Albania State Exam - Speech Therapist cheat sheet

Cranial nerves for speech: V (trigeminal, jaw/lips), VII (facial, lip rounding and facial expression), IX (glossopharyngeal, pharyngeal constriction), X (vagus, palate and vocal folds via recurrent laryngeal nerve), XII (hypoglossal, tongue).

The larynx has three functions: airway protection during swallow, respiration, and phonation; the cricothyroid (external branch of superior laryngeal nerve) raises pitch, while the thyroarytenoid (recurrent laryngeal nerve) lowers pitch and adducts the folds.

Myoelastic-aerodynamic theory (van den Berg): vocal folds vibrate because of subglottal pressure plus tissue elasticity, not because of active muscle contraction per cycle.

Source-filter theory: the larynx generates a harmonic source; the vocal tract filters it into formants F1 (inversely related to tongue height) and F2 (related to tongue front-back position).

Velopharyngeal closure is achieved mainly by levator veli palatini plus the superior pharyngeal constrictor (Passavant ridge); failure produces hypernasality and nasal emission.

Auditory pathway order: cochlea → spiral ganglion → cochlear nucleus → superior olivary complex → lateral lemniscus → inferior colliculus → medial geniculate body → primary auditory cortex (Heschl gyrus).

Conductive hearing loss reduces sound reaching the cochlea; sensorineural loss reflects cochlear or retrocochlear damage and typically shows recruitment and reduced speech discrimination.

The outer hair cells sharpen frequency tuning (cochlear amplifier); inner hair cells are the primary transducers synapsing with most type I afferent fibers.

Prelinguistic sequence: cooing (~2 months), canonical babbling (~6-9 months), variegated babbling and jargon (~10-12 months); canonical babbling is a strong predictor of later phonology.

First words around 12 months; 50-word vocabulary and two-word combinations around 18-24 months; vocabulary spurt follows the naming insight.

Brown's morphemes emerge in a fairly fixed order: present progressive -ing, in, on, plural -s, irregular past, possessive 's, uncontractible copula, articles, regular past -ed, third-person -s, contractible auxiliary.

Mean length of utterance (MLU) is computed as total morphemes divided by number of utterances; MLU 1.0-2.0 = Brown stage I, ~4.0 by age 4.

Phonological processes (final consonant deletion, reduplication, fronting, stopping) are suppressed in a predictable sequence, mostly by age 3-4; cluster reduction may persist to age 5-6.

Comprehension typically precedes production; a child normally understands more than they can say at every stage.

Joint attention and gesture use at 12-18 months predict later expressive language; absence of pointing by 18 months is a red flag for autism spectrum disorder.

Critical/sensitive period for first-language acquisition is strongest before puberty; severe deprivation after that window results in persistent grammatical deficits.

DSM-5 language disorder: persistent difficulty in acquisition and use of language across modalities, below age expectations, not attributable to hearing loss or intellectual disability, with onset in the developmental period.

Speech sound disorder classification: articulation (motor production), phonological (rule-based pattern errors), and childhood apraxia of speech (inconsistent errors, groping, prosodic impairment).

Developmental language disorder (DLD) is diagnosed when language deficits are not explained by another biomedical condition; prevalence ~7% of children.

Autism spectrum disorder: deficits in social communication plus restricted/repetitive behaviors; speech therapy targets joint attention, pragmatics, and functional communication.

Intellectual disability: language follows a slower but more typical sequence; Down syndrome shows relative strength in vocabulary and weakness in morphosyntax.

Selective mutism is an anxiety-based failure to speak in specific settings, not a language disorder; treatment is behavioral (stimulus fading) plus CBT.

Stuttering in children: ~80% recover spontaneously; risk factors for persistence include family history, male sex, onset after 3.5 years, and concomitant disorders.

Hearing screening is mandatory before diagnosing a pediatric language disorder; undetected mild-moderate loss can mimic DLD.

Broca aphasia: nonfluent, effortful speech, agrammatism, relatively preserved comprehension, right hemiparesis; lesion in left inferior frontal gyrus (Brodmann 44/45).

Wernicke aphasia: fluent, paraphasic speech with poor comprehension and poor repetition; lesion in left posterior superior temporal gyrus.

Conduction aphasia: fluent speech, good comprehension, markedly impaired repetition; lesion in arcuate fasciculus.

Global aphasia: severe deficits in all modalities; large left-hemisphere lesion involving frontal, parietal, and temporal cortex.

Dysarthria types: flaccid (LMN), spastic (UMN/bilateral), ataxic (cerebellar), hypokinetic (basal ganglia, Parkinson), hyperkinetic (basal ganglia, Huntington), mixed (ALS).

Apraxia of speech: impaired planning/programming of articulation with groping, inconsistent errors, and preserved automatic speech; distinct from dysarthria (execution) and aphasia (language).

Aphasia severity is measured with the Western Aphasia Battery (WAB) or Boston Diagnostic Aphasia Examination; aphasia quotient (AQ) summarizes severity.

Right-hemisphere damage causes aprosodia, neglect, and pragmatic deficits; left-hemisphere damage causes aphasia.

Voice evaluation includes perceptual (GRBAS or CAPE-V), acoustic (jitter, shimmer, harmonics-to-noise ratio), aerodynamic (maximum phonation time, s/z ratio), and laryngeal imaging.

Maximum phonation time norms: adult males ~15-25 s, adult females ~10-20 s; s/z ratio >1.4 suggests glottal incompetence.

Vocal fold nodules are bilateral, symmetric, at the junction of anterior and middle thirds; associated with phonotrauma; treated with voice therapy first.

Spasmodic dysphonia: adductor type (strained-strangled, breaks on vowels) treated with botulinum toxin injections into thyroarytenoid; abductor type (breathy breaks).

Pubertal voice change: mutation falsetto from incomplete laryngeal adjustment; therapy targets lowering pitch and coordinating airflow.

Stuttering definitions: repetitions, prolongations, blocks; secondary behaviors (eye blinks, head movements) and avoidance develop after the core behaviors.

Fluency shaping (prolonged speech, easy onset, light contact) versus stuttering modification (cancellation, pull-out, preparatory set) are the two main treatment approaches.

Cluttering: rapid, disorganized speech with excessive normal disfluencies and poor self-monitoring; distinct from stuttering.

Pure-tone audiometry thresholds: normal ≤25 dB HL; mild 26-40; moderate 41-55; moderately severe 56-70; severe 71-90; profound >90 dB HL.

Speech banana: most speech energy lies between 250-4000 Hz and 30-60 dB HL; hearing loss in this region impairs speech perception.

Tympanometry types: Type A (normal peak), Type B (flat, effusion or perforation), Type C (negative pressure, Eustachian dysfunction), Type As (shallow), Type Ad (deep).

Otoacoustic emissions (OAEs) reflect outer hair cell function; absent OAEs with normal middle ear suggests cochlear loss.

Auditory brainstem response (ABR) is used for newborn screening and retrocochlear assessment; wave V latency increases with lower stimulus intensity.

Aided audibility is verified with real-ear measurement (REM) and speech mapping; target is speech at conversational level across 500-4000 Hz.

Cochlear implants are indicated for severe-profound bilateral sensorineural loss with limited benefit from hearing aids; outcomes depend on age at implantation and auditory training.

Speech perception in noise is more affected than in quiet for sensorineural loss; signal-to-noise ratio is a key classroom accommodation.

Four phases of swallow: oral preparatory, oral transit, pharyngeal, esophageal; the pharyngeal phase is involuntary and lasts ~1 second.

Signs of aspiration: coughing, choking, wet voice, throat clearing, desaturation, recurrent pneumonia; silent aspiration produces no overt signs.

Bedside swallow evaluation (clinical) versus instrumental: videofluoroscopic swallow study (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES).

Penetration-aspiration scale (PAS) 1-8: 1 = no penetration, 8 = silent aspiration below the vocal folds.

Diet texture levels follow IDDSI framework (0 thin liquids through 4 pureed, 5-7 solids); thickened liquids slow bolus transit.

Mendelsohn maneuver elevates the larynx and prolongs UES opening; supraglottic swallow closes the airway before and after the swallow.

Pediatric feeding disorder criteria: failure to meet nutrition/hydration needs, growth faltering, or psychosocial dysfunction; often multifactorial.

Dysphagia after stroke is common; early screening reduces aspiration pneumonia; nil per os (NPO) decisions require instrumental confirmation when possible.

Assessment domains: case history, standardized testing, dynamic assessment, language sample, and observation across settings.

Standard scores: mean 100, SD 15 (most language tests); scaled scores mean 10, SD 3; T-scores mean 50, SD 10; percentile ranks are not interval data.

Standard error of measurement (SEM) = SD × √(1 − reliability); confidence intervals around obtained scores account for measurement error.

Diagnosis requires converging evidence: standardized scores below −1.5 to −2 SD, functional impact, and exclusion of alternative explanations (hearing loss, intellectual disability).

Dynamic assessment (test-teach-retest) distinguishes language difference from disorder, especially for bilingual children.

Language sample analysis: MLU, type-token ratio, mean length of longest utterance, and narrative macrostructure; preferable to single standardized tests for pragmatics.

Differential diagnosis of stuttering vs. cluttering vs. normal disfluency relies on frequency, type, awareness, and secondary behaviors.

Clinical reasoning frameworks: hypothesis testing, ICF (impairment, activity, participation), and evidence-based practice (best evidence + clinical expertise + client values).

Evidence-based practice triangle: best available research, clinician expertise, and client values/preferences; all three must be considered.

Aphasia treatment approaches: impairment-based (Constraint-Induced Language Therapy, melodic intonation therapy), functional/compensatory (PACE, supported conversation), and group therapy.

Dysarthria treatment: rate control (pacing boards, delayed auditory feedback), effort closure exercises, LSVT LOUD for hypokinetic dysarthria (high-effort loud phonation).

Apraxia of speech treatment: articulatory-kinematic approaches (PROMPT, Sound Production Treatment) and intersystemic facilitation/reorganization.

Speech sound disorder treatment: traditional articulation therapy, phonological contrast approaches (minimal pairs, cycles), and motor-based approaches for CAS.

Voice therapy: resonant voice therapy, vocal function exercises, Lee Silverman Voice Treatment; hygiene and vocal rest for phonotrauma.

Fluency shaping versus stuttering modification; the Lidcombe Program is a behavioral treatment for preschool children using parent-delivered contingencies.

AAC: unaided (gestures, sign) versus aided (low-tech boards, high-tech SGDs); consider when natural speech is insufficient for functional communication.

Informed consent: client must understand purpose, risks, benefits, and alternatives before assessment or treatment; documented in the record.

Confidentiality: disclose only with client consent or as required by law (mandatory reporting of abuse, court order, danger to self/others).

Scope of practice: speech therapists assess and treat communication and swallowing disorders; do not practice outside training or licensure.

Dual relationships and conflicts of interest must be avoided; gifts and bartering are generally discouraged.

Record keeping: maintain accurate, timely, and secure documentation; retention periods follow local law and institutional policy.

Supervision of assistants and students: the supervising clinician retains legal and ethical responsibility for services.

Cultural competence and non-discrimination: services must be provided without bias based on race, ethnicity, language, disability, or socioeconomic status.

Referral and interprofessional boundaries: refer when the client's needs exceed competence or require medical/psychological expertise.

Team models: multidisciplinary (parallel, separate goals), interdisciplinary (shared goals, regular communication), and transdisciplinary (role release, single service provider).

Collaboration partners for speech therapy: ENT, neurology, audiology, pediatrics, psychology, education, occupational therapy, and physical therapy.

Counseling microskills: active listening, open questions, paraphrasing, reflecting feelings, summarizing, and silence.

Client-centered counseling (Rogers): empathy, unconditional positive regard, and congruence facilitate change; avoid advice-giving and premature reassurance.

Motivational interviewing: OARS (open questions, affirmations, reflections, summaries); elicit change talk and roll with resistance.

Breaking bad news and goal-setting: use shared decision-making, plain language, teach-back, and written materials at appropriate reading level.

Family-centered practice in pediatrics: parents are partners in goal-setting; consider family routines, culture, and language.

Interpreter use: trained medical interpreters, not family members, for clinical communication; document interpreter use.