good recovery from a stroke more difficult to achieve.

The lesion localisation in Broca's aphasia is usually in the left inferior frontal cortex, anterior to the motor strip. The motor strip controls voluntary movements of the articulators and other structures involved in speech production (e.g. larynx). If the damage that causes Broca's aphasia extends to involve the motor strip, a client may have apraxia of speech as well as Broca's aphasia.

Five features which are consistent with a diagnosis of Broca's aphasia: (1) impaired verbal fluency; (2) word-finding deficit; (3) agrammatic verbal output; (4) client is aware of communication difficulties; and (5) auditory comprehension is superior to expressive language.

BB is only able to produce nouns (e.g. boy, window) and set phrases (‘don't know’). There is no verb production and words from all other grammatical classes (e.g. determiners, prepositions, conjunctions) are absent.

parts (b) and (d)

The examiner gave BB this instruction as she wanted to see if he could produce verbs in the absence of their arguments.

The pictures depicted only animate actors and inanimate patients in order that BB had to produce sentences like The man kicked the ball. The pictures required BB to produce irreversible sentences only.

In order to generate a sentence around a verb, BB must produce the arguments that attend a particular verb. This may be one argument (e.g. Tim smiles), two arguments (e.g. The boy hid the book) or three arguments (e.g. The man gave the comb to the girl).

The man hit the boy.

This task is attempting to assess if BB recognises the integrity of the phrase. So, for example, in the sentence Paula bought some chocolate in the shop, ‘some chocolate’ and ‘in the shop’ constitute phrases (noun and prepositional phrases, respectively), while ‘bought some’ and ‘chocolate in’ do not.

BB's performance in this task shows that his retrieval and production of verbs in the absence of their arguments are relatively intact. ‘Running’ (a gerund) is an example of the form that BB's ‘doing’ words took.

1. (a) push; writing; drink; climb; eat

2. (b) kicking ‘push’; writing ‘read’; drinking ‘eat’

3. (c) writing

4. (d) The girl is writing a letter: writing…/r/…/r/…read…girl

   • The boy is climbing a ladder: me! (indicating boy) no…boy /k/…climb up…yes!

   • The boy is drinking orange: /b/…boy…ah!…boy is…/i/…eat…no…um

5. (e) The boy is riding the bike: girl…no boy…bike…well…um…boy…um

   • The boy is digging the garden: /g/…/g/…don't know…(cued 1st syll.) garden…boy…is…no

On SVO picture description, BB was able to produce seven actor arguments. However, no actor arguments were produced when he was provided with the infinitive form of the verb. This difference can be explained as an effect of the task – BB was given a verb and started his sentence construction with the verb in each case. On SVO picture description, BB produced three patient arguments. This increased to seven patient arguments on the infinitive verb task. Three of these arguments were semantic paraphasias (book ‘letter’; apple ‘food’; orange ‘beer’). There is little evidence on either of these tasks of BB being able to consistently access and use verb argument structure.

A simple active reversible sentence: The man chases the boy. The reason this type of sentence is difficult for BB to understand is that either noun phrase could be the actor in the sentence, and BB must use his knowledge of argument structure to determine which one is the actor. However, BB's knowledge of argument structure is disrupted. This deficit is confirmed by the results of the Word Order Test. When presented with a sentence and asked to match it to one of three pictures, BB consistently selected the picture in which the arguments were reversed.

BB is able to recognise the constituents of phrases, allowing him to segment sentences according to their different phrases. However, because he does not understand how phrases relate to each other within sentences, he is unable to construct grammatical sentences from individual phrases.

(1) Intransitive verbs were used to introduce the concept of actor because the actor is the only obligatory argument in these verbs. The absence of other arguments simplifies the production for the client.

• The girl cries (human subject); The dog barks (animal subject)

(2) Transitive verbs have an obligatory theme.

• The woman knocked the door (the woman = WHO? the door = WHAT?)

Verbs like ‘put’ are three-argument verbs. The therapist used sentences in which the prepositional phrase appears at the beginning of the sentence (In the garden Robert grew herbs) and at the end of the sentence (Robert grew herbs in the garden) in order to avoid a situation in which the client learns (erroneously) that it is always the final argument in the sentence that answers to the question ‘where?’.

At midnight the bomb exploded (when?)

Sally went to Paris for a conference (why?)

He bolted quickly through the door (how?)

The pragmatic constraint on sentence production is that these elements are optional and are introduced depending on the informational needs of the listener.

In an irreversible passive voice sentence (e.g. The ball was kicked by the boy), world knowledge alone indicates that the boy is responsible for the action of the verb and that the ball is the recipient of that action. No knowledge of the meaning relations expressed by the arguments in the sentence is required in order to decode the sentence successfully. In reversible passive voice sentences (e.g. The boy was chased by the man), knowledge of the meaning relations expressed by the arguments is required for successful decoding to occur. This is why the therapist introduced irreversible passives before reversible passives in therapy.

Cookie theft picture description:

‘woman drying the washing up’

‘water falling to the floor’

‘the window is open’

‘girl wants one’

Narrative production: In all three examples, the actor is missing.

‘sold potatoes’

‘drive van to Cambridge’

‘pack the van’

1. (a) ‘boy is kicking the ball’

2. (b) BB utters ‘girl’ for boy

3. (c) ‘the girl…no boy…is eating an apple’

4. (d) ‘the boy is…eh…um…oh…a ladder no!’

5. (e) ‘the girl…is writing…a letter…to…eh…friend’ (‘to a friend’ is an optional argument)

On the Word Order Test in July 1985, BB is still making argument errors when asked to rearrange sentence elements and when required to match a spoken sentence to one of three pictures. The errors all appear to involve the reversal of arguments.

prepositions (e.g. on concrete floor)

determiners (e.g. the two cups)

auxiliary verbs (e.g. the girl is reaching up)

actor arguments (e.g. the woman is washing up)

main verbs (e.g. the boy is reaching for cookies)

Three discourse anomalies: (i) A topic shift occurs when BB starts to talk about his stroke during a narrative about his previous employment; (ii) BB uses repetitive language when he talks about driving to Cambridge and selling chips; (iii) BB uses the pronoun ‘we’ in the absence of a clear referent.

parts (a), (b) and (e)

(a) metaphor; (b) idiom; (c) conventional implicature; (d) sarcasm; (e) indirect speech act

Speakers use intonation and other aspects of prosody to signal different types of speech acts. For example, a speaker can use one and the same utterance (e.g. Bob is in town) as a statement or a question, and it is the use of prosody which signals which speech act the speaker expects to obtain in a particular case. Clients with RHD who make poor use of prosody can expect some of their utterances to be misunderstood by hearers during communication.

Phonology, morphology and syntax are well preserved in RHD. The preservation of these aspects of language sets RHLD apart from classical aphasia.

(a) true; (b) false; (c) true; (d) false; (e) true

Myers states that adults with RHD ‘miss the implication of [a] question and respond in a most literal and concrete way’. This statement corresponds to the finding that adults with RHD have difficulty understanding indirect speech acts. For example, such an adult may reply ‘yes’ to the question ‘Can you sit down?’, a response which suggests that he has failed to grasp that this is a request to sit down.

Myers remarks that the components of a narrative could not be ‘integrated into a whole’. This description suggests a problem with weak central coherence on the part of Myers’ subjects.

Humour is often based on non-literal language. To the extent that the understanding of non-literal language is compromised in adults with RHD, one might expect to find a failure to appreciate humour in these subjects.

Emotional prosody conveys information about the affective state with which an utterance is produced. So the single utterance ‘John is very late’ can express quite different affective states, ranging from anger to sadness and happiness, depending on the emotional prosody with which the utterance is produced in a particular context. The use of linguistic prosody can cause one and the same utterance to be a statement on one occasion of use and a question on another occasion. Linguistic prosody conveys a speaker's communicative intention, not his or her affective state.

The utterances This homework is a nightmare and The stressed lawyer was a steam kettle would be assessed in the understanding of metaphors in the MEC.

After initial investigation, OP went on to develop epilepsy and bilateral brain lesions. Because his neurological damage extended beyond the right cerebral hemisphere, and occurred in the presence of epilepsy, OP was no longer judged to be a suitable participant in an investigation of language disorder in stroke-induced right hemisphere damage.

In indirect speech act 1, Louise is requesting her husband to wash the car. When explicitly asked by the examiner which interpretation applies to this speech act, OP opts for the literal interpretation (‘I'd probably go with option A’). However, it is clear from his extended response that he does have some appreciation of the intended, non-literal interpretation of the speech act. This is indicated through utterances such as ‘it would be convenient to wash the car’ and ‘she's […] imposing an assigned chore, regarding the husband’.

In indirect speech act 2, Mr Martinez is requesting his spouse to answer the phone. Throughout the exchange with the examiner, there is evidence that OP is pulled between two different interpretations of this speech act. OP begins by repeating information which is provided by the examiner (‘He's busy’). He then appears to veer towards the intended interpretation of the speech act when he says ‘it's assumed that he wants his wife’. A little later, the intended interpretation is directly stated: ‘what's suggested is that she should answer the phone’. That both interpretations are salient for OP is confirmed by the utterance ‘he's says both things’.

In indirect speech act 3, OP draws the inference that Martin needs the glasses in order to watch television. It is this inference which motivates Martin to request his wife to bring him his glasses from the table.

Before he arrives at the intended interpretation of indirect speech act 4, OP dwells on the work relationship between Peter and his secretary. OP reports that within this relationship, the secretary is under a ‘work obligation’ to comply with her boss's requests.

OP's understanding of the metaphor in the utterance ‘My friend's mother-in-law is a witch’ is concrete and literal in nature. In his attempt to characterise the meaning of this metaphor, OP refers only to conventional attributes of witches which are embodied in the semantic meaning of the word ‘witch’, e.g. inclusion in religious sects, the practice of black magic.

OP displays some awareness that his interpretation of the metaphor may not be accurate. This occurs when he denies that having many brooms is part of the meaning of the metaphor: ‘My friend's mother-in-law has many brooms…no!’. However, OP's awareness is limited and inconsistent. For as soon as he denies one of the conventional attributes of a witch as part of the meaning of the metaphor, he goes on to accept another conventional attribute – the practice of black magic – as part of the metaphor's meaning.

OP makes use of egocentric discourse throughout this exchange. He immediately replaces the neutral term ‘friend’ with the familial term ‘son-in-law’. OP also describes at some length aspects of his personal experience which are of no interest to the examiner, e.g. marital relationships and relationships between a couple and their daughter.

OP does not use humour appropriately in this exchange with the examiner. OP's laughter at the end of his second turn suggests that he finds his own remarks humorous. However, the examiner's response in the next turn suggests that whatever humour OP thinks he has conveyed, it has not been interpreted as such by the examiner.

OP's use of referring expressions makes a significant contribution to his discourse difficulties. In OP's second turn in the exchange, he introduces the terms ‘she’, ‘her marriage’, and ‘her husband’, all of which lack clear referents. OP is aware of this and immediately establishes a referent by saying ‘I'm referring to the mother-in-law of my son-in-law’. But this correction arrives late, and only after the examiner has had to establish a suitable referent. Other referential anomalies include the use of a definite noun phrase in the absence of a referent in ‘Because the woman is separated’ (what woman?), and the unclear referent of the pronoun in ‘she's now a poor lady’ (the woman or the daughter).

Prior to the utterance beginning ‘And so he went down…’, OP's narrative is highly repetitive. OP does little more than continually state that the farmer was digging a hole/well with a shovel and pick.

OP fails to narrate the main events in the story. All the events which follow the collapse of the well are omitted. These include the farmer placing his shirt and cap on the edge of the well and then hiding in the tree, a neighbour coming along and calling out for help, and the efforts of friends to dig the farmer out of the well.

The following remark by OP suggests that he may be experiencing visuo-perceptual deficits: ‘objects that don't look like what we call shovel and pick’.

OP's introduction of the farmer into the narrative is skilfully achieved through the use of an indefinite noun phrase: ‘There was a farmer who was digging…’. The use of an indefinite noun phrase is a standard narrative device for the first mention of story characters.

(a) false; (b) true; (c) false; (d) true; (e) false

(1) Five causes of TBI in children and adults:

1. (i) violent assaults, particularly among young males

2. (ii) abusive head trauma in violently shaken infants

3. (iii) sports injuries in contact sports like boxing and rugby

4. (iv) combat-related injuries in military personnel

5. (v) parturitional injuries sustained during and secondary to foetal delivery

In an epidural haematoma blood accumulates and forms a clot between the skull and the dura mater (the outer of the three meninges). In a subdural haematoma blood accumulates and forms a clot between the dura mater and the arachnoid mater (the middle membrane of the three meninges).

1. (a) a blunt head trauma – sensorineural hearing loss

2. (b) a blast-related brain injury – sensorineural and conductive hearing loss (the tympanic membrane can be perforated by a blast, causing a conductive hearing loss)

(4) Three reasons why speech-language pathologists do not routinely assess domains like discourse in clients with TBI:

1. (i) The analyses that are needed to assess discourse are both labour- and time-intensive to perform.

2. (ii) While clinical tests of structural language skills are in abundance, there are few clinical tools available for the assessment of pragmatics and discourse.

3. (iii) Speech-language pathologists have limited knowledge of pragmatics and discourse in comparison to phonology, syntax and semantics. SLP curricula do not include pragmatics and discourse as standard, with the result that clinicians do not feel particularly well equipped to assess these aspects of language.

Executive function deficits are so common in individuals who sustain TBI because the frontal lobe regions and their related circuitry are particularly vulnerable to TBI pathophysiology. These regions are widely implicated in a range of executive functions.

(a) true; (b) false; (c) true; (d) true; (e) false

apraxia of speech

parts (c) and (e)

parts (a), (c) and (d)

The subject's intellectual functioning is within the normal range. Intellectual functioning was assessed by means of the Raven's Colored Progressive Matrices.

part (e)

The subject's word-finding difficulty explains the lack of specificity and accuracy exhibited on the Pragmatic Protocol. In the absence of retrieval of specific words, clients with anomic aphasia (like this subject with CHI) use non-specific vocabulary like ‘thing’ and ‘stuff’.

Prosody plays a vital role in conveying a speaker's intended meaning. For example, a speaker's use of intonation can convey to a listener that he or she intends the utterance ‘What a delightful child!’ to be a sarcastic comment on the boisterous boy in the room. Similarly, a speaker's use of primary stress on the word ‘bull’ in the utterance ‘There's a bull in the field’ conveys to a listener that the speaker intends his or her utterance to be a warning rather than simply a description of a state of affairs. It is for this reason that prosody is one of the pragmatic parameters assessed in the Pragmatic Protocol.

Clients with TBI are known to have problems with a number of abstract cognitive operations. These operations include abstract reasoning and abstracting meaning from a text to arrive at the gist of a story (Anderson and Catroppa, Reference Anderson and Catroppa2005; Cook et al., Reference Cook, Chapman, Elliott, Evenson and Vinton2014).

(5) Findings which support clinical impression of tangential, repetitive, uninformative discourse:

• Tangential: 11.4% and 13.8% of issues introduced by the subject with CHI are unrelated to the monologue topic. The normal control subject does not introduce any issues that are unrelated to the monologue topic.

• Repetitive: 11.4% and 12.1% of the issues introduced by the subject with CHI are reintroduced. In effect, the subject is revisiting or repeating issues that have already been dealt with in the monologue. This compares to only 5.4% and 2.4% of reintroduced issues by the normal control subject.

• Uninformative: The percentage of ideational units which contain new information is low for the subject with CHI (48.8% and 56.0%) in comparison with the normal control subject (83.9% and 79.4%). The subject with CHI produces a higher percentage of ideational units which contain no new information than the normal control subject (12.7% and 9.7%, respectively, in the concrete condition) and introduces a smaller percentage of new issues than the normal control subject (77.1% and 94.6%, respectively, in the concrete condition).

non-specific lexemes: ‘people’; ‘things’; ‘somewhere’

The subject uses grammatical ellipsis in the utterance ‘no I haven't [been to a Halloween party]’.

incomplete utterances:

  incomplete prepositional phrase: ‘coming through […]’

  incomplete verb phrase: ‘who […] things’

  incomplete verb phrase: ‘you go […]’

The speech-language pathologist expands her question in her second turn because she appears to treat the subject's response (‘uh’) as an indication that he has not understood the question. However, this response on the part of the subject may not indicate a lack of comprehension so much as a word-finding difficulty.

The subject with CHI uses personal pronouns (‘you go’) and demonstrative pronouns (‘that's…good looking costume’) in the absence of clear referents.

1. (a) ‘it seemed to ah, (2.0) over’

2. (b) ‘you put everything in[to it]’

3. (c) ‘it seemed to ah’

4. (d) ‘I really get into it’

5. (e) ‘that's a big circle’

part (c)

(3) Markers of sympathetic circularity:

• (‘well’) ‘well it's like…art’

• (‘and’) ‘and that's what you're doing…you know’

• (‘kinda’) ‘kinda go over’

The subject only links clauses through the use of ‘and’: ‘you jus’ sit down…and you really concentrate…and you put everything in…and it…seems…like…and that's what you're doing’.

The speech-language pathologist uses her final turn in the exchange to summarise the message which she believes the subject with CHI has been attempting to communicate. She marks the beginning of her summarisation through the use of the discourse marker ‘so’. She then presents her summary by way of a yes–no question which requires only a simple confirmation or rejection on the part of the subject. This summarisation strategy allows the speech-language pathologist to check her understanding of what the subject is saying in a way which places limited demands on the subject's communication skills – he only needs to express his agreement or disagreement with the therapist's summary.

parts (a) and (e)

The language impairment in AD is described as a ‘cognitive-communication disorder’ as it is related to the cognitive deficits that occur in AD: ‘Communication is affected because the pathophysiologic processes of AD disrupt information generation and processing. Patients are said to have a “cognitive-communication” problem because progressive deterioration of cognition interferes with communication’ (Bayles and Tomoeda, Reference Bayles and Tomoeda2013: xiv).

part (c)

false

parts (b), (d) and (e)

(a) true; (b) false; (c) true; (d) false; (e) false

parts (a) and (d)

primary progressive aphasia; cognitive

part (d)

The Boston Diagnostic Aphasia Examination (Goodglass et al., Reference Goodglass, Kaplan and Barresi2001) is a standard aphasia test battery. These batteries should be supplemented by other assessments as the language impairments of clients with AD often go beyond deficits in structural language. Specifically, pragmatic and discourse deficits in AD are not readily revealed by aphasia batteries.

1. (a) ‘yes I did [drive all the way by myself]’

2. (b) Nurse: ‘Did you stop?’ Martha: ‘we stopped here and there’

3. (c) ‘to X-county and further up’

4. (d) ‘I don't have any mon-ʼ

5. (e) ‘I was so afraid’

Two linguistic features which suggest that Martha is experiencing word-finding problems: (i) the use of vague language (e.g. ‘to X-county and further up’) and (ii) the use of filled pauses before content words (e.g. ‘that small e:h Volkswagen’).

1. (a) ‘along the road’

2. (b) ‘the newest one’

3. (c) ‘I have taken my driving test so I had my license’

4. (d) ‘it was the newest one that we took’

5. (e) ‘I have been driving too of course’

In extract 2, Martha is able to produce the names of three different types of berry: strawberries; lingonberries; and bilberries.

Catherine supports Martha in the construction of her narrative by (i) producing backchannel sounds (e.g. ‘mm’), and (ii) producing evaluative statements (e.g. ‘that wasn't a bad thing’). The former behaviour indicates to Martha that Catherine is listening and that she wants Martha to continue her story. The latter behaviour indicates that Catherine appreciates the content of what Martha is saying.

(a) idiom; (b) metaphor; (c) idiom; (d) proverb; (e) metaphor

1. (a) relation – The client states that her daughter will travel to Spain.

2. (b) manner – The client relates events in the wrong order when she begins her response by saying that an ambulance took her home.

3. (c) quantity – The client's response is under-informative.

Topic development is compromised in the client with AD who produces uninformative utterances in conversation. This client is unable to contribute to the propositional development of a topic.

1. (a) The speaker fails to use ellipsis and utters ‘I would like a coffee’ when ‘a coffee’ would suffice.

2. (b) The speaker uses anaphoric reference incorrectly, as it is not clear if ‘it’ refers to the blouse or to the cardigan. The speaker also uses substitution incorrectly, as it is not clear if ‘one’ takes the place of blouse or cardigan.

3. (c) The speaker uses cataphoric reference incorrectly, as it is not clear if ‘it’ refers to the cathedral or to the castle.

4. (d) The speaker uses ellipsis incorrectly, as it is not clear which action B is prepared to undertake.

5. (e) The speaker uses anaphoric reference incorrectly, as it is not clear if ‘it’ refers to the blue dress or to the pink hat.

In order to establish that the speaker who utters ‘What a delightful child!’ in the presence of a disruptive 5-year-old does so with sarcastic intent, a hearer must be able to attribute certain mental states to the mind of the speaker. Two such states are that the speaker believes that the child is anything but delightful and that the speaker who entertains this belief and produces this utterance has a communicative intention to be sarcastic. The attribution of these mental states to the mind of the speaker requires an intact theory of mind capacity. Because this capacity is often disrupted in clients with AD, it is difficult for these clients to interpret sarcastic utterances.

In lines (1), (2) and (4), Martha utters ‘he said’. The referent of the personal pronoun ‘he’ is unclear as it could be her husband, her driving teacher or her driving examiner in this context. In line (9), Catherine says ‘I never dare think about that’. The referent of the demonstrative pronoun ‘that’ is unclear, as Martha's subsequent request for clarification indicates.

In line (10), Martha makes a request for clarification when she says ‘come again?’ to Catherine. In order to make requests for clarification, Martha must be able to monitor her comprehension of another speaker's utterances. Monitoring understanding of someone else's utterances demands the possession of metacognitive and metalinguistic skills on Martha's part.

Martha is skilled at using direct reported speech. For example, in line (2) she utters: ‘“You you took the driving test easily” he said’.

In line 17, Martha utters ‘And then we drove up to eh’. Martha uses the conjunction words ‘and then’ to indicate that she bought the car first and then went on a road journey in it.

In line (11), Catherine says ‘You're so lucky’ while pointing at Martha. This gesture enables Catherine to indicate clearly that Martha is the intended referent of the pronoun ‘you’. In line (12), Catherine produces a vague gesture which does not facilitate the communication of her message. This gesture is repeated in line (14).

part (a)

parts (a), (d) and (e)

Warren has experienced pneumonia, which may be caused by the aspiration of food and liquids. Also, he has had oral candida which can be a cause of dysphagia.

cytomegalovirus (CMV) infection

Warren is a regular user of marijuana. This may also contribute to his cognitive problems.

(a) false; (b) false; (c) true; (d) false; (e) false

parts (a), (d) and (e)

parts (c) and (d)

Depression can be an independent cause of communication problems.

parts (b) and (d)

parts (b) and (e). Both are metaphorical utterances.

part (b)

parts (b) and (e)

Warren's word-finding problems might explain his use of non-specific vocabulary on CDA. Specifically, when a client struggles to find a specific word, s/he substitutes non-specific vocabulary like ‘thing’ and ‘stuff’ in its place.

part (a)

Referential disturbances do contribute to the researcher's difficulty in following what Warren is saying. For example, there are no clear referents of the adverb ‘there’ and the pronoun ‘it’ in the following utterance: ‘So I've added there as well and the years come along and I didn't remember doing either of the first two so I did it again […]’. However, Warren is also able to use reference appropriately, as in this example of anaphoric reference: ‘I added a year at my birthday, didn't celebrate it so therefore I forgot about it’.

Warren makes use of several mental state verbs including ‘I forgot about it’, ‘I didn't remember’ and ‘I thought’. The fact that Warren is able to use these verbs in relation to himself suggests that he is able to attribute mental states to his own mind.

1. (a) ‘Someone pointed out’

2. (b) ‘In September as a halfway between two ages I start saying what the next one is’

3. (c) ‘and a new set of batteries that were still in the package so that guaranteed the calculator was working properly’

4. (d) ‘I went “no, I'm not I'm 34”’

5. (e) ‘I was 34 last year and 33 last year’

Warren appropriately uses an indefinite noun phrase on the first mention of a new person or object, and a definite noun phrase on a subsequent mention, e.g. ‘I'm gonna get me a calculator and a new set of batteries that were still in the package so that guaranteed the calculator was working properly’.

parts (b), (c) and (e)

The AIDS control tends to use minimal, but nonetheless informative and relevant responses to questions, e.g. ‘Foreign service’. Warren does make relevant, informative responses to questions, e.g. ‘Oh when I had the business, cleaning the building’. However, after making such a response, he can then engage in a lengthy digression, as is evident at the end of the second conversational extract.

When the researcher states ‘that must've been very interesting’, this is a comment which requires some further development by the AIDS control. However, it is effectively neglected by this speaker, who proceeds to describe the type of work he did.

1. (a) True: Warren can respond to grammatical questions (e.g. ‘What would be the longest job you had?’) and prosodic questions (e.g. ‘And that was when you were in your twenties?’).

2. (b) False: Warren is able to make use of anaphoric reference, e.g. ‘My great grandmother was born into a family that was indentured to a castle near Salisbury, Newcastle. Well she was supposed to be a house servant’.

3. (c) True: The AIDS control uses a lexical error when he states ‘I'm a public service’.

4. (d) False: The AIDS control can make use of anaphoric reference, e.g. ‘’cause X um and Australia are connected now with visas they don't need uh like people to issue them’.

5. (e) True: Warren engages in play on the meaning of words when he uses ‘common sense’ and ‘there's nothing common about this little black duck’. The two senses of ‘common’ are plain, ordinary good judgement and vulgar and coarse, respectively.

For the AIDS control, ‘foreign service’ appears to activate ‘public service’. For Warren, ‘common sense’ appears to activate ‘nothing common about this little black duck’.

part (c)

(a) hypophonia; (b) bradykinesia; (c) micrographia; (d) substantia nigra; (e) theory of mind

Dopamine is a neurotransmitter. In the central nervous system, it is involved in the control of locomotion, cognition, affect and neuroendocrine secretion.

(a) respiration; (b) prosody; (c) phonation; (d) articulation; (e) prosody

(b) sarcasm; (d) metaphor

All utterance interpretation involves establishing the communicative intention that motivated a speaker to produce an utterance. A communicative intention is a type of mental state. Clients with PD who have ToM deficits will be unable to attribute this mental state to the mind of a speaker who produces an utterance, and will experience problems with pragmatic understanding in consequence.

part (c)

Saldert et al. (Reference Saldert, Ferm and Bloch2014: 712) characterise intelligibility as a measure of speech signal effectiveness, and comprehensibility as the listener's understanding of the semantic content of an utterance produced in a communicative context.

A listener can use contextual cues to help him understand the speaker during an assessment of comprehensibility. These same cues are not available to the listener during an assessment of intelligibility. A speaker can thus have greater comprehensibility than might be suggested by his intelligibility.

executive function skills

This result reveals that the comprehension of both structural and pragmatic aspects of language is impaired in Parkinson's disease.

(1) Three features of Robert's pauses which indicate that they are related to a word search:

1. (a) duration – several pauses are particularly prolonged, suggesting that Robert is using them to facilitate a word search

2. (b) location – several pauses occur immediately before the production of content words such as verbs (‘read’) and nouns (‘purposes’), which are difficult for Robert to produce (see semantic fluency score)

3. (c) filler – one of Robert's pauses is followed by a filler (‘eh’), which helps him retain his turn as he searches for a word

(2) Non-specific vocabulary:

• ‘it was some priest’

• ‘purposes or influ- or something’

• ‘elderly persons and such’

Robert uses a circumlocution when he produces ‘elderly persons and such who are living on those pension schemes’ to refer to pensioners.

Robert uses pronouns in the absence of clear referents. This includes possessive pronouns (‘part of their work’) and personal pronouns (‘it was a moment of’). The absence of referents contributes to the listener's difficulty in understanding Robert.

In her final turn in the extract, Sonja attempts to bring the conversation back to her earlier enquiry about singing. This is the last point in the exchange where there was mutual understanding between Robert and Sonja. Sonja's desire to return to this point is indicated by her emphasis on the word ‘hymns’ and by the preface ‘no but’, which is used in an effort to re-direct Robert away from his troublesome talk.

(1) Non-specific vocabulary:

• ‘it is good for such’

• ‘refer to certain things’

• ‘may speak quite freely on such things’

(2) Problematic reference assignment:

• ‘what you feel about that’ (no referent for demonstrative pronoun)

• ‘it is good for such’ (no referent for personal pronoun)

• ‘it is not much’ (no referent for personal pronoun)

Sonja's repair strategy assumes the following form. She provides Robert with a suggestion about what he means, based on her understanding of what he has been struggling to communicate up to that point in the exchange. Robert is merely required to accept or reject her suggestion, thus reducing his communicative burden. Sonja's first suggestion is rejected by Robert. She then offers a second suggestion, which Robert accepts. The repair strategy is effective in establishing common ground between Robert and Sonja.

As described in (3), the repair strategy sees Sonja presenting Robert with a series of suggestions about what it is that he is attempting to communicate. For his part, Robert either accepts or rejects each of Sonja's suggestions. However, the word ‘or’ at the end of each of Sonja's utterances (e.g. ‘so you had some discussions after or?’) suggest that she may have been attempting to provide Robert with a forced choice (i.e. ‘Do you mean X or Y?’). But in each case Robert moves so swiftly to either accept or reject the X element of the forced choice that the Y component is abandoned by Sonja.

(5) Five instances of mental state language:

• Robert: ‘what you feel about that’

• Robert: ‘you don't know’

• Robert: ‘you shouldn't (1.1) understand’

• Sonja: ‘I see so you had’

• Sonja: ‘I see’

In Sonja's utterances, the verb ‘see’ has the meaning of understand. Robert's ability to use and comprehend mental state language suggests that he has a relatively intact theory of mind.

Sonja is providing Robert with an alternative (‘the organ or the piano?’). This is an example of category 5: guess/completion/suggestion.

In unit 32.4, there are two instances of the strategy called guess/completion/suggestion when Sonja makes two suggestions to Robert which he then either accepts or rejects.

The strategy called response token occurs in unit 32.3 when, after an extended and difficult turn by Robert, Sonja utters ‘mm’ while subtly nodding.

The strategy called topic shift occurs in unit 32.3, when Sonja shifts the topic away from what Robert has been trying unsuccessfully to communicate to her, back to the original topic of the singing that occurred in the church.

response token – not related to initiation of or participation in repair

contribution for flow – not related to initiation of or participation in repair

topic shift – not related to initiation of or participation in repair

open-class initiation of repair – request a clarification or modification of the message by the client

guess/completion/suggestion – provide client with solutions

elaboration/specification – provide client with solutions

parts (b), (d) and (e)

part (e)

bradykinesia (slowness of movement)

(a) false; (b) true; (c) false; (d) true; (e) true

Clients with HD who have neuropsychiatric disorders may have reduced compliance with SLT interventions relating to dysphagia and communication.

ER's children have a 1 in 2 chance of developing HD. Because HD is an autosomal dominant disorder, half the offspring of parents in which one parent has the defective gene will develop HD.

The presence of chorea affecting ER's arms and face is likely to compromise his ability to use manual gestures and facial expressions during communication.

Apathy and visual gaze difficulties are assessed by the neuropsychiatric and motor components of the UHDRS, respectively.

Dysarthria and executive function deficits in clients with HD may be assessed by the motor and cognitive components of the UHDRS, respectively.

ER's occupational and social functioning have been compromised by HD. ER has had to cease working on account of HD. ER's social functioning has been compromised as he is living in a residential care facility which has isolated him from his family (with the exception of contact with his mother).

ER's respiratory control for speech is most likely to be compromised by his severe truncal chorea.

Background noise is an environmental challenge to ER's intelligibility. It is difficult for ER to address this challenge because he has difficulty varying loudness. ER will be unable to increase his loudness to counteract the effects of background noise.

(a) true; (b) false; (c) false; (d) false; (e) false

The two aspects of ER's pragmatic skills which might be explained by his apathy are (i) his reliance on his communication partner to initiate topics, and (ii) his production of a reduced quantity of output.

The fact that ER's ratings of his communicative effectiveness were consistent with those of nursing staff and speech-language pathologists suggests that his perception of his communicative strengths and weakness is intact. ER's accurate perception of his communicative skills can be used to encourage self-monitoring of performance during intervention.

parts (c) and (d)

The results of ER's communication assessment are recorded under body structures and functions in the ICF framework.

Reduced initiation leads ER not to participate in the talking group unless directly invited to do so. Reduced initiation should be classified as a cognitive deficit under body structures and functions.

Social factors – an estranged family situation – account for ER's current difficulties in his relationship with his children. Speech factors will contribute to difficulties in this relationship in the future.

ER is already familiar with augmentative and alternative communication (AAC) in the form of communication books. He is likely to have a positive response to AAC in his own case.

The development of a legacy item allows ER to address a participation restriction in the form of not being able to perform the social role of a father to his children.

Goal (2) is intended to address environmental factors that were identified during interviews with ER's mother. Specifically, the use of a mobile phone will allow ER to have conversations with his mother in quieter locations than had hitherto been possible.

The factor which is common to these themes is cognitive deficits in HD and their adverse impact on communication.

Goal (3) is intended to address the adverse impact that ER's apathy and reduced initiation has on communication. Specifically, by extending invitations to ER to attend the weekly talking group, there is less of a requirement for him to initiate this particular activity.

ER's apathy is a personality change which reduced his ability to initiate communication with others.

parts (a) and (d)

In order to explain this finding, the process of natural recovery must occur more often in girls than in boys.

Probandwise concordance is defined as the risk of an illness or disorder (in this case, stuttering) in the co-twin of a proband-twin. The fact that concordance rates are consistently higher in monozygotic (genetically identical) twins than in dizygotic (genetically non-identical) twins is evidence that stuttering has a genetic aetiology.

The presence of comorbid conditions in stuttering must be considered by speech-language pathologists during assessment, diagnosis and treatment. For example, the SLP will need to determine during assessment if there is a distinct articulation disorder apart from the speech anomalies associated with stuttering. If such a disorder is present, the SLP will need to decide if articulation should be targeted in treatment before or alongside the speech anomalies of stuttering.

parts (a), (b) and (e)

DL's onset is typical of stuttering. It is stated in unit 34.1 that 95% of the risk for stuttering onset is over by age 4 (Yairi and Ambrose, Reference Yairi and Ambrose2013).

Stuttering is also present in four of DL's biological relatives. This pattern of familial aggregation indicates that DL has an increased genetic risk of stuttering.

The history revealed that DL has immature attention and delayed speech motor processes. There are also behaviour management difficulties in DL's case. The two comorbid conditions suggested by this history are attention deficit disorder (possibly ADHD) and articulation disorder.

The family's recent, stressful move is an environmental factor that may be contributing to DL's stutter.

parts (a), (b) and (e)

DL's percentage of stuttered words is 8.4%. This figure indicates that he is at risk of continuing to stutter. Clinicians also calculate a client's percentage of stuttered syllables as a means of assessing stuttering severity.

The dysfluencies in the utterance ‘Its its ha-ha-haaa:vn't got got a window’ can be characterised as follows: part-word repetition (ha-ha), whole-word repetition (got got) and sound prolongation (haaa:).

(a) true; (b) false; (c) false; (d) true; (e) true

(4) Three verbal behaviours:

1. (i) DL's father uses extended, linguistically complex explanations. Given his receptive language problems, DL is unlikely to comprehend these explanations.

2. (ii) DL's mother and father make excessive use of questions. Questions are likely to be challenging for DL's expressive language skills as they require a response. Other speech acts such as comments are less challenging as they do not place DL under an expectation to respond. Also, unless they are carefully chosen, questions may not be understood by DL.

3. (iii) DL's mother frequently interrupts him. This suggests a lack of awareness of the difficulties that DL faces in producing spoken language.

Two cognitive skills which are likely to be taxed by parental behaviours are memory and speed of information processing. DL's father takes lengthy turns and uses lengthy explanations, both of which are likely to exceed DL's memory capacity. His mother and father use a fast speech rate which is likely to exceed DL's speed of information processing.

During the first six weeks when no direct therapy was undertaken, measures of the number of dysfluencies per 100 words were regularly taken. This enabled the clinician to establish a no-treatment baseline which could be used to assess the effects of treatment.

DL displayed concomitant non-verbal behaviours such as facial grimacing when he produced stuttered speech. These behaviours, which can only be identified through video-recordings, would have assisted the authors of the study in identifying dysfluencies in DL's speech.

part (c)

Parental use of questions and imperatives was discouraged, and the use of comments was encouraged. Questions were discouraged as they place demands on DL's receptive and expressive language skills, which are known to be significantly delayed. Comments do not demand a response and so they are less challenging for DL in linguistic terms. The father is excessively directive in his interaction with DL. In order to reduce the father's directiveness, the use of imperatives was discouraged and replaced by comments. Comments permit DL to make an active contribution to communication, whereas imperatives consign him to a role in which he is merely complying with the father's commands during play. It should be noted that the use of questions also allowed the parents to direct DL's behaviour. Reduction of the use of questions would have had the effect of decreasing the parents’ directiveness with DL.

The purpose of the final five weeks, during which no new information or advice was offered, was to assess the maintenance of treatment effects.

The non-significant result in Phase A indicates that DL's dysfluency was not resolving spontaneously, i.e. without direct intervention.

An intervention which takes as its baseline a single measure of dysfluency at one point in time is likely to overestimate or underestimate the child's actual level of dysfluency. To overcome the inconsistency of early dysfluency in young children, investigators and clinicians must measure the number of dysfluencies produced across several points in time.

Even in the absence of formal language test results, there is some evidence that DL's language skills did improve following parent–child interaction therapy. At the end of 17 weeks, DL was reported to be using more utterances and longer (more complex) utterances.

The demands on DL's speech production system took the form of a pattern of parental interaction which unnecessarily taxed his motor planning and language skills. The aim of parent–child interaction therapy was to reduce these particular environmental demands. At the same time, developmental maturation and the linguistic stimulation provided by PCI therapy jointly bolstered DL's capacities. Intervention thus achieved a reduction in DL's rate of dysfluencies by simultaneously reducing the demands on DL's speech production system and increasing DL's motor speech and language capacities.

DL was producing more utterances and more complex utterances towards the end of the study. As the complexity and amount of DL's linguistic output increase, it is to be expected that his rate of dysfluencies will also increase.

That there is a significant gender bias among adults with developmental stuttering – a male-to-female ratio of 4:1 – has been recognised for some time. (It should be noted that Yairi and Ambrose (Reference Yairi and Ambrose2013) state that this ratio is considerably smaller in very young children near stuttering onset.) However, there is no evidence of a similar gender bias in adults with acquired stuttering.

parts (b) and (d)

part (d)

whole-word repetition; part-word repetition

developmental; choral; auditory

On the basis of this history and presentation, Mr A appears to have acquired psychogenic stuttering. This is supported by two findings: (i) Mr A reported considerable work-related stress, and (ii) a comprehensive neurological evaluation was negative.

part (c)

increase in vocal pitch; writing problems

This impairment of writing is suggestive of micrographia in Parkinson's disease. Micrographia is an abnormal reduction in writing size which is specific to Parkinson's disease.

electroencephalography (EEG)

(1) Mr A's repetitions differ from the iterations of developmental stuttering in the following ways:

1. (i) Mr A's repetitions were present on every word and syllable, whereas the iterations of developmental stuttering only occur on some words and syllables.

2. (ii) Mr A's repetitions involve full syllables and words, whereas the repetitions of developmental stuttering involve sound elements that are smaller than full syllables (e.g. phonemes or phonemes and a schwa vowel).

In developmental stuttering sound prolongations or perseverations occur. However, this is not a feature of Mr A's stuttered speech.

(3) Mr A's stuttering behaviour differs from developmental stuttering in the following three respects:

1. (i) Choral reading did not alter Mr A's stuttering. Choral reading can induce immediate fluency in the person with developmental stuttering.

2. (ii) Mr A did not display secondary characteristics or accessory features. These characteristics are often found in the person with developmental stuttering.

3. (iii) Mr A did not display avoidance behaviour or fear of words and/or situations. Both of these behaviours are often found in the person with developmental stuttering.

Fasciculations appear as random, irregular, twitching movements on the surface of the tongue. These movements are caused by involuntary contractions of small bundles of muscle fibres under the surface of the tongue. Fasciculations are indicative of lower motor neurone damage.

There is no comorbid aphasia in Mr A's case. His expressive and receptive language skills are intact.

The psychiatric intervention employed pharmacological and behavioural strategies. Neither set of strategies resulted in speech improvement.

(2) The four cardinal signs of Parkinson's disease are resting tremor, bradykinesia, rigidity and postural instability. Mr A displays all four cardinal signs:

• Resting tremor – Mr A exhibited a tremor at rest in both arms and a slight tremor at rest in the right leg.

• Bradykinesia – Mr A displayed slowness of tongue movements and his finger to nose movements were slow.

• Rigidity – Mr A's face was without expression.

• Postural instability – Pushing on Mr A's chest and back produced mild instability with no reflexive compensatory movements of his arms.

The symptoms of Parkinson's disease are typically caused by dopamine deficiency. However, SPECT scanning revealed that Mr A had normal proportions of dopamine in his brain. It must, therefore, be concluded that dopamine receptors in the brain are no longer functioning, or that Mr A's symptoms do not have a biochemical basis.

The palpebral fissures (distance between upper and lower eyelids) are wider than normal and blinking is infrequent. Eyes have a staring appearance on account of these features, and because spontaneous ocular movements are lacking. The patient's facial muscles exhibit an unnatural immobility.

parts (c) and (e)

parts (c) and (d)

Relaxation techniques were used to address Mr A's vocal pitch anomalies. The fact that Mr A's pitch anomalies improved while other aspects of his stuttered speech did not indicates that these anomalies were likely secondary to his anxiety about his speech disorder rather than a symptom of a parkinsonian-like syndrome.

A soft contact aims to achieve gentle and tension-free contact between the articulators. Sounds which are made with visible articulators such as the lips and teeth are employed to instruct clients in the use of this technique. The clinician can demonstrate the distinction between hard and soft contact by contrasting the tension that occurs during a tense, forceful production of /b/ in ‘big’ with the altogether less tense and less effortful contact that is used during a soft production of the same sound.

The respiratory–phonatory mechanism is targeted by continuous breath flow which leads to the use of voicing by humming vowels and nasal continuants.

Mr A's fluency intervention aims to increase his rate of speech.

parts (a), (d) and (e)

part (c)

In order to study the prevalence and incidence of a disorder, investigators must be able to identify it. However, there has been a lack of clinical consensus on the speech features and other behaviours which constitute cluttering. This lack of consensus has limited the extent to which it has been possible to conduct epidemiological investigations of cluttering.

The person who clutters is collapsing syllables. This behaviour is known as telescoping or the coarticulation of syllables.

true

Three motor milestones: begins to sit without support (6 months); crawls (9 months); walks alone (18 months).

Michael has a reading disorder. Reading problems are often found in people who clutter.

Michael's mother reported that there was a family history of fast talking and stuttering. This indicates that Michael was probably at an elevated genetic risk of having a communication disorder.

unusually fast speech rate

The intervention for speech intervention was probably only minimally effective because there didn't appear to be a proper understanding of the nature of Michael's speech difficulties, namely, that they were related to cluttering.

This description captures the telescoping or coarticulation of syllables and sounds in cluttering.

oral motor coordination skills

This finding is confirmed by the fact that there was an improvement in Michael's speech when a recorder was introduced into the evaluation.

The checklist finding that there is a lack of self-awareness in people who clutter explains why many individuals need to have their communication problems pointed out by others before they seek professional help.

Topic management was judged to be impaired in Michael.

The motoric and linguistic components of cluttering are both reflected in the intervention that Michael received. The motoric component of the intervention involved work on Michael's oral motor coordination skills. The linguistic component of the intervention included a focus on language skills such as narrative production and topic maintenance.

Three cognitive components of intervention: (i) focus on concentration and memory; (ii) improving awareness; and (iii) emphasis on thought organisation.

The school speech-language pathologist delivered a motor speech intervention with a focus on articulation and prosody. The hospital speech-language pathologist delivered a cognitive-linguistic intervention.

The American Speech-Language-Hearing Association (2005b) defines central auditory processing disorder as ‘difficulties in the processing of auditory information in the central nervous system (CNS) as demonstrated by poor performance in one or more of the following skills: sound localisation and lateralisation; auditory discrimination; auditory pattern recognition; temporal aspects of audition, including temporal integration, temporal discrimination (e.g., temporal gap detection), temporal ordering, and temporal masking; auditory performance in competing acoustic signals (including dichotic listening); and auditory performance with degraded acoustic signals’.

In order to narrate a story, a narrator must be able to plan and organise (or sequence) not just the key events in a story but also the linguistic utterances which will be needed to convey these events. These cognitive-linguistic processes are impaired in people who clutter.

A prosodic aspect which had clearly improved following therapy was Michael's speech rate, which was reduced. However, Michael's volume or loudness, which had been minimally aberrant before therapy, was more noticeably aberrant following therapy.

Michael's pragmatic language skills did appear to improve as a result of intervention. His topic maintenance skills improved – he did not deviate from topic as he did at his first evaluation. Also, Michael was able to sequence events where previously his language output had been disorganised.

auditory memory; awareness

Michael engaged in rapid, repetitive eye blinking in association with linguistic revisions and other speech production difficulties. This behaviour is suggestive of the secondary characteristics or accessory features that are found in stuttering.

At re-evaluation Michael frequently kept his hands in front of his mouth and did not always maintain good eye contact. The emergence of these behaviours can be explained as follows. As Michael's awareness of his communication difficulties increases, he is more likely to experience a sense of social unease about them. This sense of unease is likely to be exacerbated by the fact that Michael is approaching adolescence, a life phase where his communication difficulties will set him apart from his peers.

1. (a) infectious disease

2. (b) laryngeal trauma

3. (c) neurodegenerative disorder

4. (d) infectious disease

5. (e) neurodegenerative disorder

1. (a) endocrine disorder

2. (b) pharmacological agent

3. (c) auto-immune disease

4. (d) endocrine disorder

5. (e) pharmacological agent

parts (b) and (d)

vocal fold bowing in presbylarynx

Three occupational groups: teachers; singers; actors

Laryngeal pathology: vocal nodules

In gastroesophageal reflux, transient relaxation of the lower oesophageal sphincter allows a bolus of refluxate to move from the stomach into the oesophagus. This bolus contains acid and pepsin, which is the primary enzyme of the stomach. If the upper oesophageal sphincter (called the cricopharyngeus) is not functioning normally, this bolus spills into the larynx and pharynx, causing LPR. The airway epithelium, including the epithelium of the larynx, is fragile and more easily damaged by gastric reflux than the oesophageal epithelium. The corrosive effect of reflux on this epithelium leads to the development of a number of laryngeal pathologies.

Laryngeal pathology linked to LPR: laryngeal carcinoma

Vocal hyperfunction: vocal fatigue; hoarseness after teaching a long class

Laryngopharyngeal reflux: sensation of a lump in the throat in the morning

parts (a), (c) and (e)

(a) false; (b) true; (c) true; (d) true; (e) false

part (e)

Description 1: open quotient

Description 2: voice onset time

Stroboscopy is used to examine fine movement of the vocal folds and the mucosal wave. A microphone is placed on the neck of the patient. It allows the frequency of a strobe flashing light to be matched to the frequency of vocal fold vibration. The ‘slow-motion’ image is captured by a flexible endoscope or a 60° or 70° rigid telescope inserted into the mouth.

part (a)

The presence of a contact granuloma might be expected to increase a speaker's mean expiratory airflow as there will be inadequate adduction of the vocal folds. A successful intervention, which achieves improved glottal contact during adduction, might be expected to result in a decrease in a speaker's mean expiratory airflow.

parts (a), (c) and (e)

The emphasis of physiological voice therapy is on directly exercising and manipulating the different systems involved in voice production: ‘The hallmark of physiologic voice therapy is direct physical exercise and manipulations of the laryngeal, respiratory, and the resonance systems in an effort to improve voice quality’ (Stemple et al., Reference Stemple, Glaze and Klaben2000: 331).

This accommodation is addressed by the VFE which aims to improve the balance among the subsystems for voice production.

‘Vocal function exercises promote a glottal closure pattern (barely adducted/abducted arytenoids) that enhances efficient vocal fold vibration through the use of a semioccluded posturing of the vocal tract’ (Patel et al., Reference Patel, Pickering, Stemple and Donohue2012: 741).

The cricothyroid muscle activates during pitch elevation. It is this laryngeal muscle that is exercised during gliding from a low to a high fundamental frequency.

There is some evidence that vocal function exercises are effective in treating clients with voice disorders. Gorman et al. (Reference Gorman, Weinrich, Lee and Stemple2008) reported that vocal function exercises achieved an improvement in vocal aerodynamics in elderly men with voice problems. Roy et al. (Reference Roy, Gray, Simon, Dove, Corbin-Lewis and Stemple2001) found that teachers with voice disorders who received vocal function exercises reported a significant reduction in mean Voice Handicap Index scores. They also reported more overall voice improvement and greater ease and clarity in their speaking and singing voice following vocal function exercises than teachers with voice disorders who received vocal hygiene only.

Open quotient is the duration of the cycle during which the vocal folds remain open divided by the duration of the entire cycle. If the folds are open for the entire cycle, as they were in PT's case before treatment, it is not possible to arrive at a calculation of open quotient.

Image B corresponds to the pre-therapy description. Image A corresponds to the post-therapy description.

These findings suggest that acoustic measurements are somewhat insensitive to the impact of a contact granuloma on PT's vocal function.

There was a 4.07% increase in PT's respiratory volume following VFEs. This suggests that these exercises were successful in training PT how to breathe to his maximum capacity for voice production.

A speech-language pathologist might defend the cost-effectiveness of PT's voice therapy in the following terms. He or she could argue that even a mildly deviant voice quality could put PT at risk of psychological distress (e.g. depression) which, in turn, might require him having to take time off work. There are economic consequences for PT and his employer if he is on sick leave. These economic consequences could be averted if PT received timely voice therapy.

parts (b) and (d)

(2) Three medical and health professionals:

• otorhinolaryngologist

• speech-language pathologist

• psychotherapist/clinical psychologist/psychiatrist

parts (a), (c) and (e)

Psychogenic dysphonia is frequently misdiagnosed because (i) it is preceded by conditions such as acute laryngitis and allergy/asthma symptoms, and (ii) acute laryngitis and psychogenic dysphonia create similar perceptual aberrations in the voice.

part (b)

parts (c) and (e)

Ms S reports experiencing low mood and feelings of anxiety.

occupational functioning

Ms S is a teaching assistant at a local school. This is an occupation which places high vocal demands on individuals and places them at risk of organic disorders such as vocal nodules. Until a complete laryngological assessment has been conducted, an organic disorder of this type cannot be excluded as a cause of Ms S's voice disorder.

It is known that psychogenic dysphonia is frequently misdiagnosed. This may account for the limited success of Ms S's previous interventions.

part (b)

A good volitional cough indicates that Ms S is able to achieve adequate adduction of the vocal folds.

The fact that Ms S has worse GRBAS scale scores during speaking than during phonation indicates that there is likely to be a psychogenic aetiology to her disorder. If an organic abnormality was the cause of Ms S's voice problems, her GRBAS scale scores would be the same during speaking and phonation.

These values are within the normal range for someone of Ms S's age and sex (Xue et al., Reference Xue, Hao, Xiu and Moranski2008).

Ms S's maximum phonation duration of 4 seconds is not within the normal range. The maximum phonation duration of a woman aged 50 years should be 21.34 seconds (standard deviation: 5.66) (Gallena, Reference Gallena2007).

Ms S has considerable issues around speaking out and having her voice heard. She feels she cannot express her opinions and thoughts to her spouse or to her wider family. Her voice is not heard or is dismissed as having no worth.

Communication is also one of the ways in which conflict is expressed between Ms S and her spouse. They both express anger by not talking to each other for days.

Fluctuations in Ms S's vocal symptoms are reflective of her emotional state. During joint sessions with her spouse, Ms S's voice was hoarse and became aphonic when an argument occurred.

Ms S has received the attention and concern of her children, and particularly her daughters, on account of having a voice disorder. This is a possible secondary gain for Ms S of her dysphonia.

There is evidence that a combined treatment involving psychotherapy and speech therapy is more effective than speech therapy alone. Martins et al. (Reference Martins, Tavares, Ranalli, Branco and Pessin2014) found that all patients with psychogenic dysphonia in their study showed remission of vocal symptoms after speech therapy and psychological treatment. However, when speech therapy was used alone, only 12.5% of patients reported vocal symptom improvement.

parts (b) and (e)

The expression ‘soft contact’ refers to a type of vocal fold adduction where the vocal folds are gently adducted to achieve the onset of voicing. It is the opposite of a type of vocal fold adduction called hard glottal attack.

During a discussion of vocal hygiene, clients are made aware of environmental and behavioural factors which can have an adverse impact on the voice. This can include the dehydrating effects of caffeine, alcohol, heating and certain drugs (e.g. anti-histamines) on the vocal fold mucosa, the carcinogenic and other effects of tobacco smoke on the laryngeal mechanism, and the vocal fold damage which can be caused by persistent coughing and throat clearing.

Clients with psychogenic dysphonia can make compensatory maladjustments which put the laryngeal mechanism at risk of organic pathologies. For example, they may begin to recruit laryngeal muscles that are not normally involved in vocal fold adduction. To avoid the use of potentially damaging vocal patterns, voice clients must be educated about voice misuse.

GRBAS scale scores of zero across all parameters indicate that Ms S's voice was perceptually normal by the termination of treatment.

Historically, as male smoking rates have declined, female smoking rates have increased. The Office for National Statistics in the UK reports that in 1974, 51% of men smoked compared with 41% of women. In 2011, 21% of men smoked compared with 19% of women. A 10 percentage point difference in 1974 has narrowed to a 2 percentage point difference in 2011. This gender-related trend in smoking rates is the most likely explanation of the fact that women are representing an increasing proportion of cases of laryngeal cancer over time.

Piselli et al.'s subjects exhibit the following risk factors for laryngeal cancer: (i) as liver transplant recipients, they had immunosuppression, and (ii) these subjects had alcoholic liver disease, indicating excessive alcohol consumption.

In gastroesophageal reflux disease, transient relaxation of the lower oesophageal sphincter allows a bolus of refluxate to move from the stomach into the oesophagus. This bolus contains acid and pepsin, which is the primary enzyme of the stomach. If the upper oesophageal sphincter (called the cricopharyngeus) is not functioning normally, this bolus spills into the larynx and pharynx, causing laryngopharyngeal reflux. The airway epithelium, including the epithelium of the larynx, is fragile and more easily damaged by gastric reflux than the oesophageal epithelium. The corrosive effect of reflux on this epithelium leads to the development of laryngeal carcinomas.

part (c)

(a) false; (b) true; (c) true; (d) false; (e) true

Most new laryngeal cancers are diagnosed in people aged between 55 and 64 years. At 62 years of age, MT falls within this age range. Most laryngeal cancers also develop in men. So in terms of both age and sex, MT conforms to the demographic profile of individuals who are most likely to develop laryngeal cancer.

MT has smoked cigarettes for 40 years and also consumes alcohol, both of which are lifestyle risk factors for laryngeal cancer.

Because of its capacity to disrupt the vibratory pattern of the vocal folds, a glottic carcinoma will cause hoarseness at an early stage in tumour development. Supraglottic and subglottic carcinomas will only cause hoarseness at a later stage of tumour development when the tumour has invaded the glottis.

The term ‘odynophagia’ refers to the symptom of painful swallowing. It derives from the Greek words odyno (pain) and phagein (to eat). The term ‘otalgia’ refers to ear pain. It can be caused by conditions in the ear itself (primary otalgia) or, as in the case of laryngeal cancer, can be referred from other locations in the head and neck (referred otalgia).

(5) Three other symptoms of laryngeal cancer:

1. (i) stridor is a harsh, vibratory sound of variable pitch which is caused by partial obstruction of the respiratory passages. Inspiratory stridor indicates obstruction of the airway above the glottis and is a symptom of many vocal fold pathologies including laryngeal carcinoma. Expiratory stridor indicates obstruction in the lower trachea.

2. (ii) dyspnoea is a subjective sensation of difficulty breathing. As well as being a symptom of laryngeal carcinoma, it can also be a sign of cardiac, respiratory and neuromuscular disease.

3. (iii) haemoptysis is the coughing of blood from a source below the glottis. This can take the form of blood-streaked sputum or a significant haemorrhage. Haemoptysis can be a symptom of a range of pathologies including laryngeal and lung cancer.

(1)  

A supraglottic laryngectomy is warranted in MT's case. This is because the tumour involves the epiglottis and left false vocal fold. Additionally, neck dissection will need to be performed to address the cervical lymph node which contains squamous cell carcinoma clusters.

After supraglottic laryngectomy, MT is likely to experience dysphagia. His poor dentition will serve as an aggravating factor at the oral stage of swallowing as it will compromise his ability to form a bolus of safe consistency for swallowing.

Panendoscopy is an examination of the upper part of the aerodigestive tract. It can include any of the following procedures: rhinoscopy, nasopharyngoscopy, inspection of the oral cavity and oropharynx, direct laryngoscopy and hypopharyngoscopy, oesophagoscopy and bronchoscopy. The procedure can be performed in order to biopsy a tumour that is not accessible under local anaesthesia in the clinic. This was not necessary in MT's case as a biopsy was performed during laryngoscopy. The procedure is also performed to rule out an associated malignancy. In MT's case, the presence of a second primary tumour was excluded by means of panendoscopy.

The TNM staging system stands for Tumour (T), Node (N) and Metastasis (M). MT's tumour was classified as T2N1M0. T2 indicates that the tumour has invaded more than one portion of the supraglottis or glottis and there is abnormal vocal cord movement. N1 indicates that there is metastasis in a single ipsilateral lymph node which is less than 3 cm. M0 indicates that there is no distant metastasis.

The aspect of MT's post-surgical rehabilitation which will be of most concern to the speech-language pathologist is swallowing. This is because clients who are treated with supraglottic laryngectomy have acceptable voice quality on perceptual and subjective assessment (Topaloğlu et al., Reference Topaloğlu, Salturk, Atar, Berkiten, Büyükkoc and Çakir2014). Instead, it is swallowing function that is most compromised by this surgical procedure. Prades et al. (Reference Prades, Simon, Timoshenko, Dumollard, Schmitt and Martin2005) examined 110 patients who had standard and extended supraglottic laryngectomies. Pulmonary complications due to aspiration were observed in 6% of patients with standard supraglottic laryngectomy, 15% of patients with laterally extended supraglottic laryngectomy and 19% of patients with anteriorly extended supraglottic laryngectomy.

The pharyngeal stage of swallowing is most compromised after supraglottic laryngectomy. This is because a standard supraglottic laryngectomy involves the resection of the following structures: the hyoid bone, the epiglottis, the valleculae, the aryepiglottic folds, the upper third of the thyroid cartilage and the false vocal cords (Schweinfurth and Silver, Reference Schweinfurth and Silver2000). Some of these structures (e.g. the epiglottis) are involved in the protection of the airway during the pharyngeal stage of swallowing. Also, the removal of these structures results in the loss of supraglottic sensation. This can lead to improper timing of upper oesophageal relaxation. If this occurs, entry of the bolus into the oesophagus may be hindered, resulting in aspiration (Schweinfurth and Silver, Reference Schweinfurth and Silver2000).

MT received postoperative radiotherapy. This is likely to contribute to any swallowing problems. Alicandri-Ciufelli et al. (Reference Alicandri-Ciufelli, Piccinini, Grammatica, Chiesi, Bergamini, Luppi, Nizzoli, Ghidini, Tassi and Presutti2013) examined the swallowing function of 32 patients who underwent partial laryngectomies between June 2003 and November 2010. Postoperative radiotherapy was the only factor that was found to influence swallowing function. Radiotherapy statistically significantly affected dysphagia score and penetration aspiration in these patients.

Transoral laser supraglottic laryngectomy is an alternative procedure to open (transcervical) supraglottic laryngectomy. A number of studies have compared the voice and swallowing outcomes of these two approaches. Cabanillas et al. (Reference Cabanillas, Rodrigo, Llorente, Suárez, Ortega and Suárez2004) reported no significant difference in swallowing capacity in 26 patients who were treated with a transoral approach and 26 patients who underwent transcervical supraglottic laryngectomy. Peretti et al. (Reference Peretti, Piazza, Cattaneo, De Benedetto, Martin and Nicolai2006) compared functional outcomes in 14 patients who underwent endoscopic supraglottic laryngectomy by carbon dioxide laser for selected T1–T3 supraglottic squamous cell carcinomas and 14 patients who were treated with open-neck supraglottic laryngectomy. There were no statistically significant differences between the two groups in the results of a comprehensive voice analysis, the M.D. Anderson Dysphagia Inventory, complication and aspiration rates. Significant differences between the groups were found for video nasal endoscopic examination of swallowing, videofluoroscopy, hospitalisation, feeding tube duration and tracheotomy duration. Peretti et al. concluded that endoscopic supraglottic laryngectomy had a significantly lower functional impact on swallowing than open-neck supraglottic laryngectomy.

MT's neck specimen revealed extracapsular spread. Extracapsular extension in squamous cell carcinoma nodal metastases usually predicts worse outcome (Lewis et al., Reference Lewis, Carpenter, Thorstad, Zhang and Haughey2011).

(a) true; (b) true; (c) false; (d) false; (e) true

Role functioning, social functioning and mental health have all been found to contribute to quality of life in clients after laryngectomy (Singer et al., Reference Singer, Danker, Guntinas-Lichius, Oeken, Pabst, Schock, Vogel, Meister, Wulke and Dietz2014; Perry et al., Reference Perry, Casey and Cotton2015). As well as making a direct contribution to quality of life, effective alaryngeal communication can also make an indirect contribution by way of improving clients’ role functioning, social functioning and mental health.

(a) electronic larynx; (b) voice prosthesis; (c) oesophageal speech; (d) voice prosthesis; (e) voice prosthesis

Because they depend on the vibratory capacity of the PE segment, oesophageal voice and the use of a tracheoesophageal voice prosthesis are the methods of alaryngeal communication that are most compromised by PE stenosis. PE stenosis also compromises swallowing function.

To be considered a candidate for TEVP, a client must have functional manual dexterity and functional visual acuity, or at least have access to a carer who has these skills.

Studies which base their estimates of the prevalence of gender dysphoria on the number of individuals who attend gender clinics are likely to be underestimating the true prevalence of gender dysphoria in the general population. This is because there are individuals who experience gender dysphoria and do not present themselves to specialist clinics for treatment.

(a) true; (b) false; (c) true; (d) true; (e) false

fundamental frequency

parts (b) and (d)

part (b)

(a) true; (b) false; (c) true; (d) false; (e) true

In males, there are abrupt changes in voice characteristics between Tanner stages G3 and G4 (Harries et al., Reference Harries, Walker, Williams, Hawkins and Hughes1997). By the time LA is seen at 15;3 years of age for voice and communication therapy, she has already experienced the changes associated with voice mutation.

LA had poor voice-related quality of life at the point of referral to a university voice clinic. LA reported that her voice caused her embarrassment, made her feel less feminine, and got in the way of her living as a female.

LA was identified as a female speaker in face-to-face interaction 70% of the time. However, when visual stimuli were not available, and listeners had to identify LA's gender from auditory–perceptual characteristics of her voice on the phone, the identification of LA as a female dropped to just 50%.

Abusive vocal behaviours are associated with hyperfunctional dysphonias. Acid reflux and alcohol and tobacco use can place an individual at risk of organic laryngeal pathologies. LA's voice clinicians need to know about these factors in order to establish whether she is at risk of organic and hyperfunctional voice disorders.

parts (a), (c), (d) and (e)

It is important to include different speech tasks in a voice assessment as there is evidence that vocal parameters vary across tasks. Watts et al. (Reference Watts, Ronshaugen and Saenz2015) examined cepstral/spectral acoustic measures in adult males in two speech tasks: production of sustained vowels and reading of a connected speech stimulus. Older men displayed significantly greater Cepstral/Spectral Index of Dysphonia measures than younger men in connected speech but not during sustained vowel production. Abu-Al-makarem and Petrosino (Reference Abu-Al-makarem and Petrosino2007) found that mean speaking fundamental frequency of young Arabic men was significantly higher during reading than in spontaneous speech.

Studies have shown that mean speaking fundamental frequency is associated with the perception of the gender of the speaker more than other acoustic measures. In a study of male, female and transgendered subjects, Gelfer and Mikos (Reference Gelfer and Mikos2005) found that gender identifications were based on fundamental frequency, even when fundamental frequency and formant frequency information was contradictory. Skuk and Schweinberger (Reference Skuk and Schweinberger2014) examined the relative importance of four acoustic parameters – fundamental frequency, formant frequencies, aperiodicity and spectrum level – on voice gender perception. The strongest cue related to gender perception was fundamental frequency followed by formant frequencies and spectrum level. Aperiodicity did not influence gender perception.

part (b) (see Gelfer (Reference Gelfer1999) for discussion)

There is evidence that speaking rate and loudness are greater in men than in women (Brockmann et al., Reference Brockmann, Storck, Carding and Drinnan2008; Jacewicz et al., Reference Jacewicz, Fox and Wei2010). In order for LA to be perceived as female, it is likely that there will need to be some modification of her speaking rate and loudness.

LA's clinician will be aiming to avoid the use of clavicular breathing. This is the least efficient pattern of breathing for voice production. Clavicular breathing relies on the neck accessory muscles. The shoulders elevate during inhalation and breathing can be effortful.

Modifications of oral resonance in male-to-female transsexuals can increase perception of the speaker as female. Carew et al. (Reference Carew, Dacakis and Oates2007) examined the effectiveness of an oral resonance therapy that targeted lip spreading and forward tongue carriage in 10 male-to-female transsexuals. Listener ratings of recordings made pre- and post-therapy indicated that the majority of participants were perceived to sound more feminine following treatment.

(a) true; (b) false; (c) false; (d) false; (e) true

Male-to-female transsexuals are at an increased risk of voice disorder because they can develop maladaptive vocal patterns in an effort to achieve pitch elevation. The educational aspect of LA's intervention, and specifically the information that LA received about abusive vocal behaviours, is intended to reduce this risk.

LA's breathy voice quality might be explained by these endoscopic and stroboscopic findings.

LA's voice therapy was highly effective as it produced a significant improvement in her voice-related quality of life. LA's voice improved from a pre-therapy level where it was negatively affecting her life to a severe degree to a post-therapy level where she reported a positive change in attitude and self-perception.

If LA's suprahyoid and laryngeal tension had been allowed to persist, LA would have been placed at risk of developing a hyperfunctional voice disorder. Palmer et al. (Reference Palmer, Dietsch and Searl2012) reported that there were indications of vocal hyperfunction in all the male-to-female transsexuals in their study, either by self-report or on laryngeal examination.

High shimmer values confirm the impression of breathiness.

Upon completion of treatment, LA's mean fundamental frequency is just within the low end of the mean fundamental frequency range of natal females (i.e. 197–227 Hz).

LA's speaking rate decreased from 282 wpm at the start of therapy to 200 wpm by the end of therapy. This reduction in rate might have facilitated LA in making the modifications in tongue position that were necessary to bring about a change in resonance.

malformation of the ear ossicles; conductive hearing loss

hearing loss; intellectual disability

abnormalities of the semicircular canals

microtia; atresia of the external auditory canal. Atresia can cause a maximum conductive hearing loss of 40–50 dB (Ackley, Reference Ackley and Cummings2014).

cochlear hypoplasia

George was the second of triplets. Twinning and multiple births are risk factors for Goldenhar syndrome or OAVS.

Aspiration pneumonia is an infectious process caused by the inhalation of oropharyngeal secretions that are colonised by pathogenic bacteria. Its relevance to the speech-language pathologist is that it suggests the presence of dysphagia in clients.

OAVS is related to disturbances in the first and second branchial arches during embryogenesis. The key period for these disturbances to arise is 30–45 days of gestation (Gorlin et al., Reference Gorlin, Cohen and Hennekam2001: 790). This is very early in a pregnancy and long before George's mother was administered ritodrine at seven months in order to inhibit premature labour.

language development; motor development; cognitive development

parts (c) and (d)

Clefts of the lip and palate are also embryological malformations of the first and second branchial arches. This explains their presence alongside OAVS.

Three cerebral anomalies: (i) interventricular and periventricular haemorrhages; (ii) hydrocephalus; (iii) frontal and temporal cortical atrophy.

cerebrospinal fluid; ventricles

parts (a), (c) and (d)

parts (a) and (d)

George's difficulties with speech production are compromising his expressive language skills. This explains the receptive–expressive gap in his language performance.

George makes use of gestural and physical prompts to facilitate his impaired comprehension of language.

George has right ear atresia. So his responses on audiological testing cannot be on account of his right ear.

George's limited phonetic inventory is likely to be on account of (i) his malformed articulatory anatomy and (ii) his conductive hearing loss.

Velopharyngeal incompetence is the likely articulatory basis of George's hypernasal voice and audible nasal emission.

George did not have intellectual disability which would adversely affect language acquisition and limit progress in therapy.

George has intact pragmatic language skills at his second evaluation. He is able to use language appropriately, and displays a range of speech acts (e.g. requests).

At his first evaluation, George was only able to produce the bilabial and velar nasals (/m/, /ŋ/). At his second evaluation he is able to produce a number of other sounds in addition to these nasal sounds. These sounds include the alveolar nasal /n/, bilabial and velar plosives /b, k, g/ and the glide /w/.

Surgical intervention for velopharyngeal incompetence: palatoplasty

Prosthetic intervention for velopharyngeal incompetence: palatal lift or obturator

George had a behavioural age of 22.4 months on the Wisconsin Behavior Rating Scale. The WBRS uses a 3-point rating scale to assess each of the following areas: gross and fine motor skills; expressive and receptive language; play skills; socialisation; domestic activities; eating; toileting; dressing and grooming. Several of these areas (e.g. socialisation and play skills) are particularly sensitive to the deficits of autism. The fact that George achieved a score on this assessment which exceeded his chronological age of 19 months suggests that he does not have autism.

parts (b) and (d)

hyperbilirubinaemia (metabolic cause); neomycin (pharmacological cause)

parts (a), (c) and (d)

bound morphemes: -s (e.g. walks); -ed (e.g. walked); -ing (e.g. walking)

Duration of cochlear implant experience and the amount of hearing available to a child before implantation are significant factors in determining language outcome (Nicholas and Geers, Reference Nicholas and Geers2007).

Chelsea's lack of exposure to language during the developmental period was on account of her sensory (hearing) impairment. However, she was otherwise brought up in a supportive family environment where she received normal social stimulation from her parents and siblings. The situation of feral children is quite different. They have been exposed to situations of extreme neglect where social as well as linguistic stimulation is lacking.

Chelsea's social communication skills may have been protected on account of the normal social stimulation that she received within her family. As a key contributor to those skills, pragmatic language may also be relatively intact.

parts (a), (d) and (e)

At 32 years of age, there will be reduced plasticity of the auditory cortex. This will limit the capacity of the auditory cortex to process and recognise verbal and non-verbal auditory stimuli.

otoacoustic emission testing; automated auditory brainstem response testing

parts (b) and (e)

Even Chelsea's highest performance IQ of 89 falls short of the range 107 to 109 which is typical of deaf adolescents. Chelsea's lower performance IQ compared to deaf adolescents probably reflects her lack of formal education and amplification, both of which are normally accessed by deaf individuals.

parts (a), (c), (d) and (e)

The PPVT examines receptive vocabulary. Chelsea's performance on this test is facilitated by the use of signing. In August 1981, the test was conducted with and without signing. The use of signing increased Chelsea's vocabulary age by over one year.

(5) Alongside the comprehension of colours (red, green), shapes (circle, square) and actions (put, touch), these commends are assessing the comprehension of the following aspects of language:

1. (a) locative preposition ‘on’

2. (b) coordinating conjunction ‘or’

3. (c) conditional ‘if’

4. (d) adverbs ‘slowly’ and ‘quickly’

5. (e) two-word preposition ‘together with’

parts (b) and (d)

The fact that Chelsea's pragmatic skills are relatively intact in the presence of her limited language suggests that pragmatic competence is largely independent of linguistic competence.

maxim of quantity

Expressive prosody: The use of a specific intonation pattern may change a statement into a question. For example, when uttered with rising pitch at the end, the utterance ‘John is leaving tomorrow’ may be used to ask a question.

Receptive prosody: The hearer who can detect the placement of stress and increased vocal intensity on the word delightful in the utterance ‘What a delightful child!’ is able to establish that the speaker of this utterance intends it to stand as a sarcastic remark.

Chelsea exhibits a number of pragmatic skills which suggest that she has no deficits in theory of mind. The ability to introduce and develop topics in conversation, the ability to respond appropriately to speech acts such as directives, and the ability to use facial expressions appropriately all require the ability on Chelsea's part to attribute cognitive and affective mental states both to her own mind and to the minds of others. The fact that all three of these pragmatic skills are intact in Chelsea suggests that she has no deficits in theory of mind.

Chelsea is producing language at a single-word level. Her inability to link two words together suggests that she has not acquired the syntax of language. The single exception is ‘Don't think’ which, in its use of both an auxiliary verb and negative ‘not’, far exceeds the grammatical complexity of her other utterances in the exchange.

After such an extended period of auditory stimuli deprivation, Chelsea's articulation of speech is unlikely to be completely intact. However, on the basis of this short exchange, we can at least say that her speech production is not so poor that she is unintelligible to the interviewer. It is clear that the interviewer understands each of her single-word utterances, and does not have to ask her to repeat unintelligible words.

A number of the non-verbal behaviours that Chelsea uses have no communicative function, e.g. unwrapping the gift. However, other non-verbal behaviours do have a communicative function, such as when she shakes her head to indicate to the interviewer that she doesn't know what the gift is.

Chelsea displays an appreciation of the dyadic structure of conversation in that she exchanges turns appropriately with the interviewer. Chelsea also displays an appreciation of humour in conversation when she laughs at the interviewer's statement that she has tricked her. Chelsea also understands that there are politeness constraints at work in conversation when she thanks the interviewer for her gift.

When Chelsea utters ‘You…collar’, she is attempting to ask the interviewer about the scarf she is wearing (or a scarf she previously wore). This utterance sees Chelsea move beyond her role as a passive respondent in the exchange to one where she takes control, if only momentarily, by asking the interviewer a question.

parts (b), (c) and (e)

To achieve electrode placement during cochlear implantation, a postauricular mastoidectomy (removal of mastoid bone) is performed to gain access to the inner ear. A small opening is made in the cochlea (cochleostomy) anterior/inferior to the round window to permit placement of the electrode into the scala tympani.

Labyrinthitis ossificans is the formation of new bone in the fluid-filled scalae of the cochlea. The scala tympani in the basal turn of the cochlea is the most frequent area of ossification. This condition is a hindrance to cochlear implantation as it makes electrode insertion difficult. Accordingly, earlier implantation is recommended before significant ossification has occurred. Labyrinthitis ossificans related to meningitis is associated with the greatest amount of ossification (Green et al., Reference Green, Marion and Hinojosa1991).

Reading, spelling and writing are the aspects of language that contribute most to academic achievement. Evidence for improvements in these aspects of language following cochlear implantation is mixed. Geers and Hayes (Reference Geers and Hayes2011) examined reading, spelling and expository writing in 112 high school students who received cochlear implants as pre-schoolers. Although these adolescents performed within or above the average range for hearing peers on reading tests, they were poorer spellers and expository writers than hearing peers. Venail et al. (Reference Venail, Vieu, Artieres, Mondain and Uziel2010) reported delayed reading and writing in 19 of 74 (26%) prelingually deaf children who received cochlear implants before 6 years of age.

The contribution of an individual's cognitive ability to post-implantation gains is both supported and refuted by studies. Sarant et al. (Reference Sarant, Harris, Bennet and Bant2014) reported that higher cognitive ability was associated with significantly better language outcomes in 91 children with unilateral or bilateral cochlear implants. In a study of 114 postlingually deaf adult cochlear implant recipients, Holden et al. (Reference Holden, Finley, Firszt, Holden, Brenner, Potts, Gotter, Vanderhoof, Mispagel, Heydebrand and Skinner2013) found that cognitive ability was significantly and positively related to outcome, measured in terms of word recognition scores. However, after controlling for age, cognition no longer affected outcome.

parts (c) and (e)

PB satisfies the criterion that he derived no apparent benefit from the use of hearing aids.

We can tell that PB does not have hearing loss in the presence of a syndrome as he has no additional needs and is neurologically and intellectually age appropriate.

In relation to (i), there is evidence that clients who undergo unilateral cochlear implantation perform poorly in binaural hearing tasks such as speech understanding in the presence of background noise and the ability to localise the source of sounds. Bilateral cochlear implants can restore these abilities (Peters et al., Reference Peters, Litovsky, Lake and Parkinson2004). In relation to (ii), evidence is less definitive, as the benefits and disadvantages of sequential and simultaneous implantation have not been well researched: ‘there are no developmental studies that have examined the advantages and disadvantages of sequential versus simultaneous implantation in a systematic way’ (Sharma et al., Reference Sharma, Gilley, Martin, Roland, Bauer and Dorman2007: 218). For their part, Sharma et al. (Reference Sharma, Gilley, Martin, Roland, Bauer and Dorman2007) reported no difference between sequential and simultaneous implantation: ‘Our results suggest that bilateral implantation, whether simultaneous or sequential, occurring within the sensitive period of 3.5 years, takes place within a central auditory nervous system that shows a high degree of developmental plasticity’ (223).

Complications have been reported in 19% of cochlear implant recipients (Theunisse et al., Reference Theunisse, Mulder, Pennings, Kunst and Mylanus2014). Three such complications are bacterial meningitis, mastoiditis and facial palsy (Farinetti et al., Reference Farinetti, Gharbia, Mancini, Roman, Nicollas and Triglia2014).

The term ‘free field’ describes a region in space where sound may propagate free from any form of obstruction. It is a homogeneous medium that lacks boundaries or reflecting surfaces. The term ‘aided hearing’ describes an individual's hearing when using hearing aids or a cochlear implant. The term ‘binaural hearing’ describes the perception of sound by stimulation in two ears. Binaural hearing allows individuals to understand speech in silence and noisy conditions and is an essential requirement for spatial hearing and sound localisation.

Prior to implantation, PB displayed some aided hearing in the lower frequencies. Vowels are produced at these frequencies. Accordingly, they would have been the class of speech sounds that PB was able to perceive best prior to implantation.

The voiceless alveolar and velar plosives /t, k/ have frequencies between 2000 and 4000 Hz. The fricative sounds /f, s, h, ð/ have frequencies between 4000 and 8000 Hz. It is likely that PB would have been able to perceive all these speech sounds for the first time after implantation.

Sound localisation requires the use of binaural hearing. This hearing became available to PB for the first time following the fitting of his second cochlear implant.

parts (b), (c), (d) and (e)

(a) false; (b) true; (c) false; (d) false; (e) true

In closed-set tests, the number of response alternatives is limited to a small set, usually between 4 and 10 depending on the procedure used. By contrast, there is an unlimited number of response alternatives in open-set tests. Accordingly, open-set tests are more difficult for hearing impaired clients.

The audiologist who is using a word recognition test must ensure that the target words are all within the receptive vocabulary of the children assessed by means of the test.

Unlike the MTP test which only examines word recognition, the LiP Profile also examines phoneme recognition. Because of the reduced redundancy of phonemes, phoneme recognition is more difficult than word recognition. This greater difficulty may explain PB's reduced performance on the LiP Profile relative to the MTP test.

PB's LiP Profile scores suggest that he did not experience the ‘initial drop’ phenomenon. However, this phenomenon cannot be excluded based on these scores alone, as the LiP Profile scores of Sainz et al.'s subjects also did not show a decrease of auditory performance immediately after first fitting. A significant temporary decrease after initial fitting, however, was observed in the scores on the MTP test in Sainz et al.'s subjects. There was no evidence of a decrease in PB's MTP test scores at 12, 18 and 24 months.

1. (a) AWST-R; Word Production subtest of the SETK-2

2. (b) TROG-D; Sentence Comprehension subtest of the SETK-2

3. (c) Encoding of Semantic Relations subtest of the SETK 3–5

4. (d) Word Comprehension subtest of the SETK-2

5. (e) Morphological Syntax subtest of the SETK 4–5

Pragmatics is not assessed by the formal language tests that were used to evaluate PB. Yet, there is evidence that pragmatics can be impaired in implanted children who perform within normal limits on formal language tests. Nicastri et al. (Reference Nicastri, Filipo, Ruoppolo, Viccaro, Dincer, Guerzoni, Cuda, Bosco, Prosperini and Mancini2014) examined discourse inferencing skills and metaphor comprehension in 31 children with unilateral cochlear implants who attained a normal language level. There was no significant difference between these children's discourse inferencing skills and the inferencing skills of 31 normal hearing matched peers. However, children with cochlear implants performed significantly below their normal hearing peers in verbal metaphor comprehension.

PB has normal memory for sentences and a normal memory span for words. These results indicate that PB has intact phonological short-term memory.

The presence of developmental disabilities (e.g. autism) reduces the likelihood that a good language outcome will be achieved following cochlear implantation. Cruz et al. (Reference Cruz, Vicaria, Wang, Niparko and Quittner2012) examined 188 deaf children. Among these children, 85% had a single diagnosis of severe-to-profound hearing loss and 15% had an additional disability. Although deaf children with and without additional disabilities experienced significant improvement in their oral language skills post-implantation, children with developmental disorders such as autism made slower progress in language.

There is substantial evidence that hearing impaired children without implants experience elevated levels of behavioural problems. Barker et al. (Reference Barker, Quittner, Fink, Eisenberg, Tobey and Niparko2009) reported more behavioural difficulties in 116 severely and profoundly deaf children than in normally hearing children. The hearing impaired children in this study had all been referred for cochlear implant surgery. Even after cochlear implantation there is evidence of elevated levels of behavioural problems in children. Wu et al. (Reference Wu, Lee, Chao, Tsou and Chen2015) examined behaviour problems in 60 Mandarin-speaking children with cochlear implants. Significantly more children with implants had problems with aggressive behaviour and overall behaviour than in a normative sample.

(a) false; (b) true; (c) false; (d) true; (e) false

Two ways in which children with craniofacial anomalies are at an increased risk of (C)APD: (i) Many craniofacial anomalies occur in the context of syndromes in which there are CNS defects (e.g. Goldenhar syndrome). These defects can include (C)APD; and (ii) children with craniofacial anomalies are at an increased risk of otitis media with effusion. OME has also been linked to (C)APD.

Awareness of injury-related deficits is limited in children, adolescents and adults with TBI (Lewis and Horn, Reference Lewis and Horn2013; Lloyd et al., Reference Lloyd, Ownsworth, Fleming and Zimmer-Gembeck2015). This lack of awareness explains the failure of these subjects with closed head injury to report any signs of auditory impairment.

neurological aetiology – APD related to stroke-induced brain damage

neurodevelopmental disorder – APD in children with learning difficulties

(C)APD is likely to worsen over time in those individuals with neurodegenerative disorders such as Alzheimer's disease.

There is evidence that low birth weight is a risk factor for (C)APD. Davis et al. (Reference Davis, Doyle, Ford, Keir, Michael, Rickards, Kelly and Callanan2001) compared the audiological function of children with very low birth weight (< or = 1500g) to that of children with normal birth weight (> 2499g). Children with very low birth weight had higher rates of some central auditory processing problems than children of normal birth weight. There were no significant differences between these children in rates of hearing impairment, abnormal tympanograms, figure–ground problems or digit recall.

Normally developing infants are able to sit alone without support between 5 and 6 months. Sally started sitting at 10 months. Normally developing infants are able to walk while holding an adult's hand between 6 and 9 months. Sally was walking at 14 months.

Grommet insertion indicates that Sally has otitis media with effusion. OME is another risk factor for (C)APD.

The presence of low muscle tone (hypotonia) and frontal lobe epilepsy suggests that Sally's auditory processing problems may have a neurological aetiology. (C)APDs have been reported in a number of epilepsies including clients with temporal lobe epilepsy and generalised and partial seizures (Han et al., Reference Han, Ahn, Kang, Lee, Lee, Bae and Chung2011; Ortiz et al., Reference Ortiz, Pereira, de Carvalho Borges and Vilanova2009).

The IAM is the opening of the internal auditory canal, a canal in the temporal bone that transmits nerves and blood vessels from within the posterior cranial fossa to the hearing mechanism. An acoustic neuroma (or vestibular schwannoma) can be detected by a CT scan. This is a benign tumour that typically arises from the vestibular portion of the eighth cranial nerve. As an acoustic neuroma expands, it fills the IAM and compresses the cochlear and facial nerves.

parts (b), (c) and (e)

The WISC-III revealed that Sally has impaired short-term memory. This impairment might explain her reading difficulties. In a meta-analysis of studies that examined the academic, cognitive and behavioural performance of children with and without reading disabilities, Kudo et al. (Reference Kudo, Lussier and Swanson2015) found that short-term memory was one of a number of specific cognitive processes that significantly moderated overall group effect size differences.

part (d)

Regular words (e.g. ‘hit’) can be read by means of grapheme-to-phoneme rules. The lexicon does not need to be accessed in order to read these words but it can be accessed. Irregular words (e.g. ‘yacht’) can only be read by accessing the lexicon. If these words are read using grapheme-to-phoneme rules, mispronunciations will result. Non-words (e.g. ‘splank’) can only be read by using grapheme-to-phoneme rules as they have no entry in the lexicon. Because there are different reading routes for different types of words, each type must be separately examined in an assessment of reading.

As well as measuring receptive vocabulary, the PPVT-III has also been used to provide an estimate of verbal intelligence. This would explain why Sally's PPVT-III score is consistent with her WISC-III results. However, Strauss et al. (Reference Strauss, Sherman and Spreen2006) remark that ‘[a]lthough the PPVT-III is still used occasionally as an IQ estimate, its use in this way is not recommended’ (951).

1. (a) Visual reinforcement orientation audiometry (VROA) is suitable for infants who are developmentally 7 or 8 months to 3 years of age. The child is taught or conditioned to turn his or her head when a sound is heard. To achieve initial conditioning, stimuli are presented at moderately high levels, with the audiologist waiting until the child looks for the source of sound. As a reward, the child is shown a colourful, moving puppet or toy under illumination. This reinforces the child's turning behaviour or orientation. Once this conditioned response is reliable, stimuli can be presented at steadily decreasing levels until an auditory threshold is reached.

2. (b) In auditory brainstem response (ABR) audiometry, an evoked potentials measurement of the auditory nervous system is conducted. Through electrodes taped to the skull, signals are delivered to each ear independently. Microvolt sensory responses from the auditory nerve and brainstem are detected through these electrodes. Slight modifications of the auditory brainstem response technique permit measurement of the middle latency response, an evoked response that occurs between the brainstem and auditory cortex.

3. (c) Electrocochleography (ECoG) measures gross potentials that originate from the vicinity of the cochlea. These potentials include the cochlear microphonic and the summating potential, and the whole nerve action or compound action potential which corresponds to wave I of the ABR. A small needle electrode is placed through the tympanic membrane and on the promontory (the bulge in the medial wall of the middle ear, inferior to the stapes). The electrode may also be placed on the tympanic membrane and in the ear canal. The technique is most often used for intra-operative monitoring of the cochlea and the eighth cranial nerve and in the diagnosis of Ménière's disease.

4. (d) Otoacoustic emission testing is a technique which can be used to test for the presence of sensorineural hearing loss in newborns. It is based on the observation that the cochlea can actually generate sounds (technically, emissions) either spontaneously (spontaneous otoacoustic emissions) or in response to acoustic stimulation (evoked otoacoustic emissions). These emissions are absent in mild inner ear deafness.

5. (e) Computerised axial tomography (a CAT or CT scan) is a technique in which an x-ray source produces a narrow, fan-shaped beam of x rays to irradiate a section of the body. On a single rotation of the x-ray source around the body, many different ‘snapshots’ are taken. These are then reconstructed by a computer into a cross-sectional image of internal organs and tissues for each complete rotation. CT scanning has many uses in the management of otological disorders, including middle ear cholesteatoma, inner ear aplasia and mastoiditis related to chronic middle ear infection.

Tympanometry is a quantitative technique for measuring the mobility or compliance of the tympanic membrane as a function of changing air pressures in the external auditory canal. It can be used to establish middle ear pressure through the measurement of the amount of air pressure in the external auditory canal that is needed to achieve maximum mobility of the eardrum. Negative middle ear pressure is associated with middle ear pathology, specifically acute otitis media, which can cause conductive hearing loss.

Vowels are low frequency sounds (they extend a little above 1000 Hz), while consonants are high frequency sounds (they extend only a little below 1000 Hz). Sally's hearing is poorest at 500 Hz and 1 kHz, so the perception of vowels will be most compromised for her.

A CT scan might serve to eliminate the presence of an acoustic neuroma and perinatal encephalopathy. Both conditions are consistent with the ABR results obtained (Romero et al., Reference Romero, Méndez, Tello and Torner2008; Shih et al., Reference Shih, Tseng, Yeh, Hsu and Chen2009).

Sally's hearing aids provided amplification which was not required. If it continued, this amplification would cause noise-induced hearing loss through the destruction of outer and inner hair cells in the cochlea.

Difficulty listening in background noise is frequently reported by the parents of children with APD. In a study of 19 children with APD, Ferguson et al. (Reference Ferguson, Hall, Riley and Moore2011) reported that the most common difficulty indicated by parents of these children was listening in background noise. This difficulty occurred in 13 (68.4%) of children.

Sally achieved a score of 6 on the short-term memory task of the WISC-III when 7 to 13 is considered to be the average range. The behavioural observation that Sally has difficulty with auditory memory is consistent with this cognitive finding.

Sally's performance on the Frequency Pattern Test (FPT) and the Random Gap Detection Test (RGDT) fell outside the normal range. The FPT and the Duration Pattern Test (DPT) are both used in clinical settings to assess an individual's ability to discriminate temporal order or sequence in stimuli. In these tests, subjects are instructed that they will hear sets of three consecutive tones which vary in pitch or duration. Subjects are required to verbalise the tonal patterns by indicating the frequency patterns (e.g. high–low–high, low–low–high) and the duration patterns (e.g. long–short–long, short–short–long). The RGDT is used to assess temporal resolution in clinical settings: ‘Auditory temporal resolution ability enables the detection of changes in the duration of a sound stimulus and/or the detection of gaps inserted in an auditory stimulus’ (Dias et al., Reference Dias, Jutras, Acrani and Pereira2012: 175).

The FPT, DPT and the RGDT hold diagnostic significance for APD. In this way, Iliadou et al. (Reference Iliadou, Bamiou, Kaprinis, Kandylis, Vlaikidis, Apalla, Psifidis, Psillas and St Kaprinis2008) arrived at a diagnosis of CAPD in a young girl who was preterm at birth on the basis of severe deficits in three non-speech temporal tests – frequency and duration pattern tests and the random gap detection test.

Aaronson and Bernier (Reference Aaronson, Bernier and Volkmar2013) define mismatch negativity (MMN) as ‘an event-related potential evoked in response to a perceived change in sensory stimuli. It is commonly elicited in an oddball paradigm in which a standard stimulus is paired with a deviant stimulus, the standard being presented the majority of instances’ (1878). The reason that the absence of MMN for all sounds has uncertain diagnostic significance is that MMN can be absent in children with disorders other than APD. And even children with APD can display intact MMN. For example, Muniz et al. (Reference Muniz, Lopes and Schochat2015) reported that all typically developing children in their study exhibited an MMN response. However, so too did 84% of individuals in an APD group and 76% of individuals in a group with specific language impairment.

The Easy Listener personal FM system can be used with hearing aids or as a stand-alone hearing system. The device can help combat background noise, distance to sound source, and/or reverberation, all of which can interfere with speech understanding in individuals with APD. Johnston et al. (Reference Johnston, John, Kreisman, Hall and Crandell2009) examined children with APD who were fitted with FM devices for home and classroom use. Prior to FM use, these children exhibited significantly lower speech perception scores, decreased academic performance and psychosocial problems in comparison to a control group matched for age and gender. Following FM use, these children displayed improved speech perception in noisy classroom environments as well as significant academic and psychosocial gains. Moreover, after prolonged FM use, there was also improvement in the unaided (no FM device) speech perception of these children.

The higher prevalence of selective mutism in females than in males sets this condition apart from a range of disorders in speech-language pathology which are more commonly found in males. These disorders include communication disorders such as specific language impairment and developmental phonological disorder, and conditions such as ADHD and ASD which have communication deficits as part of their phenotype.

Children with a background of migration encounter a new language and culture in the areas in which they settle. A lack of proficiency in the new language of an area and a lack of familiarity with aspects of its culture may reduce these children to silence rather than be exposed to the negative reactions of members of the settled population.

It is too simplistic to attribute a direct, causal role to anxiety within the aetiology of selective mutism for three reasons. First, children can display anxiety but not develop selective mutism. Second, the co-occurrence of anxiety and selective mutism may be because anxiety is a consequence of a child having selective mutism. Third, the co-occurrence of anxiety and selective mutism may be on account of a third variable (e.g. genetic factors) which is an independent cause of both anxiety and selective mutism.

The mutism of these children makes it difficult for researchers and clinicians to obtain samples of expressive language for analysis. Children with selective mutism are unlikely to produce responses during language testing, participate in conversation with clinicians or generate extended language in the form of narratives. Audio- and video-recordings of children at home are often the only source of expressive language.

(a) true; (b) false; (c) false; (d) false; (e) true

A number of factors may explain the late referral of children with selective mutism. First, family physicians (general practitioners) and health visitors are usually the first professionals that parents turn to with concerns about their children's development and well-being. However, awareness of selective mutism among these professionals is low. Second, parents may discount their concerns because children with selective mutism continue to communicate normally at home. Third, communication disorders such as speech sound disorders often have significant implications for communication which cannot be easily overlooked (e.g. severe unintelligibility). These implications are not a feature of selective mutism, with the result that parents may be inclined to respond with less urgency to their children's mutism.

Even in the absence of spoken language Mimi displays a willingness to communicate with others through handwritten notes and the use of gestures.

The fact that Mimi's father spoke Spanish suggests that she has a background of immigration.

There are factors in Mimi's history which may have interacted with each other to produce her anxiety in speaking. Her mouth trauma led to a medical intervention (stitches). A later medical intervention for a high fever provoked considerable anxiety on account of the many needle sticks that Mimi received. By association Mimi may have come to link her anxiety around medical procedures to the mouth injury that necessitated some of these procedures and, ultimately, to the act of speaking itself.

Mimi's mother assumed the role of communicator for her daughter, thus removing any need for Mimi to communicate for herself. Mimi's mother also anticipated her every need and managed her life to such an extent that communication for Mimi became unnecessary.

Mimi's note reveals that she is able to use direct reported speech. She writes: ‘my mother told me “don't talk to strangers”’.

(2) Three communication milestones:

• Babbling (6–9 months)

• Use of first words (12–18 months)

• Use of two-word utterances (18–24 months)

It is likely that Mimi is engaging in the gliding of the liquids /l/ and /r/. The gliding of liquids normally resolves around 5 years of age. Its presence in a child of 9 years is a cause for concern.

(4) Three aspects of immature syntax:

• Omission of ‘is’ as a copular verb (e.g. ‘This [is] a boy’)

• Omission of determiner (e.g. ‘what [my] family do’)

• Omission of genitive (e.g. ‘This one[ʼs] name Andy’)

Because children with selective mutism do not have experience of conversation, they do not get practice in a range of conversational skills. These skills include turn-taking, conversational openings/closings, topic management and the use of a range of speech acts. These skills largely fall within the pragmatic domain.

(1) Three reasons why gains in Mimi's non-verbal communication skills are to be encouraged:

1. (i) Improved non-verbal communication can help Mimi to increase her classroom participation.

2. (ii) Non-verbal communication is Mimi's only means of expressing her needs and desires until vocalisation is achieved. In the absence of effective non-verbal communication, Mimi will experience frustration at her inability to communicate. Gains in non-verbal communication should be encouraged in order to avoid this scenario.

3. (iii) In the absence of speech, Mimi is at risk of becoming passive in communication, with other people assuming the role of communicator on her behalf. Gains in non-verbal communication will enable Mimi to play an active role in communication.

Stimulus fading is a behavioural technique which has been known for some time to be effective in the treatment of children with selective mutism. Wulbert et al. (Reference Wulbert, Nyman, Snow and Owen1973) used stimulus fading to treat a 6-year-old girl with selective mutism. This girl received reinforcement for responding to demands for verbal and motor responses in the presence of someone who already had stimulus control of such behaviour, while a stranger was slowly faded into stimulus control.

parts (a) and (c)

Shaping is another behavioural technique in the treatment of selective mutism. In this technique, the therapist reinforces mouth movements that resemble speech (Mendlowitz and Monga, Reference Mendlowitz and Monga2007).

Contingency management is a reinforcement strategy in behaviour therapy. It involves rewarding verbal behaviour and not reinforcing mute behaviour (Krysanski, Reference Krysanski2003).

(a) false; (b) false; (c) true; (d) true; (e) false

part (d)

Mimi displays good social communication skills. Mimi's classroom teacher reports that she is well-liked by other students, many of whom have attempted to help her with her mutism. As soon as whispering was established in therapy, Mimi used it to good effect by becoming a more active participant in the classroom and more animated in her conversational exchanges. Mimi's case demonstrates that good social communication skills are possible even in the absence of vocalisation.

(4) Mimi's speech and language problems appear to be making, at most, a relatively minor contribution to her mutism. Evidence in support of this claim includes:

1. (i) Mimi communicates freely and easily at home in spite of her immature speech and language skills.

2. (ii) Although Mimi's speech and language skills are impaired, they are still more than adequate for spoken communication to occur.

3. (iii) There is no evidence from either parental or teacher reports that Mimi experienced early communication failures with peers as a result of her immature speech and language skills. If these failures had occurred, they could have prompted an anxiety reaction around speaking, thus leading to mutism.

(5) Three reasons why speech-language pathologists should assess and treat children with selective mutism as part of a multidisciplinary team:

1. (i) The expertise of mental health professionals is needed to understand and manage the anxiety disorder of these children.

2. (ii) The input of other professionals (e.g. classroom teachers) is needed to identify behaviours which may perpetuate mutism in these children.

3. (iii) Skills acquired during speech-language intervention must be generalised to the classroom and wider community, and this requires the participation of professionals such as teachers.

(a) true; (b) false; (c) false; (d) true; (e) true

The fact that the concordance rate for ADHD in the monozygotic twin boys in the study by Lichtenstein et al. (Reference Lichtenstein, Carlström, Råstam, Gillberg and Anckarsäter2010) was 44% and not 100% shows that the aetiology of ADHD cannot be entirely genetic in nature.

parts (c) and (e)

It is important for speech-language pathologists to have knowledge of comorbidities in ADHD for two reasons. First, some comorbid conditions (e.g. speech disorder) are assessed and treated by speech-language pathologists. Second, other comorbid conditions (e.g. depression) might adversely affect an individual's communication skills and compliance with intervention.

part (d)

(a) true; (b) false; (c) true; (d) true; (e) true

Academic underachievement in ADHD is best accounted for by poor word reading and written expression in children with ADHD.

(a) hyperactivity–impulsivity; (b) inattention; (c) hyperactivity–impulsivity; (d) inattention; (e) hyperactivity–impulsivity

The child with ADHD is struggling with the following aspects of narrative production: (i) he fails to relate events in the correct temporal order (e.g. he describes how he left the house and got into the car before he got dressed and had his breakfast); (ii) he fails to use an indefinite noun phrase (e.g. ‘a woman’) for the first mention of characters. A listener could legitimately ask ‘what woman?’ and ‘what small boy?’.

part (b)

It is important for the speech-language pathologist to know the language(s) spoken in these children's home environments, as there is clear evidence that bilingual and multilingual home environments serve to exacerbate the extent of any language impairment. Cleave et al. (Reference Cleave, Girolametto, Chen and Johnson2010) found that dual language learners with SLI achieved lower scores on standardised tests of morphosyntax than monolingual children with SLI. Cheuk et al. (Reference Cheuk, Wong and Leung2005) found that a multilingual home environment is associated with SLI. In a sample of 326 children with SLI, multilingual exposure significantly reduced the language quotient and language comprehension standard score of children with SLI.

During language testing, children with ADHD might: (i) fail to listen carefully to instructions about how to perform tasks; (ii) initiate a response before a stimulus utterance has been fully issued; and (iii) might become distracted by background stimuli and lose focus on a task.

parts (a), (b) and (d)

Percentile scores indicate the percentage of individuals in the norm group who scored below the level of the cohort member. So a percentile score of 4 indicates that 4% of the norm group achieved a lower score on the OWLS than Adam. Similarly, a percentile score of 3 indicates that 3% of the norm group achieved a lower score on the OWLS than Abraham.

The OWLS assesses structural aspects of language. It does not examine pragmatic aspects of language and discourse.

Adam's first utterance in the extract is an example of a maze: ‘I went to my cousin's house and when I went to my cousin's house that was later when I when I we went back home for um from snow tubing.’ It contains repetitions (Adam repeats that he went to his cousin's house), fillers (‘um’), and revisions (after repeating ‘when I’, Adam revises his utterance to become ‘we went back home’).

There is evidence that Adam understands indirect speech acts. When the teacher says ‘Can you tell us about snow tubing?’, Adam clearly interprets this utterance as a request on the part of the teacher and not as a question about his ability to describe snow tubing.

Structural language deficits: (i) ‘a hooks’ – Adam uses an indefinite article with a plural noun; (ii) ‘you got hold’ – Adam uses the past tense verb ‘got’ instead of the present tense verb ‘get’; (iii) ‘you got hold onto a rope’ – Adam uses the preposition ‘onto’ instead of the preposition ‘of’.

‘they have a machine’ (the referent of the pronoun ‘they’ cannot be identified)

‘you tell my parents from up there’ (the referent of the adverb ‘there’ cannot be identified)

‘he spins you’ (the referent of the pronoun ‘he’ cannot be identified)

Adam is a highly sociable child who is liked by teachers and peers alike. Notwithstanding his language difficulties, he clearly enjoys relating stories to others and wants to communicate. His strong social skills and desire to communicate indicate that a diagnosis of ASD is not appropriate in his case.

In the utterance ‘I throw the ball at my baby brother’, Abraham uses the present tense verb ‘throw’ instead of the past tense ‘threw’. Although Abraham is unable to use the correct past tense form of an irregular verb in this instance, on other occasions he is able to make use of irregular past tense verbs, e.g. ‘he took the pillow’.

(a) true; (b) true; (c) true; (d) false; (e) false

(3) Two conjunctions:

• ‘so he can play with it’ (‘so’ is short for ‘so that’ which has the meaning reason or explanation)

• ‘then he took the pillow’ (‘then’ has a temporal meaning)

Abraham makes most use of the conjunction ‘then’.

Abraham displays a sophisticated appreciation of the mental states of others in two ways. First, he understands the teacher when she asks him if his baby brother liked having the ball thrown at him. Second, Abraham is able to use his brother's laughter to establish that his mental state is one of enjoyment.

In Abraham's final turn in the extract, he uses the pronoun ‘I’ when he should be using ‘he’ to describe the actions of his brother – he said ‘look out’ and he threw the pillow.

Side effects of clozapine that must be addressed by the speech-language pathologist include sialorrhoea (drooling) and stuttering.

parts (a), (c) and (e)

part (d); poverty of speech

part (d)

part (c)

A discourse analytic approach is advisable because clients with schizophrenia exhibit anomalies in areas such as topic management and reference. These areas cannot be adequately assessed using sentence-level formats (as in standardised language batteries) or even by examining local sequences in isolated adjacency pairs.

(2) The two parts of an adjacency pair need not be consecutive turns. For example, in the following conversational exchange, the response to the question in turn 1 is not forthcoming until turn 4. What intervenes is another question–answer adjacency pair in turns 2 and 3.

1. 1 A: How much is a scotch on the rocks?

2. 2 B: Would you like a small or large?

3. 3 A: A large

4. 4 B: It's £5.99

1. (a) relevance; quantity (over-informative)

2. (b) quantity (under-informative)

3. (c) manner

4. (d) relevance; quantity (over-informative)

5. (e) quantity (under-informative)

1. (a) The speaker does not indicate which type of poultry (turkey or chicken) he would like. There is missing propositional content.

2. (c) The referent of the pronoun in ‘She has such a gorgeous house’ is unclear – it could be either Sue or June. There is vague propositional content.

B's utterance is an infelicitous turn, in that it completely violates the expectations of A in the exchange.

The client's turn was judged to be deviant because it involved ‘unexpected associations of topics’. The topics in question are the client's paranoid experiences and music.

1. (a) Ellipsis: ‘they don't [leave me alone]’

2. (b) Anaphoric reference: ‘my mother has to behave herself, but…she is sometimes discourteous in her words and she can be a bit rude’.

After an appropriate response to the doctor's initial question, the speaker with schizophrenia pursues a sequence of topics which is characterised by linguistic and other associations between key words and ideas. The speaker's introduction of the topic of his name is somewhat irrelevant as a response to the doctor's question about ‘special abilities’ and is the start of a chain of topics that is increasingly difficult to follow. After stating that people laugh at his name, and then being unable to clarify this remark for the doctor, the speaker abruptly changes topic to begin talking about people from a certain area. The trigger for this topic change appears to be the fact that people from the area in question have the same name as the speaker's family name. There is then a remark that the speaker's name (this is somewhat unclear) is ‘a kind of sacred relic’. When asked by the doctor to clarify this remark, the speaker with schizophrenia shifts the topic again to talk about a town called X which is seen on the news. He then returns to the topic of his name by stating that, if he had a choice, he would rather be known as Marko. When pressed by the doctor about the reason for a name change, the speaker indicates that it would be ‘cool’ to have this new name. The entire sequence is characterised by a gradual, radial extension of topics.

(4) The propositional content of these utterances in extract 2 is vague:

In the first utterance, it is unclear if the pronoun ‘it’ refers to the name or location. The intended referent of the subsequent demonstrative pronoun ‘that’ is similarly unclear. In the second utterance, the client employs substitution on two occasions in his use of ‘one’. The first use of ‘one’ appears to refer to a relic. However, it is unclear if the second use of ‘one’ refers to a relic or being an inhabitant of a certain area.

In extract 2, the client exhibits difficulty with the quality maxim when he twice makes the erroneous statement that X is the town.

(1) Referential anomalies are evident in the following utterances:

• ‘they watch it and such like that’ – ‘they’ most likely refers to some people and ‘it’ most likely refers to soccer. However, there is no clear referent of ‘that’.

• ‘They are a bit like a group of their own and such. They are jobless’ – the first use of ‘they’ and ‘their’ appear to refer to trades/professions. However, there is no clear referent of the second use of ‘they’, although it must refer to people who practice trades/professions if it is to make sense in this context.

• ‘Well, I'm thinking about these kind of things’ – there is no clear referent of ‘these’, as is evidenced by the fact that we are left asking ‘What kind of things?’

(2) Vague and non-specific vocabulary is evident in the following utterances:

• ‘they are stars and the like’

• ‘I'm thinking about these kind of things’

• ‘I do watch something’

• ‘A group of people can come up with wise things’

• ‘things are not like that now’

1. (a) Topicalisation: ‘Trades/professions I kind of think about’

2. (b) Ellipsis: ‘but I am not [better educated]’

3. (c) Anaphoric reference: ‘some people, well they are stars’