Systematic review of ultrasound visual biofeedback in intervention for speech sound disorders

Usability of Two Ultrasound Tongue Imaging Devices in Speech-Language Pathology

PURPOSE

Ultrasound tongue imaging is a promising tool in speech-language pathology; however, little is known about the usability of ultrasound scanners for speech-language pathologists (SLPs), who typically have low familiarity with ultrasound imaging. This study looks at the usability of two ultrasound scanner models for SLPs: a Sonosite all-in-one scanner with a wired probe, and a Clarius wireless probe scanner, used with a tablet app.

METHOD

Twelve SLPs and phonetics experts (all female) participated in two filmed sessions in our lab where they learned to use the two models of scanners with custom-written manuals. Each scanner was used in each session to complete a simple task including recording videos of their or the experimenter's tongue. After each use of a scanner, participants completed a modified and translated version of the System Usability Scale. The time required to complete the task was measured. Two expert judges rated the quality of the video recordings.

RESULTS

Participants took less time to complete the task and improved their choice of settings from the first to the second session, regardless of the scanner being used. In the usability scale, SLPs showed a higher satisfaction with the wireless tablet interface than with the all-in-one ultrasound interface. The tablet interface with the wireless scanner also allowed better choices of settings. However, in the second session, positioning of the probe was better with the all-in-one scanner, which has a smaller and lighter probe.

CONCLUSIONS

For SLPs, the usability of a wireless ultrasound scanner with a mobile application seems better than that of an all-in-one scanner. However, its cumbersome probe seems to hamper probe positioning. Future studies should include a lightweight ultrasound scanner that connects via USB to a laptop or tablet and provide image interpretation training for the SLPs.

Clinicians' Perspectives on Using Ultrasound Visual Biofeedback for Research and Practice with People with Cleft Palate ± Cleft Lip

ObjectiveUltrasound visual biofeedback has the potential to be a useful tool in cleft palate ± lip care but there is little research on its effectiveness, nor on clinicians' views on using it in research and practice. This study reports on cleft-specialist speech and language therapists' (SLTs) views on the acceptability of the technique in clinical practice and on their readiness to contribute to future clinical trials of its effectiveness.DesignA qualitative design comprising semi-structured focus groups/interviews.SettingClinicians reflected on how easy it would be to use ultrasound in their regional cleft services.ParticipantsClinicians were recruited via invitation to a UK-wide list of cleft-specialist SLTs. Eleven participants took part over 2 focus groups and 2 interviews.AnalysisFocus groups/interviews were recorded, transcribed verbatim, and an inductive thematic analysis was undertaken. Once complete, a deductive analysis using the theoretical framework of acceptability was conducted to summarise the findings.ResultsFour themes emerged: (1) value of ultrasound as an approach; (2) intrinsic drawbacks of acquiring and utilising ultrasound; (3) competence in effective performance within a clinical trial; and (4) incentives for clinicians and patients in participation in research.ConclusionsParticipants were positive about the benefits of ultrasound for visualising the articulators and improving patient outcomes. Barriers to adoption included the cost of the equipment and the time to travel to appointments. Across clinical and research uses of ultrasound the need for high-quality training and networking within a community of practice was highlighted.

Ultrasound Tongue Imaging in Research and Practice with People with Cleft Palate ± Cleft Lip

Ultrasound tongue imaging is becoming popular as a tool for both phonetic research and biofeedback for treating speech sound disorders. Despite this, it has not yet been adopted into cleft palate ± cleft lip care. This paper explores why this might be the case by highlighting recent research in this area and exploring the advantages and disadvantages of using ultrasound in cleft palate ± cleft lip care. Research suggests that technological advances have largely overcome some of the difficulties of employing ultrasound with this population and we predict a future increase in the clinical application of the tool.

A mixed-methods pilot randomized control trial of ultrasound visual biofeedback versus standard intervention for children with cleft palate ± cleft lip: Parents' and children's perspectives

BACKGROUND

Ultrasound visual biofeedback (UVBF) has the potential to be useful for the treatment of compensatory errors in speakers with cleft palate ± lip (CP±L), but there is little research on its effectiveness, or on how acceptable families find the technique. This study reports on parents' and children's perspectives on taking part in a pilot randomized control trial of UVBF compared with articulation intervention.

AIMS

To determine the acceptability of randomization, UVBF and articulation intervention to families. We set feasibility criteria of at least 75% of responses rated as acceptable or positive in order to determine progression from a pilot to a full randomized control trial.

METHODS & PROCEDURES

A total of 19 families who received UVBF therapy (11 families) and articulation intervention (eight families) were invited to participate. Mixed methods were employed: two questionnaires to determine the acceptability of UVBF and articulation intervention, respectively; and semi-structured focus groups/interviews. Questionnaires were analysed for frequency of positive versus negative acceptability and the focus groups/interviews were analysed using thematic analysis and coded using the theoretical framework of acceptability.

OUTCOMES & RESULTS

More than 75% of families rated randomization as acceptable and more than 75% of families rated both interventions as acceptable, with the caveat that half of the participants did not wish to continue articulation intervention after the study. For some families, this was because they felt further intervention was not required. Six families (three in each intervention) volunteered to take part in the focus groups/interviews. Results showed more positive than negative themes regarding acceptability, particularly affective attitude where high levels of enjoyment were expressed, although some participants found the articulation intervention 'boring'. In both groups, there was a considerable burden involved in travelling to the hospital location.

CONCLUSIONS & IMPLICATIONS

Randomization in a clinical trial is acceptable to families; UVBF and articulation intervention are acceptable and indeed enjoyable. The burden of the additional outcome measures required for a clinical trial is manageable, although there is a travel burden for participants. Future studies should seek to mitigate the travel burden by considering additional locations for intervention.

WHAT THIS PAPER ADDS

What is already known on the subject UVBF shows potential for teaching children with speech sound disorders new articulations. Previous studies looking at the acceptability of using ultrasound in speech intervention have only asked for the drawbacks of the intervention: finding the ultrasound gel to be cold and sticky and the probe to be uncomfortable. SLTs, however, believe that the technique offers advantages due to its ability to visualize tongue movements. What this paper adds to the existing knowledge This study asks parents and children for their full views about using ultrasound in speech intervention and compared this to articulation intervention. We also asked parents how they feel about being randomized to one of these interventions. Results were positive for both interventions, with parents highlighting the importance of intelligible speech to their child. Children enjoyed both interventions, though the articulation intervention could be 'boring' or 'repetitive'. For all families, there was a considerable burden travelling to clinics. What are the potential or actual clinical implications of this work? Clinicians can be assured that both articulation therapy and ultrasound therapy are acceptable to families. Efforts could be made to ensure that articulation intervention is not repetitive and that appointments are offered at locations which are accessible to families where possible.

Feasibility of using ultrasound visual biofeedback to treat persistent speech sound disorders in children with cleft palate- a case series

The current study aimed to assess the effectiveness of incorporating ultrasound visual biofeedback (UVB) into a treatment programme addressing persistent speech sound disorders linked to cleft palate in children who have been unresponsive to traditional therapy approaches. Materials and Methods. A single-subject multiple baseline experiment was conducted with five children aged 6:5-13:5 over a period of 16 therapy sessions. Treatment focused on providing cues from real-time ultrasound images to assist children in modifying their tongue movements. Probe data were collected before, mid, and post-treatment to assess target consonant accuracy for 50 untreated words. The results of the statistical analysis suggested participants showed a significant increase in percent target consonant accuracy as a result of intervention using UVB. Although most of the participants exhibited progress in generalising learned phonemes to untreated words, some did not show improvement in gaining generalisation from treated phonemic contexts to those untreated ones. When traditional methods fail to yield significant progress, incorporating ultrasound biofeedback into the treatment programme emerges as a viable option to enhance sound accuracy in children with persistent speech sound disorders resulting from cleft palate.

Mirrors and toothaches: commonplace manipulations of non-auditory feedback availability change perceived speech intelligibility

This paper investigates the impact of two non-technical speech feedback perturbations outside the auditory modality: topical application of commercially-available benzocaine to reduce somatosensory feedback from speakers' lips and tongue tip, and the presence of a mirror to provide fully-detailed visual self-feedback. In experiment 1, speakers were recorded under normal quiet conditions (i.e., baseline), then again with benzocaine application plus auditory degradation, and finally with the addition of mirror feedback. Speech produced under normal and both feedback-altered conditions was assessed via naïve listeners' intelligibility discrimination judgments. Listeners judged speech produced under bisensory degradation to be less intelligible than speech from the un-degraded baseline, and with a greater degree of difference than previously observed with auditory-only degradation. The introduction of mirror feedback, however, did not result in relative improvements in intelligibility. Experiment 2, therefore, assessed the effect of a mirror on speech intelligibility in isolation with no other sensory feedback manipulations. Speech was recorded at baseline and then again in front of a mirror, and relative intelligibility was discriminated by naïve listeners. Speech produced with mirror feedback was judged as less intelligible than baseline tokens, indicating a negative impact of visual self-feedback in the absence of other sensory manipulations. The results of both experiments demonstrate that relatively accessible manipulations of non-auditory sensory feedback can produce speech-relevant effects, and that those effects are perceptible to naïve listeners.

An Articulatory Analysis of American English Rhotics in Children With and Without a History of Residual Speech Sound Disorder

PURPOSE

This study investigated articulatory patterns for American English /ɹ/ in children with and without a history of residual speech sound disorder (RSSD). It was hypothesized that children without RSSD would favor bunched tongue shapes, similar to American adults reported in previous literature. Based on clinical cueing practices, it was hypothesized that children with RSSD might produce retroflex tongue shape patterns at a higher relative rate. Finally, it was hypothesized that, among children who use a mixture of bunched and retroflex shapes, phonetic context would impact tongue shape as reported in the adult literature.

METHOD

These hypotheses were tested using ultrasound data from a stimulability task eliciting /ɹ/ in syllabic, postvocalic, and onset contexts. Participants were two groups of children/adolescents aged 9-15 years: 36 with RSSD who completed a study of ultrasound biofeedback treatment and 33 with no history of RSSD. Tongue shapes were qualitatively coded as bunched or retroflex using a flowchart from previous research.

RESULTS

Children with no history of RSSD were found to use bunched-only tongue shape patterns at a rate higher than adults, but those who used a mixture of shapes for /ɹ/ followed the expected phonetic contextual patterning. Children with RSSD were found to use retroflex-only patterns at a substantially higher rate than adults, and those using a mixture of shapes did not exhibit the expected patterning by phonetic context.

CONCLUSIONS

These findings suggest that clients receiving ultrasound biofeedback treatment for /ɹ/ may be most responsive to clinician cueing of retroflex shapes, at least early on. However, retroflex-only cueing may be a limiting and insufficient strategy, particularly in light of our finding of a lack of typical variation across phonetic contexts in children with remediated /ɹ/. Future research should more specifically track cueing strategies to better understand the relationship between clinician cues, tongue shapes, and generalization across a range of contexts.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.26801050.

Connecting Auditory-Perceptual Prompts Used in Voice Therapy to Anatomy and Physiology: Application to the Estill Voice Model and the Rehabilitation Treatment Specification System

PURPOSE

This clinical tutorial will present the concept of applying auditory-perceptual prompts (implicit instruction) typically used in voice therapy to the anatomy and physiology of the voice production system (explicit instruction) via the Estill Voice Model (EVM) and the Rehabilitation Treatment Specification System (RTSS).

METHODS

EVM offers an integrated implicit-explicit instructional approach to voice training allowing for isolated practice of vocal structures (explicit) that interact to produce functional voice qualities (implicit), such as modal speech and louder projected voice qualities. In EVM, voice quality is correlated with the specific anatomy and physiologic adjustments via 13 Estill Figures and Options (eg, Larynx Figure has three options: High, Mid, and Low). RTSS provides a framework to connect client change in functioning (ie, target) with clinician action (ie, ingredients). Mechanisms of action connect the target to the ingredients by hypothesizing how the treatment is expected to work.

RESULTS

Evidence is provided for connecting auditory-perpetual voice prompts with the anatomy and physiology of voice and supporting an integrated implicit-explicit approach to voice therapy. The concept of linking commonly used implicit auditory-perceptual prompts used in voice therapy (eg, humming, loud "aahh") to explicit anatomy and physiology training (eg, 13 Estill Figures and Options) is demonstrated using EVM and the RTSS framework with case studies and video examples.

CONCLUSIONS

Clinicians may choose to use anatomy and physiology of voice to define and provide explicit instruction for typically used implicit auditory-perceptual prompts. Future research is warranted to test the concept applied to voice therapy models in the literature across prevention and treatment of voice disorders.

An Ultrasound Investigation of Tongue Dorsum Raising in Children with Cleft Palate +/- Cleft Lip

OBJECTIVE

This study aimed to determine whether increased raising of the back of the tongue is evident in children with repaired cleft palate with or without cleft lip (CP+/-CL). We hypothesized that children with CP+/-CL would show increased raising of the tongue dorsum, a compensatory pattern.

METHOD

Secondary data analysis of mid-sagittal ultrasound tongue imaging data from 31 children with CP+/-CL and 29 typically developing children were used. We annotated the consonants /ʃ, t, s, k/ at the point of maximum constriction in an /aCa/ environment. Children with CP+/-CL said the tokens 10 times, typically developing children said them once. We automatically fitted splines to the tongue contour and extracted the Dorsum Excursion Index (DEI) for each consonant. This metric measures the relative use of the tongue dorsum, with more posterior consonants having higher values. We compared DEI values across groups and consonants using a linear mixed effects model. DEI was predicted by the interaction of consonant (baseline: /ʃ/) and speaker type (baseline: TD), including by-speaker random slopes for consonant and random intercepts for speaker.

RESULTS

Overall DEI was not higher in children with CP+/-CL compared to typically developing children. Between groups the only significant difference was the position of /k/ relative to /ʃ/, where the difference between these two consonants was smaller in the children with CP+/-CL.

CONCLUSIONS

There was no support for the hypothesis that increased raising of the tongue dorsum is a common characteristic in children with repaired CP+/-CL. However, individual children may present with this pattern.

Acoustic and Articulatory Visual Feedback in Classroom L2 Vowel Remediation

This paper presents L2 vowel remediation in a classroom setting via two real-time visual feedback methods: articulatory ultrasound tongue imaging, which shows tongue shape and position, and a newly developed acoustic formant analyzer, which visualizes a point correlating with the combined effect of tongue position and lip rounding in a vowel quadrilateral. Ten Czech students of the Swedish language participated in the study. Swedish vowel production is difficult for Czech speakers since the languages differ significantly in their vowel systems. The students selected the vowel targets on their own and practiced in two classroom groups, with six students receiving two ultrasound training lessons, followed by one acoustic, and four students receiving two acoustic lessons, followed by one ultrasound. Audio data were collected pre-training, after the two sessions employing the first visual feedback method, and at post-training, allowing measuring Euclidean distance among selected groups of vowels and observing the direction of change within the vowel quadrilateral as a result of practice. Perception tests were performed before and after training, revealing that most learners perceived selected vowels correctly already before the practice. The study showed that both feedback methods can be successfully applied to L2 classroom learning, and both lead to the improvement in the pronunciation of the selected vowels, as well as the Swedish vowel set as a whole. However, ultrasound tongue imaging seems to have an advantage as it resulted in a greater number of improved targets.

Outcome measures for children with speech sound disorder: an umbrella review

OBJECTIVE

Speech sound disorder (SSD) describes a 'persistent difficulty with speech sound production that interferes with speech intelligibility or prevents verbal communication'. There is a need to establish which care pathways are most effective and efficient for children with SSD. Comparison of care pathways requires clearly defined, evidence-based, interventions and agreement on how to measure the outcomes. At present, no definitive list of assessments, interventions or outcomes exists. The objective of this umbrella review paper is to provide a rigorous and detailed list of assessments, interventions and outcomes which target SSD in children.

DESIGN

In December 2022, a systematic search of Ovid Medline, OVID Embase, CINAHL, PsycInfo and Cochrane and a number of grey literature platforms were undertaken. 18 reviews were included, and subsequently 415 primary research articles were assessed for data related to assessments, interventions or outcomes. The AMSTAR (Assessing the Methodological Quality of Systematic Reviews) framework was used to assess the quality of the retained reviews.

SETTING

Reviews were retained which took place in any setting.

PARTICIPANTS

The population is children of any age with a diagnosis of SSD of unknown origin.

PRIMARY AND SECONDARY OUTCOME MEASURES

Reviews reporting outcomes, assessment and interventions for children with SSD.

RESULTS

Extraction and analysis identified 37 assessments, 46 interventions and 30 outcome measures used in research reporting of SSD. Not all of the listed outcomes were linked to specific outcome measurement tools, but these were measurable through the use of one or more of the assessments extracted from the retained reviews.

CONCLUSIONS

The findings of this review will be used to develop a Core Outcome Set for children with SSD. The findings are part of a rigorous process essential for advancing healthcare research and practice in the specific area of speech and language therapy for children with SSD.

PROSPERO REGISTRATION NUMBER

CRD42022316284.

Masked Modeling-Based Ultrasound Image Classification via Self-Supervised Learning

Recently, deep learning-based methods have emerged as the preferred approach for ultrasound data analysis. However, these methods often require large-scale annotated datasets for training deep models, which are not readily available in practical scenarios. Additionally, the presence of speckle noise and other imaging artifacts can introduce numerous hard examples for ultrasound data classification. In this paper, drawing inspiration from self-supervised learning techniques, we present a pre-training method based on mask modeling specifically designed for ultrasound data. Our study investigates three different mask modeling strategies: random masking, vertical masking, and horizontal masking. By employing these strategies, our pre-training approach aims to predict the masked portion of the ultrasound images. Notably, our method does not rely on externally labeled data, allowing us to extract representative features without the need for human annotation. Consequently, we can leverage unlabeled datasets for pre-training. Furthermore, to address the challenges posed by hard samples in ultrasound data, we propose a novel hard sample mining strategy. To evaluate the effectiveness of our proposed method, we conduct experiments on two datasets. The experimental results demonstrate that our approach outperforms other state-of-the-art methods in ultrasound image classification. This indicates the superiority of our pre-training method and its ability to extract discriminative features from ultrasound data, even in the presence of hard examples.

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.

Neural Changes in Children With Residual Speech Sound Disorder After Ultrasound Biofeedback Speech Therapy

PURPOSE

Children with residual speech sound disorders (RSSD) have shown differences in neural function for speech production, as compared to their typical peers; however, information about how these differences may change over time and relative to speech therapy is needed. To address this gap, we used functional magnetic resonance imaging (fMRI) to examine functional activation and connectivity on adaptations of the syllable repetition task (SRT-Early Sounds and SRT-Late Sounds) in children with RSSD before and after a speech therapy program.

METHOD

Sixteen children with RSSD completed an fMRI experiment before (Time 1) and after (Time 2) a speech therapy program with ultrasound visual feedback for /ɹ/ misarticulation. Progress in therapy was measured via perceptual ratings of productions of untreated /ɹ/ word probes. To control for practice effects and developmental change in patterns of activation and connectivity, 17 children with typical speech development (TD) completed the fMRI at Time 1 and Time 2. Functional activation was analyzed using a region-of-interest approach and functional connectivity was analyzed using a seed-to-voxel approach.

RESULTS

Children with RSSD showed a range of responses to therapy. After correcting for multiple comparisons, we did not observe any statistically significant cross-sectional differences or longitudinal changes in functional activation. A negative relationship between therapy effect size and functional activation in the left visual association cortex was on the SRT-Late Sounds after therapy, but it did not survive correction for multiple comparisons. Significant longitudinal changes in functional connectivity were observed for the RSSD group on SRT-Early Sounds and SRT-Late Sounds, as well as for the TD group on the SRT-Early Sounds. RSSD and TD groups showed connectivity differences near the left insula on the SRT-Late Sounds at Time 2.

CONCLUSION

RSSD and treatment with ultrasound visual feedback may thus be associated with neural differences in speech motor and visual association processes recruited for speech production.

Auditory-perceptual evaluation with visual analogue scale: feasibility and preliminary evidence of ultrasound visual feedback treatment of Finnish [r]

Accumulating evidence suggests that ultrasound visual feedback increases the treatment efficacy for persistent speech sound errors. However, the available evidence is mostly from English. This is a feasibility study of ultrasound visual feedback for treating distortion of Finnish [r]. We developed a web-based application for auditory-perceptual judgement. We investigated the impact of listener's experience on perceptual judgement and the intra-rater reliability of listeners. Four boys (10-11 years) with distortion of [r], otherwise typical development, partook in eight ultrasound treatment sessions. In total, 117 [r] samples collected at pre- and post-intervention were judged with visual analogue scale (VAS) by two listener groups: five speech and language therapists (SLTs) and six SLT students. We constructed a linear mixed-effects model with fixed effects for time and listener group and several random effects. Our findings indicate that measurement time had a significant main effect on judgement results, χ² = 78.82, p < 0.001. Effect of listener group was non-significant, but a significant main effect of interaction of group × time, χ² = 6.33, p < 0.012 was observed. We further explored the effect of group with nested models, and results revealed a non-significant effect of group. The average intra-rater correlation of the 11 listeners was 0.83 for the pre-intervention samples and 0.92 for post-intervention showing a good or excellent degree of agreement. Finnish [r] sound can be evaluated with VAS and ultrasound visual feedback is a feasible and promising method in treatment for distortion of [r], and its efficacy should be further assessed.

A Qualitative Analysis of Clinician Perspectives of Ultrasound Biofeedback for Speech Sound Disorders

PURPOSE

Ultrasound biofeedback therapy (UBT) is a relatively new type of technology-assisted speech-language therapy and has shown promise in remediating speech sound disorders. However, there is a current lack of understanding of the barriers and benefits that may influence the usage behavior and clinical decision making for the implementation of UBT from a clinician perspective. In this qualitative study, we explore the perspectives of speech-language pathologists (SLPs) who have used ultrasound biofeedback in programs of speech sound therapy using the unified theory of acceptance and use of technology (UTAUT) model.

METHOD

Seven SLPs who had clinical experience treating speech sound disorders with UBT participated. Semistructured in-depth interviews were conducted and video-recorded. Two coders coded and categorized the transcribed data, with consensus established with a third coder. Using thematic analysis, the data were exploratorily grouped into themes along components of the UTAUT model.

RESULTS

The highest number of codes was sorted into the "effort expectancy" theme, followed by "performance expectancy," "social influence," and "facilitating conditions" themes of the UTAUT model. Clinicians identified multiple perceived barriers and benefits to the use of ultrasound technology. The top identified barrier was limited accessibility, and the top benefit was the ability to visualize a client's articulatory response to cues on a display.

CONCLUSIONS

Clinicians prioritized "effort expectancy" and "performance expectancy" when reflecting on the use of ultrasound biofeedback for speech sound disorders. Clinicians spoke favorably about using UBT for speech sound disorder treatment but acknowledged institutional barriers and limitations at organizational and social levels.

Physiology of the tongue with emphasis on taste transduction

The tongue is a complex multifunctional organ that interacts and senses both interoceptively and exteroceptively. Although it is easily visible to almost all of us, it is relatively understudied and what is in the literature is often contradictory or is not comprehensively reported. The tongue is both a motor and a sensory organ: motor in that it is required for speech and mastication, and sensory in that it receives information to be relayed to the central nervous system pertaining to the safety and quality of the contents of the oral cavity. Additionally, the tongue and its taste apparatus form part of an innate immune surveillance system. For example, loss or alteration in taste perception can be an early indication of infection as became evident during the present global SARS-CoV-2 pandemic. Here, we particularly emphasize the latest updates in the mechanisms of taste perception, taste bud formation and adult taste bud renewal, and the presence and effects of hormones on taste perception, review the understudied lingual immune system with specific reference to SARS-CoV-2, discuss nascent work on tongue microbiome, as well as address the effect of systemic disease on tongue structure and function, especially in relation to taste.

A Pilot Randomized Control Trial of Motor-Based Treatments for Childhood Apraxia of Speech: Rapid Syllable Transition Treatment and Ultrasound Biofeedback

PURPOSE

Both Rapid Syllable Transition Treatment (ReST) and ultrasound biofeedback are effective approaches to treating childhood apraxia of speech (CAS). The purpose of the study was to compare outcomes from these two motor-based treatment approaches for school-age children with CAS.

METHOD

In a single site, single blind randomized control trial, 14 children with CAS ages 6-13 years were randomly assigned to 12 sessions over 6 weeks of either of ultrasound biofeedback treatment (with a speech motor chaining practice structure) or ReST. Treatment was delivered at The University of Sydney by students trained and supervised by certified speech-language pathologists. Transcriptions from blinded assessors were used to compare the two groups on speech sound accuracy (percent phonemes correct) and prosodic severity (lexical stress errors and syllable segregation) in untreated words and sentences at three time points: pretreatment, immediately posttreatment, and 1-month posttreatment (i.e., retention).

RESULTS

Both groups showed significant improvement on treated items indicating a treatment effect. At no time was there a difference between groups. Both groups showed a significant improvement in speech sound accuracy on untreated words and sentences from pre to post and neither group showed an improvement in prosody pre-post. Changes to speech sound accuracy were retained by both groups at 1-month follow-up. Significant improvement in prosodic accuracy was reported at the 1-month follow-up.

CONCLUSIONS

ReST and ultrasound biofeedback were equally effective. Either ReST or ultrasound biofeedback may be viable treatment options for school-age children with CAS.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.22114661.

Classification of accurate and misarticulated /r/ for ultrasound biofeedback using tongue part displacement trajectories

Ultrasound biofeedback therapy (UBT), which incorporates real-time imaging of tongue articulation, has demonstrated generally positive speech remediation outcomes for individuals with residual speech sound disorder (RSSD). However, UBT requires high attentional demands and may therefore benefit from a simplified display of articulation targets that are easily interpretable and can be compared to real-time articulation. Identifying such targets requires automatic quantification and analysis of movement features relevant to accurate speech production. Our image-analysis program TonguePART automatically quantifies tongue movement as tongue part displacement trajectories from midsagittal ultrasound videos of the tongue, with real-time capability. The present study uses such displacement trajectories to compare accurate and misarticulated American-English rhotic /ɑr/ productions from 40 children, with degree of accuracy determined by auditory perceptual ratings. To identify relevant features of accurate articulation, support vector machine (SVM) classifiers were trained and evaluated on several candidate data representations. Classification accuracy was up to 85%, indicating that quantification of tongue part displacement trajectories captured tongue articulation characteristics that distinguish accurate from misarticulated production of /ɑr/. Regression models for perceptual ratings were also compared. The simplest data representation that retained high predictive ability, demonstrated by high classification accuracy and strong correlation between observed and predicted ratings, was displacements at the midpoint of /r/ relative to /ɑ/ for the tongue dorsum and blade. This indicates that movements of the dorsum and blade are especially relevant to accurate production of /r/, suggesting that a predictive parameter and biofeedback target based on this data representation may be usable for simplified UBT.

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.

Using ultrasound tongue imaging to support the phonetic transcription of childhood speech sound disorders

This study aims to determine whether adding an additional modality (ultrasound tongue imaging) improves the inter-rater reliability of phonetic transcription in childhood speech sound disorders (SSDs) and whether it enables the identification of different or additional errors in children's speech. Twenty-three English speaking children aged 5-13 years with SSDs of unknown origin were recorded producing repetitions of /aCa/ for all places of articulation with simultaneous audio and ultrasound. Two types of transcriptions were undertaken off-line: (1) ultrasound-aided transcription by two ultrasound-trained speech-language pathologists (SLPs) and (2) traditional phonetic transcription from audio recordings, completed by the same two SLPs and additionally by two different SSD specialist SLPs. We classified transcriptions and errors into ten different subcategories and compared: the number of consonants identified as in error by each transcriber; the inter-rater reliability; and the relative frequencies of error types identified by the different types of transcriber. Results showed that error-detection rates were different across the transcription types, with the ultrasound-aided transcribers identifying more errors than were identified using traditional audio-only transcription. Analysis revealed that these additional errors were identified on the dynamic ultrasound image despite being transcribed as correct, suggestive of subtle motor speech differences. Interrater reliability for classifying the type of error was substantial (κ = 0.72) for the ultrasound-aided transcribers and ranged from fair to moderate for the audio-only transcribers (κ = 0.38 to 0.52). Ultrasound-aided transcribers identified more instances of increased variability and abnormal timing errors than the audio-only transcribers.

An initial framework for use of ultrasound by speech and language therapists in the UK: Scope of practice, education and governance

Background:

There is growing evidence to support the use of ultrasound as a tool for the assessment and treatment of speech, voice and swallowing disorders across the Speech and Language Therapy profession. Research has shown that development of training competencies, engagement with employers and the professional body are vital to progressing ultrasound into practice.

Methods:

We present a framework to support translation of ultrasound into Speech and Language Therapy. The framework comprises three elements: (1) scope of practice, (2) education and competency and (3) governance. These elements align to provide a foundation for sustainable and high-quality ultrasound application across the profession.

Results:

Scope of practice includes the tissues to be imaged, the clinical and sonographic differentials and subsequent clinical decision-making. Defining this provides transformational clarity to Speech and Language Therapists, other imaging professionals and those designing care pathways. Education and competency are explicitly aligned with the scope of practice and include requisite training content and mechanisms for supervision/support from an appropriately trained individual in this area. Governance elements include legal, professional and insurance considerations. Quality assurance recommendations include data protection, storage of images, testing of ultrasound devices as well as continuous professional development and access to a second opinion.

Conclusion:

The framework provides an adaptable model for supporting expansion of ultrasound across a range of Speech and Language Therapy specialities. By taking an integrated approach, this multifaceted solution provides the foundation for those with speech, voice and swallowing disorders to benefit from advances in imaging-informed healthcare.

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.

Protocol for SonoSpeech Cleft Pilot: a mixed-methods pilot randomized control trial of ultrasound visual biofeedback versus standard intervention for children with cleft lip and palate

Background

Children with cleft lip and palate can continue to have problems producing clear speech after surgery. This can lead to social, emotional, and educational challenges. Typical treatment involves teaching children the correct tongue movements to produce speech sounds. This is known as articulation intervention. However, this intervention is challenging because the tongue is hidden from view and movements are difficult to see and describe. This pilot randomized control trial will try a new treatment, ultrasound visual biofeedback (U-VBF) versus standard articulatory intervention for children with cleft lip and palate, as comparison. Feasibility outcomes will be determined.

Methods/design

The Sonospeech project will enroll up to 40 children with cleft lip and palate aged 4;6 to 16 in a mixed-methods randomized controlled trial with blinded assessors. Children will receive either six sessions of U-VBF or articulation intervention. The primary goals of this pilot are to assess the feasibility and inform the design of a full-scale RCT of U-VBF for children with cleft speech characteristics. This will be achieved by determining the following outcome measures: recruitment/attrition rates; measures of pre-post follow-up completion; and acceptability of the randomization and interventions to families.

Discussion

Larger trials of speech interventions for children with cleft lip and palate are needed. This pilot/feasibility study will determine whether a larger randomized control trial comparing ultrasound and articulation interventions is feasible.

Trial registration

ISRCTN, ISRCTN17441953. Registered 22 March 2021. See Table 2 in Appendix 1 for all items.

Effectiveness of an Ultrasound Visual Biofeedback Training for Tongue Shape Assessment During Speech Sound Production

PURPOSE

This proof-of-concept study examined the effectiveness of an ultrasound visual biofeedback (UVB) training within the Participatory Adult Teaching Strategy framework for instructing speech-language pathologists (SLPs) on the assessment of sonographic tongue configuration for remediation of speech sound errors.

METHOD

This research followed a multiple-baseline, multiple-probe single-case research methodology replicated across behaviors for data collection and analysis. Two school-based SPLs with no previous knowledge or experience with UVB were recruited.

RESULTS

Visual analysis of data and effect size calculations using the percentage of nonoverlapping data indicated that training was highly effective in teaching SLPs skills for the assessment of sonographic tongue configuration and how to promote changes in tongue configuration for the remediation of speech sound errors.

CONCLUSIONS

This study addressed the current gap in the literature regarding the lack of empirical evidence of UVB training for SLPs. Our findings support the exploration of evidence-based teaching strategies to train SLPs in the use of UVB for assessment of tongue configuration and remediation of speech sound errors. This can be of interest to academic programs and organizers of training opportunities through continued education units.

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

PURPOSE

Although mobile apps are used extensively by speech-language pathologists, evidence for app-based treatments remains limited in quantity and quality. This study investigated the efficacy of app-based visual-acoustic biofeedback relative to nonbiofeedback treatment using a single-case randomization design. Because of COVID-19, all intervention was delivered via telepractice.

METHOD

Participants were four children aged 9-10 years with residual errors affecting American English /ɹ/. Using a randomization design, individual sessions were randomly assigned to feature practice with or without biofeedback, all delivered using the speech app Speech Therapist's App for /r/ Treatment. Progress was assessed using blinded listener ratings of word probes administered at baseline, posttreatment, and immediately before and after each treatment session.

RESULTS

All participants showed a clinically significant response to the overall treatment package, with effect sizes ranging from moderate to very large. One participant showed a significant advantage for biofeedback over nonbiofeedback treatment, although the order of treatment delivery poses a potential confound for interpretation in this case.

CONCLUSIONS

While larger scale studies are needed, these results suggest that app-based treatment for residual errors can be effective when delivered via telepractice. These results are compatible with previous findings in the motor learning literature regarding the importance of treatment dose and the timing of feedback conditions.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.18461576.

Quantifying changes in ultrasound tongue-shape pre- and post-intervention in speakers with submucous cleft palate: an illustrative case study

Ultrasound Tongue Imaging is increasingly used during assessment and treatment of speech sound disorders. Recent literature has shown that ultrasound is also useful for the quantitative analysis of a wide range of speech errors. So far, the compensatory articulations of speakers with cleft palate have only been analysed qualitatively. This study provides a pilot quantitative ultrasound analysis, drawing on longitudinal intervention data from a child with submucous cleft palate. Two key ultrasound metrics were used: 1. articulatory t-tests were used to compare tongue-shapes for perceptually collapsed phonemes on a radial measurement grid and 2. the Mean Radial Difference was reported to quantify the extent to which the two tongue shapes differ, overall. This articulatory analysis supplemented impressionistic phonetic transcriptions and identified covert contrasts. Articulatory errors identified in this study using ultrasound were in line with errors identified in the speech of children with cleft palate in previous literature. While compensatory error patterns commonly found in speakers with cleft palate have been argued to facilitate functional phonological development, the nature of our findings suggest that the compensatory articulations uncovered are articulatory in nature.

Using ultrasound tongue imaging to analyse maximum performance tasks in children with Autism: a pilot study

This study proposes a protocol for assessing speech motor control in children using maximum performance tasks with simultaneous acoustic and ultrasound recording. The protocol was piloted on eight children with autism spectrum disorders and nine typically developing children. Diadochokinesis rate, accuracy, and consistency were elicited using an imitation paradigm where speakers repeat mono-, bi-, and tri-syllabic stimuli at increasing rates. Both traditional measures of rate, accuracy and consistency and an ultrasound tongue-shape analysis of slow versus fast productions were undertaken. Preliminary results suggest that the protocol is feasible with children with communication disorders. Instrumental measures suggest greater variability in tongue movements in the children with autism that is not detected using perceptual measures of accuracy. A subgroup of children with autism showed some evidence of differences in speech motor control. Ultrasound tongue imaging appears to be a useful method for gaining additional insight into speech motor control.

The tween years: A systematic literature review for services for children aged 10-13 years

AIM

To explore the literature about services and interventions provided to tween children as the basis for informing future practice and policy.

BACKGROUND

The tween years (10-13 years) is a period in human development where children experience rapid physical and mental development; their thinking and actions are influenced by peer pressure, risk taking, concerns about their body image, size, and gender, and may become victims to bullying and increasing levels of mental ill-health. It may also be a time of transition between schooling institutions. Despite the multiplicity of these factors, pre-adolescents appear to be receiving little attention from both service providers and policy makers.

METHODS

Following the PRISMA reporting guidelines, a systematic search of peer-reviewed papers was conducted between June 2020 and April 2021. Studies were selected by screening their abstracts and titles. In total, 44 articles were included for in-depth analysis. Of these, 17 were randomised studies and 10 were non-randomised, and all were subjected to the assessment of risk of bias using the Review Manager Tool and ROBINS-I Tool respectively.

DATA EXTRACTION AND SYNTHESIS

Data was extracted by type of service/intervention/program, country, and type of study/methodology, aim, sample size, age range, and findings. Data synthesis was performed using thematic analysis and content analysis. The results are presented in an outcome summary table highlighting the study's outcomes including the provided programs, their acceptability, and their impacts on factors such as anxiety and depression levels, change of attitude, behavioural control, weight loss, resilience and coping, emotional regulation, self-esteem, and improved well-being.

CONCLUSION

The majority of programs described in this review reported positive results, and as a result have the potential to make a valuable contribution to future practice, policy, and research involving the tweens.

Treatment generalization from trained /ɹ/ to untrained /l/: a case study of persisting distortion errors

The extent to which treatment of speech errors that are phonetic in nature (i.e., distortions) produces generalization to untrained sounds is not well understood. This case study reports a child referred for treatment of a velarized distortion of American English /ɹ/, who also demonstrated an inconsistent velarized distortion of /l/. Acoustic analysis revealed evidence of a covert contrast between /ɹ/ and /l/ prior to treatment. Ultrasound biofeedback treatment and perceptual training targeted /ɹ/ only, but progress was tracked for both /ɹ/ and /l/. Substantial improvements in perceptually rated accuracy and significant changes in acoustic features were observed for both sounds, indicating generalization. These results highlight that generalization from trained to untrained sounds is possible for children with residual speech errors characterized by phonetic distortions.

Making the case for the collection of a minimal dataset for children with speech sound disorder

BACKGROUND

NHS case note data are a potential source of practice-based evidence which could be used to investigate the effectiveness of different interventions for individuals with a range of speech, language and communication needs. Consistency in pre- and post-intervention data as well as the collection of relevant variables would need to be demonstrated as a precursor to adopting this approach in future investigations of speech and language therapy intervention.

AIMS

To explore whether routine clinical data collection for children with speech sound disorder (SSD) could be a potential source for examining the effectiveness of intervention(s).

METHODS & PROCEDURES

We examined case notes from three UK NHS services, reviewing 174 sets of case notes and 234 blocks of therapy provided for school-age children with SSD.

MAIN CONTRIBUTION

We found there was significant variation in pre- and post-intervention data and variables collected by the services. The assessment data available in the case notes across all sites were insufficient to be used to compare the effectiveness of different interventions. Specific issues included lack of consistent reporting of pre- and post-intervention data, and use of a variety of both formal and informal assessment tools.

CONCLUSIONS & IMPLICATIONS

The case notes reviewed were from three sites and may not represent wider clinical practice, nevertheless the findings suggest the sample explored indicates the need for more consistent and contemporaneous collection of data for children with SSD to facilitate the investigation of different interventions in practice. Researchers should work with the clinical community to determine a minimal dataset that includes a core outcome set and potential variables. This should be feasible to collect in clinical practice and provide a dataset for future investigations of clinically relevant research questions. This would provide an invaluable resource to the clinical academic and research communities enabling research questions to be addressed that have the potential to lead to improved outcomes and more cost-effective services.

WHAT THIS PAPER ADDS

What is already known on the subject While there is some evidence for the efficacy of therapy for children with SSD, studies typically focus on very specific populations who meet strict selection criteria and take place in university clinics or laboratory-style settings which do not reflect typical clinical practice in the UK and elsewhere. An alternative approach to investigating the effectiveness of interventions would be to use NHS case note data. It is not clear from the existing literature whether case note data are sufficiently robust to facilitate such an analysis. What this paper adds to existing knowledge This study found that case note data, in particular assessment data, were highly variable across services and would be insufficient to compare different interventions for this population. Agreement on what should be included in a minimal dataset for children with SSD is required to maximize the potential for NHS clinical case notes to become a resource for future research. What are the actual or potential clinical implications of this work? This study indicates that current clinical practice in SLT for children with SSD is inconsistent with regards to the reporting of pre- and post-intervention assessment data and other important variables in case notes. We make the case for agreeing a minimal dataset with a need for clinicians to work with researchers to determine core outcomes and additional relevant data, which can be feasibly collected in clinical practice.

Visual feedback of the tongue influences speech adaptation to a physical modification of the oral cavity

Studies examining sensorimotor adaptation of speech to changing sensory conditions have demonstrated a central role for both auditory and somatosensory feedback in speech motor learning. The potential influence of visual feedback of oral articulators, which is not typically available during speech production but may nonetheless enhance oral motor control, remains poorly understood. The present study explores the influence of ultrasound visual feedback of the tongue on adaptation of speech production (focusing on the sound /s/) to a physical perturbation of the oral articulators (prosthesis altering the shape of the hard palate). Two visual feedback groups were tested that differed in the two-dimensional plane being imaged (coronal or sagittal) during practice producing /s/ words, along with a no-visual-feedback control group. Participants in the coronal condition were found to adapt their speech production across a broader range of acoustic spectral moments and syllable contexts than the no-feedback controls. In contrast, the sagittal group showed reduced adaptation compared to no-feedback controls. The results indicate that real-time visual feedback of the tongue is spontaneously integrated during speech motor adaptation, with effects that can enhance or interfere with oral motor learning depending on compatibility of the visual articulatory information with requirements of the speaking task.

Comparing Biofeedback Types for Children With Residual /ɹ/ Errors in American English: A Single-Case Randomization Design

Purpose Research comparing different biofeedback types could lead to individualized treatments for those with residual speech errors. This study examines within-treatment response to ultrasound and visual-acoustic biofeedback, as well as generalization to untrained words, for errors affecting the American English rhotic /ɹ/. We investigated whether some children demonstrated greater improvement in /ɹ/ during ultrasound or visual-acoustic biofeedback. Each participant received both biofeedback types. Individual predictors of treatment response (i.e., age, auditory-perceptual skill, oral somatosensory skill, and growth mindset) were also explored. Method Seven children ages 9-16 years with residual rhotic errors participated in 10 treatment visits. Each visit consisted of two conditions: 45 min of ultrasound biofeedback and 45 min of visual-acoustic biofeedback. The order of biofeedback conditions was randomized within a single-case experimental design. Acquisition of /ɹ/ was evaluated through acoustic measurements (normalized F3-F2 difference) of selected nonbiofeedback productions during practice. Generalization of /ɹ/ was evaluated through acoustic measurements and perceptual ratings of pretreatment/posttreatment probes. Results Five participants demonstrated acquisition of practiced words during the combined treatment package. Three participants demonstrated a clinically significant degree of generalization to untreated words on posttreatment probes. Randomization tests indicated one participant demonstrated a significant advantage for visual-acoustic over ultrasound biofeedback. Participants' auditory-perceptual acuity on an /ɹ/-/w/ identification task was identified as a possible correlate of generalization following treatment. Conclusions Most participants did not demonstrate a statistically significant difference in acoustic productions between the ultrasound and visual-acoustic conditions, but one participant showed greater improvement in /ɹ/ during visual-acoustic biofeedback. Supplemental Material https://doi.org/10.23641/asha.14881101.

The Dorsal Differentiation of Velar From Alveolar Stops in Typically Developing Children and Children With Persistent Velar Fronting

Purpose This study has two key aims: first, to provide developmental articulatory norms for the alveolar-velar distinction in 30 English-speaking typically developing (TD) children; second, to illustrate the utility of the reported measures for classifying and quantifying the speech of children with a history of persistent velar fronting as they develop the contrast longitudinally. Method This study involved secondary data analysis of the UltraSuite corpus comprising ultrasound tongue imaging recordings of speech materials from 30 typical children and longitudinal data from five children with persistent velar fronting undergoing ultrasound visual biofeedback intervention. We present two new measures of coronal dorsal differentiation: KTMax and KT crescent area. These measures distinguish /k/ and /t/ by quantifying the magnitude of this distinction in absolute spatial terms (mm of linear dorsal difference). For the typical children, we report these measures in corner vowel contexts. We then compare these to dorsal productions by the children with speech disorders, before, during, and after intervention. Results Both measures reliably distinguished /k/ and /t/ in TD children. There was an effect of vowel, with larger KTmax and KT crescent area in /a/ and /o/ vowel contexts than in an /i/ context. The children with persistent velar fronting showed KTmax values near zero before intervention, showing a complete merger between /k/ and /t/. During intervention, they showed variable KTmax values. Post intervention, they showed values within the range of typical children. Conclusions This study provides articulatory norms derived from ultrasound tongue imaging for the dorsal differentiation in alveolar and velar stops in TD children. By applying these norms to children with persistent velar fronting as they acquire this contrast, we see that /k/ is acquired in an articulatorily gradient manner.

Use of ultrasound visual feedback in speech intervention for children with cochlear implants

The purpose of the present study was to evaluate the efficacy of ultrasound visual feedback in speech intervention for young children with cochlear implants. Although ultrasound technology has been used for intervention in children with speech sound disorders, there is little systematic evidence regarding relative efficacy of ultrasound visual feedback for young children with cochlear implants. Two children with cochlear implants participated in this study. The children's articulation was tested using Goldman-Fristoe Test of Articulation-2 and probes. Therapy was provided semi-weekly for 30-minute sessions over the course of nine to 10 weeks. Visual inspection showed an increasing trend in production accuracy to the criterion accuracy of 80% for target sounds. Maintenance of skills were observed at two weeks and two months post-intervention. The results of this study indicated that ultrasound visual feedback is likely an effective intervention tool for treating speech sound disorders in children with cochlear implants. Future studies including a larger sample size should be conducted to verify these findings.

Toward an index of oral somatosensory acuity: Comparison of three measures in adults

PURPOSE

Somatosensory targets and feedback are instrumental in ensuring accurate speech production. Individuals differ in their ability to access and respond to somatosensory information, but there is no established standard for measuring somatosensory acuity. The primary objective of this study was to determine which of three measures of somatosensory acuity had the strongest association with change in production accuracy in a vowel learning task, while controlling for the better-studied covariate of auditory acuity.

METHOD

Three somatosensory tasks were administered to 20 female college students: an oral stereognosis task, a bite block task with auditory masking, and a novel phonetic awareness task. Individual scores from the tasks were compared to their performance on a speech learning task in which participants were trained to produce novel Mandarin vowels with visual biofeedback.

RESULTS

Of the three tasks, only bite block adaptation with auditory masking was significantly associated with performance in the speech learning task. Participants with weaker somatosensory acuity tended to demonstrate larger increases in production accuracy over the course of training.

CONCLUSIONS

The bite block adaptation task measures proprioceptive awareness rather than tactile acuity and assesses somatosensory knowledge implicitly, with limited metalinguistic demands. This small-scale study provides preliminary evidence that these characteristics may be desirable for the assessment of oral somatosensory acuity, at least in the context of vowel learning tasks. Well-normed somatosensory measures could be of clinical utility by informing diagnosis/prognosis and treatment planning.

Auditory-perceptual acuity in rhotic misarticulation: baseline characteristics and treatment response

The rhotic sound /r/ is one of the latest-emerging sounds in English, and many children receive treatment for residual errors affecting /r/ that persist past the age of 9. Auditory-perceptual abilities of children with residual speech errors are thought to be different from their typically developing peers. This study examined auditory-perceptual acuity in children with residual speech errors affecting /r/ and the relation of these skills to production accuracy, both before and after a period of treatment incorporating visual biofeedback. Identification of items along an /r/-/w/ continuum was assessed prior to treatment. Production accuracy for /r/ was acoustically measured from standard/r/stimulability probes elicited before and after treatment. Fifty-nine children aged 9-15 with residual speech errors (RSE) affecting /r/ completed treatment, and forty-eight age-matched controls who completed the same auditory-perceptual task served as a comparison group. It was hypothesized that children with RSE would show lower auditory-perceptual acuity than typically developing speakers and that higher auditory-perceptual acuity would be associated with more accurate production before treatment. It was also hypothesized that auditory-perceptual acuity would serve as a mediator of treatment response. Results indicated that typically developing children have more acute perception of the /r/-/w/ contrast than children with RSE. Contrary to hypothesis, baseline auditory-perceptual acuity for /r/ did not predict baseline production severity. For baseline auditory-perceptual acuity in relation to biofeedback efficacy, there was an interaction between auditory-perceptual acuity and gender, such that higher auditory-perceptual acuity was associated with greater treatment response in female, but not male, participants.

Auditory Perception and Ultrasound Biofeedback Treatment Outcomes for Children With Residual /ɹ/ Distortions: A Randomized Controlled Trial

Purpose This study evaluated whether outcomes from treatment, which includes ultrasound visual feedback (UVF), would be more or less effective when combined with auditory perception training for children with residual /ɹ/ errors. Method Children ages 8-16 years with /ɹ/ distortions participated in speech therapy that included real-time UVF of the tongue. Thirty-eight participants were randomized to speech therapy conditions that included a primary focus on articulation using UVF or a condition that included auditory perceptual training plus UVF (incorporating category goodness judgments and self-monitoring). Generalization of /ɹ/ production accuracy to untrained words was assessed before and after 14 hr of therapy. Additionally, the role of auditory perceptual acuity was explored using a synthetic /ɹ/-/w/ continuum. Results There was no difference between the treatment groups in rate of improvement of /ɹ/ accuracy (increase of 34% for each group; p = .95, ηp2 = .00). However, pretreatment auditory acuity was associated with treatment progress in both groups, with finer perceptual acuity corresponding to greater progress (p = .015, ηp2 = .182). Conclusion Similar gains in speech sound accuracy can be made with treatment that includes UVF with or without auditory perceptual training. Fine-grained perceptual acuity may be a prognostic indicator with treatment. Supplemental Material https://doi.org/10.23641/asha.11886219.

Protocol for Correcting Residual Errors with Spectral, ULtrasound, Traditional Speech therapy Randomized Controlled Trial (C-RESULTS RCT)

Background

Speech sound disorder in childhood poses a barrier to academic and social participation, with potentially lifelong consequences for educational and occupational outcomes. While most speech errors resolve by the late school-age years, between 2 and 5% of speakers exhibit residual speech errors (RSE) that persist through adolescence or even adulthood. Previous findings from small-scale studies suggest that interventions incorporating visual biofeedback can outperform traditional motor-based treatment approaches for children with RSE, but this question has not been investigated in a well-powered randomized controlled trial.

Methods/design

This project, Correcting Residual Errors with Spectral, ULtrasound, Traditional Speech therapy Randomized Controlled Trial (C-RESULTS RCT), aims to treat 110 children in a parallel randomized controlled clinical trial comparing biofeedback and non-biofeedback interventions for RSE affecting the North American English rhotic sound /ɹ/. Eligible children will be American English speakers, aged 9–15 years, who exhibit RSE affecting /ɹ/ but otherwise show typical cognitive-linguistic and hearing abilities. Participants will be randomized, with stratification by site (Syracuse University or Montclair State University) and pre-treatment speech production ability, to receive either a motor-based treatment consistent with current best practices in speech therapy (40% of participants) or treatment incorporating visual biofeedback (60% of participants). Within the biofeedback condition, participants will be assigned in equal numbers to receive biofeedback in the form of a real-time visual display of the acoustic signal of speech or ultrasound imaging of the tongue during speech. The primary outcome measure will assess changes in the acoustics of children’s production of /ɹ/ during treatment, while a secondary outcome measure will use blinded listeners to evaluate changes in the perceived accuracy of /ɹ/ production after the completion of all treatment. These measures will allow the treatment conditions to be compared with respect to both efficacy and efficiency.

Discussion

By conducting the first well-powered randomized controlled trial comparing treatment with and without biofeedback, this study aims to provide high-quality evidence to guide treatment decisions for children with RSE.

Trial registration

ClinicalTrials.gov identifier NCT03737318, November 9, 2018.

Re-Evaluating Evidence for Best Practice in Paediatric Speech-Language Pathology

BACKGROUND

Systematic reviews of treatment trials for children with speech and language difficulties often exemplify the limited clinical usefulness of the evidence base, reflecting recent literature in evidence-based medicine. Other studies report that clinicians often fail to seek information about best practice, across the health professions. Consequently, clinical researchers, including those in speech-language pathology, have sought alternative methodologies for determining best practice.

SUMMARY

Some approaches focus on "pragmatic trials," usually as part of existing health services. Others place case management of individuals at the centre of intervention presenting studies of one or more cases, including N-of-1 randomized controlled trials and cross-over group designs. Clinical case studies can provide important theoretical data contributing to our understanding of the development of typical and atypical communication. Precision medicine (also known as personalized medicine) is an emerging approach to building the clinical evidence base that acknowledges the importance of individual genetic and environmental differences between people. With increasing knowledge of aetiological heterogeneity, even within children presenting with the same diagnosis (e.g., childhood apraxia of speech), data reinforce the edict that children are not all born equal. Key Message: This review argues that to understand response to treatment, it is critical to examine child-related factors as well as the variables of the intervention itself.