Telepractice Treatment of Residual Rhotic Errors Using App-Based Biofeedback: A Pilot Study

Protocol for visual-acoustic intervention with service delivery in-person and via telepractice (VISIT) non-inferiority trial for residual speech sound disorder

BACKGROUND

Residual speech sound disorder (RSSD) is a high-prevalence condition that negatively impacts social and academic participation. Telepractice service delivery has the potential to expand access to technology-enhanced intervention methods that can help remediate RSSD, but it is not known whether remote service delivery is associated with a reduction in the efficacy of these methods. This project will systematically measure the outcomes of visual-acoustic biofeedback intervention when delivered in-person or online.

METHODS/DESIGN

This project, Visual-acoustic Intervention with Service delivery In-person and via Telepractice (VISIT), aims to treat 76 children in a parallel randomized controlled clinical trial in which children with RSSD will receive visual-acoustic biofeedback treatment either in person or via telepractice. Eligible children will be speakers of American English aged 9-17 years who exhibit RSSD affecting /ɹ/ but otherwise show cognitive-linguistic and hearing abilities within the typical range. All participants will receive twenty sessions of visual-acoustic biofeedback; they will be randomized, with stratification by pre-treatment speech production ability and site, to complete their treatment sessions either in the laboratory setting or at home via telepractice. For the primary outcome measure, blinded listeners will evaluate changes in the perceived accuracy of /ɹ/ production after the end of treatment.

DISCUSSION

By comparing outcomes in children randomized to receive a standard course of biofeedback treatment either via telepractice or in-person, this study will provide evidence-based guidance for clinicians seeking flexible service delivery options for a challenging and prevalent condition.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT06517225, 07/23/2024. URL: https://clinicaltrials.gov/study/NCT06517225 .

Back to Normal or New Reality? How the COVID-19 Pandemic Continues to Influence School-Based Speech-Language Pathologists at the Start of the 2023-2024 School Year

PURPOSE

The COVID-19 pandemic was a far-reaching disruptor in K-12 education beginning in the spring of 2020 when nearly all schools pivoted to remote instruction. Although the pandemic was officially declared over by the World Health Organization in May 2023, many questions remain about the long-term impact of the pandemic on K-12 education. The purpose of this study was to gain a deeper understanding of the continued impact of the pandemic among school-based speech-language pathologists (SLPs) at the onset of the 2023-2024 school year.

METHOD

This study involved a survey of 193 school-based SLPs between September and December 2023. The results of the survey were analyzed both qualitatively and quantitatively to identify key themes and trends related to how the pandemic influences both their direct work with students and how they approach and reflect on their own careers. Multiple efforts were made to ensure the credibility and trustworthiness of the analysis.

RESULTS

This survey found that although many SLPs in public schools have largely returned to prepandemic practices, most perceived that the pandemic continues to influence their work in key ways. Specifically, survey responses highlighted the altered needs of students (e.g., social-emotional needs and academic gaps) as well as changes to how SLPs reflect on their careers as professionals serving communities.

CONCLUSION

The results of this study indicate that although the most obvious effects of the pandemic are no longer visible in schools (e.g., masking, distancing, relying on virtual services), the pandemic continues to make the work of school-based SLPs more challenging as they navigate the disconnect between the postpandemic demands of their work and prepandemic expectations, policies, and regulations.

A Randomized Controlled Trial of Treatment Distribution and Biofeedback Effects on Speech Production in School-Age Children With Apraxia of Speech

PURPOSE

This study examines how ultrasound biofeedback and intensive treatment distribution affect speech sound generalization during an evidence-based treatment, Speech Motor Chaining, for children with persisting speech errors associated with childhood apraxia of speech (CAS).

METHOD

In a 2 × 2 factorial randomized controlled trial, children ages 9-17 years meeting CAS criteria were randomized to receive (a) a distributed treatment (20 sessions twice weekly over 10 weeks) or intensive treatment (20 hr in 5 weeks, with 10 hr in Week 1) and (b) treatment with or without biofeedback. Due to the COVID pandemic, some participants were randomized to distributed/intensive telepractice treatment only. The primary outcome was percent target sounds correct on untreated phrases (i.e., generalization) at the 10-week time point. More than 50,000 narrow phonetic transcriptions were analyzed.

RESULTS

Forty-eight participants completed treatment. Intensive treatment significantly increased generalization at all time points. The effect of biofeedback was significant at 5 weeks from the start of treatment but not significant at the primary 10-week time point. However, when comparing each group immediately after their 20 hr of treatment finished, generalization was significantly greater in intensive over distributed treatment and greater in ultrasound over no-ultrasound treatment (with a significant interaction favoring intensive treatment with ultrasound). Only the advantage of intensive treatment remained significant 5 weeks after groups finished treatment. There was no significant difference between face-to-face and telepractice modalities.

CONCLUSIONS

When the number of treatment hours is fixed, an intensive schedule of Speech Motor Chaining facilitated greater improvement than a distributed schedule. Ultrasound biofeedback initially accelerated learning, but the benefits may dissipate as treatment continues or after it ends.

Introducing a novel clinical tool to describe child engagement in telehealth speech and language assessments

Purpose: Telehealth may be a solution to access barriers in speech-language pathology. Previous investigations of telehealth assessment have alluded to factors affecting children's engagement, though these factors have not been comprehensively described.Aim: This study aimed to develop a novel clinical tool to describe the factors affecting children's engagement in paediatric telehealth assessments.Method: The Factors Affecting Child Engagement in Telehealth Sessions (FACETS) tool was developed using a mixed methods approach. Iterative analysis was conducted through a qualitative evidence synthesis, followed by the application of the tool to seven children aged between 4;3 and 5;7 years old who participated in a speech and language assessment via telehealth. Descriptive data were obtained regarding engagement on both a child-by-child and task-by-task basis. Reliability of the FACETS was determined via percent agreement and Cohen's kappa between two independent raters.Result: Using a mixed methods design, the FACETS framework was developed and refined. Application of the tool to seven case studies revealed variability in engagement with acceptable inter-rater reliability.Conclusion: The FACETS may be a useful resource for describing the factors that influence children's engagement in telehealth during the assessment. The FACETS requires further testing with clinical populations.

Intervention for residual speech errors in adolescents and adults: A systematised review

When speech sound errors persist beyond childhood they are classified as residual speech errors (RSE) and may have detrimental impacts on an individual's social, educational and employment participation. Despite this, individuals who present with RSE are usually not prioritised on large caseloads. The aim of this literature review was to examine what intervention approaches are available in remediating RSE, and how effective are they for adolescents and adults? A systematised review was undertaken. Comprehensive and systematic searching included search of terms across seven databases, forward and reverse citation searching, and key author contact. Thirty articles underwent critical appraisal before data extraction. Inductive thematic analysis was done before completion of a narrative review. Twenty-three (76.6%) of the articles were from the US and most studies involved intervention for 'r' (90%). Intervention approaches for RSE involved traditional articulation therapy, auditory perceptual training, instrumental approaches, and approaches based on principles of motor learning. Twenty-one studies (70%) investigated the use of more than one intervention approach. Measures of intervention efficacy varied between studies; however, any intervention approach tended to be more successful if delivered in a more intensive schedule. A variety of approaches can be used for RSE, but a combination of high intensity, traditional therapy with adjunctive instrumental biofeedback may be most effective, especially with highly motivated individuals. Unfortunately, this usually requires costly equipment and training to implement. More information about the best dosage and intensity intervention for RSE, evaluated for a larger number of phonemes across other languages and dialects is required.

Traditional and Visual-Acoustic Biofeedback Treatment via Telepractice for Residual Speech Sound Disorders Affecting /ɹ/: Pilot study

Purpose

This study aimed to examine the feasibility of telepractice delivery of a treatment package including visual-acoustic biofeedback and motor-based treatment for residual speech sound disorder affecting /ɹ/ in school-age children. The overall study used a single-case randomization design; however, this preliminary report will simply quantify changes in accuracy before and after completion of the treatment package. The present analysis did not differentiate between the relative contributions of biofeedback and motor-based treatments.

Method

Seven children aged 9-14 received speech therapy for /ɹ/ distortions via telepractice. The study design consisted of three phases: baseline (four sessions), treatment (20 sessions), and post-treatment (three sessions). Treatment included two sessions weekly for a duration of 10 weeks. The participants received one motor-based/non-biofeedback session and one visual-acoustic biofeedback session per week. The order of treatment within each week was randomly determined prior to the start of therapy. Overall progress was assessed using untrained listeners' ratings of word probes administered in the baseline and posttreatment phases.

Results

Findings revealed that six of the seven participants showed a clinically significant response to the overall treatment package, although the magnitude of individual responses varied across speech contexts (consonantal and vocalic) and participants.

Conclusion

The present results suggest that a treatment combining visual-acoustic biofeedback and motor-based treatment for residual /ɹ/ errors treatment can be effectively delivered via telepractice. Considerations for technology setup and treatment protocols are provided.

The Multilevel Word Accuracy Composite Scale: A Novel Measure of Speech Production in Childhood Apraxia of Speech

PURPOSE

The Multilevel word Accuracy Composite Scale (MACS) is a novel whole-word measure of speech production accuracy designed to evaluate behaviors commonly targeted in motor-based intervention for childhood apraxia of speech (CAS). The MACS yields a composite score generated through ratings of segmental accuracy, word structure maintenance, prosody, and movement transition. This study examined the validity of the MACS through comparison to established measures of speech accuracy. Reliability was also examined within and between practicing speech-language pathologists (SLPs).

METHOD

The MACS was used to rate 117 tokens produced by children with severe CAS. Ratings were performed in the laboratory setting by two expert raters and by practicing SLPs (N = 19). Concurrent validity was estimated through comparison of expert MACS ratings (i.e., MACS score and each component rating) to measures of speech accuracy (percent phoneme correct and the 3-point scale) using correlational analyses. Reliability was examined between expert raters and across SLP raters using the intraclass correlation coefficient to examine interrater reliability of expert ratings, in addition to inter- and intrarater reliability of SLP ratings.

RESULTS

Correlation analyses between MACS ratings (i.e., MACS score and component ratings) and existing measures of speech accuracy revealed small to large positive correlations between measures. Reliability analyses revealed moderate to excellent reliability for MACS ratings performed by expert raters and between (interrater) and within (intrarater) SLP raters.

CONCLUSIONS

Analyses of concurrent validity indicate that the MACS aligns with established measures, yet contributes novel elements for rating speech accuracy. Results further support the MACS as a reliable measure for rating speech accuracy in children with severe speech impairment for ratings performed by expert raters and practicing clinicians.

Tutorial: Using Visual-Acoustic Biofeedback for Speech Sound Training

PURPOSE

This tutorial summarizes current practices using visual-acoustic biofeedback (VAB) treatment to improve speech outcomes for individuals with speech sound difficulties. Clinical strategies will focus on residual distortions of /ɹ/.

METHOD

Summary evidence related to the characteristics of VAB and the populations that may benefit from this treatment are reviewed. Guidelines are provided for clinicians on how to use VAB with clients to identify and modify their productions to match an acoustic representation. The clinical application of a linear predictive coding spectrum is emphasized.

RESULTS

Successful use of VAB requires several key factors including clinician and client comprehension of the acoustic representation, appropriate acoustic target and template selection, as well as appropriate selection of articulatory strategies, practice schedules, and feedback models to scaffold acquisition of new speech sounds.

CONCLUSION

Integrating a VAB component in clinical practice offers additional intervention options for individuals with speech sound difficulties and often facilitates improved speech sound acquisition and generalization outcomes.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21817722.

Baseline Stimulability Predicts Patterns of Response to Traditional and Ultrasound Biofeedback Treatment for Residual Speech Sound Disorder

PURPOSE

This study aimed to identify predictors of response to treatment for residual speech sound disorder (RSSD) affecting English rhotics. Progress was tracked during an initial phase of traditional motor-based treatment and a longer phase of treatment incorporating ultrasound biofeedback. Based on previous literature, we focused on baseline stimulability and sensory acuity as predictors of interest.

METHOD

Thirty-three individuals aged 9-15 years with residual distortions of /ɹ/ received a course of individual intervention comprising 1 week of intensive traditional treatment and 9 weeks of ultrasound biofeedback treatment. Stimulability for /ɹ/ was probed prior to treatment, after the traditional treatment phase, and after the end of all treatment. Accuracy of /ɹ/ production in each probe was assessed with an acoustic measure: normalized third formant (F3)-second formant (F2) distance. Model-based clustering analysis was applied to these acoustic measures to identify different average trajectories of progress over the course of treatment. The resulting clusters were compared with respect to acuity in auditory and somatosensory domains.

RESULTS

All but four individuals were judged to exhibit a clinically significant response to the combined course of treatment. Two major clusters were identified. The "low stimulability" cluster was characterized by very low accuracy at baseline, minimal response to traditional treatment, and strong response to ultrasound biofeedback. The "high stimulability" group was more accurate at baseline and made significant gains in both traditional and ultrasound biofeedback phases of treatment. The clusters did not differ with respect to sensory acuity.

CONCLUSIONS

This research accords with clinical intuition in finding that individuals who are more stimulable at baseline are more likely to respond to traditional intervention, whereas less stimulable individuals may derive greater relative benefit from biofeedback.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.20422236.

Prologue to the Forum: Speech and Language Tele-Intervention: The Future Is Now

PURPOSE

This prologue introduces the LSHSS Forum: Speech and Language Tele-Intervention: The Future Is Now. The aims of the forum are (a) to report on the process of moving established in-person interventions to virtual delivery and (b) to provide speech-language pathologists (SLPs) with empirically based guidance on designing and implementing tele-interventions, in order to support academic success for school-age children with speech and language needs. The included articles explore the process, benefits, and challenges of providing intervention in speech, language, and literacy domains in a virtual environment with children.

CONCLUSION

Although there are some logistical challenges, established treatments such as those targeting morphosyntax as well as communication partner training can be adapted for successful delivery online. In addition, the forum supports the delivery of an app-based articulation-focused intervention. SLPs report a number of challenges in relation to adapting and delivering interventions through telepractice, and parents express concerns in relation to SLPs' online evaluation of complex speech sound difficulties for children born with cleft lip and palate. Finally, using the principles of Minimal Intervention Needed for Change, a systematic approach to the adaptation of evidence-based interventions for online delivery, is outlined.