I. NECK-HELD INSTRUMENTS

 A. Demonstrate how instrument sounds without speech & then with speech.

 B. Palpate pt's neck to locate most supple area & place instrument there.

 C. Instruct Pt to count while you manipulate button for sound production.
      * Best areas are under the jaw & just lateral to midline of neck.
      * Try cheek to see if clearer production is produced.
      * Head of instrument must be place so full head is in contact with skin.
      * It's not necessary to press device into neck, but the seal must be complete.
      * Escape of sound is noisy & interferes with intelligibility.

 D. Instruct Pt to shape words as clearly as possible but without exaggeration.

 E. Caution Pt against forceful exhalation accompanying speech attempt.
      * Movement of mouth to shape words is primary importance.

 F. If acceptable sound is elicited, then instruct Pt in handling instrument.
      * Check handedness of pt; instruct using the opposite hand.
      * May need a mirror to identify correct placement of instrument.
      * Make an 'X' on client's supple area and do target practice.
 
 G. Instruction on proper usage of instrument include:
      1. coordination between the finger and the mouth so speech & sound begin & end simultaneously
      2. learning to turn off sound during natural pauses in speech (not staccato)
      3. learning to reduce speech rate
      4. learning to increase precision of articulation

 H. Instruction in articulation should begin with production of voiceless consonants.
      * Pt cannot produce sounds such as /s, f / with continuous stream of air.
      * Must be produced by using the air within mouth as short bursts of sound.
      * Instruct to practice producing all voiceless consonants sharply.

 I. Articulation practice may extend to clear production of voiced sounds.
      * Have pt practice words that contain a particular sound while using instrument and listening carefully for that sound.

 J. May need to instruct Pt in phrasing.
      * Note if pt routinely keeps sound on throughout long utterances.
      * Teach to phrase sentences without interruption of sound at phrase break.
      * If staccato style of speech, teach to use a flow of speech with uninterrupted sound for entire phrase.

 K. Coordination between manual initiation & cessation of sound & movement of mouth is important.
      * Note if pt begins speaking before starting sound or continues speaking after having released sound.
      * Note if pt begins releasing sound before mouth stars to move or continues the release of sound after mouth stops moving.
      * Call to pt's attention right away.

 L. Pay attention to nonverbal behaviors.
      * Instruct Pt to look directly at person who they are speaking.
      * Eliminate any extraneous or superfluous mannerisms quickly.

II.        ORAL TYPES OF INSTRUMENTS

A Demonstrate how instrument sounds without speech and then with speech

B. Demonstrate proper placement of oral tube
     *   ~ 1 to 1 ½ inches of tube must be placed within mouth on top of tongue
                                     (not just tip of tube)
     *  Have pt experiment with placement of tube; can be inserted from corner of mouth and lie across tongue or can enter at
         midpoint of mouth (make sure tongue does not block tip of tube)

C. Stress clarity of articulation without forceful exhalation
     *  Pt must learn to move mouth as naturally as possible
     *  Pt can't hold onto tube with tongue & lips and produce intelligible speech

D. Practice on voiceless consonants
     *  Pt must learn to produce sounds in presence of object in mouth at all times
     *  Some sounds (such as /s/) may require that pt bite down on tube

E. Instruct coordination of sound with movement of nouth, cessation of sound for natural pauses, & reduce rate of speech

F. Note nonverbal behaviors
     *  Make sure pt doesn't hold their hand in front of mouth as they speak
     *  Good eye contact should be maintained between speaker and listener