Planning and self-assessment in articulatory training

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.

Tutorial: Motor-Based Treatment Strategies for /r/ Distortions

Purpose This tutorial summarizes current best practices in treating American English /r/ distortions in children with residual speech errors. Method To enhance the effectiveness of clinicians' cueing and feedback, the phonetics of /r/ production is reviewed. Principles of acquisition, which can inform how to practice /r/ in the early stages of therapy, are explained. Elements of therapy that lack scientific support are also mentioned. Results Although there is significant variability in /r/ production, the common articulatory requirements include an oral constriction, a pharyngeal constriction, tongue body lowering, lateral bracing, and slight lip rounding. Examples of phonetic cues and shaping strategies are provided to help clinicians elicit these movements to evoke correct /r/ productions. Principles of acquisition (e.g., blocked practice, frequent knowledge of performance feedback) are reviewed to help clinicians structure the earliest stages of treatment to establish /r/. Examples of approaches that currently lack scientific support include nonspeech oral motor exercises, tactile cues along the mylohyoid muscle, and heterogeneous groupings in group therapy. Conclusion Treatment strategies informed by phonetic science and motor learning theory can be implemented by all clinicians to enhance acquisition of /r/ for children with residual errors. Supplemental Material https://doi.org/10.23641/asha.12771329.

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, η_p² = .00). However, pretreatment auditory acuity was associated with treatment progress in both groups, with finer perceptual acuity corresponding to greater progress (p = .015, η_p² = .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.

Remediating Residual Rhotic Errors With Traditional and Ultrasound-Enhanced Treatment: A Single-Case Experimental Study

Purpose The aim of the study was to examine how ultrasound visual feedback (UVF) treatment impacts speech sound learning in children with residual speech errors affecting /ɹ/. Method Twelve children, ages 9-14 years, received treatment for vocalic /ɹ/ errors in a multiple-baseline across-subjects design comparing 8 sessions of UVF treatment and 8 sessions of traditional (no-biofeedback) treatment. All participants were exposed to both treatment conditions, with order counterbalanced across participants. To monitor progress, naïve listeners rated the accuracy of vocalic /ɹ/ in untreated words. Results After the first 8 sessions, children who received UVF were judged to produce more accurate vocalic /ɹ/ than those who received traditional treatment. After the second 8 sessions, within-participant comparisons revealed individual variation in treatment response. However, group-level comparisons revealed greater accuracy in children whose treatment order was UVF followed by traditional treatment versus children who received the reverse treatment order. Conclusion On average, 8 sessions of UVF were more effective than 8 sessions of traditional treatment for remediating vocalic /ɹ/ errors. Better outcomes were also observed when UVF was provided in the early rather than later stages of learning. However, there remains a significant individual variation in response to UVF and traditional treatment, and larger group-level studies are needed. Supplemental Material https://doi.org/10.23641/asha.8206640.

Tutorial: Speech Motor Chaining Treatment for School-Age Children With Speech Sound Disorders

Purpose Operationalized treatments for school-age children with speech sound disorders may result in more replicable and evidence-based interventions. This tutorial describes Speech Motor Chaining (SMC) procedures, which are designed to build complex speech around core movements by incorporating several principles of motor learning. The procedures systematically manipulate factors such as feedback type and frequency, practice variability, and stimulus complexity based on the child's performance. Method The rationale and procedures for SMC are described. Examples are presented of how to design stimuli, deliver feedback, and adapt the approach. Free resources are provided to guide clinicians through implementation of the procedure. Data on fidelity of implementation and dose per session are presented. Clinical and research evidence is provided to illustrate likely outcomes with the procedure. Results SMC is a method that can result in successful acquisition of target speech patterns and generalization to untrained words. Most clinicians can implement the procedure with over 90% fidelity, and most children can achieve over 200 trials per session. Conclusion Clinicians and researchers can use or adapt the operationally defined SMC procedures to incorporate several principles of motor learning into treatment for school-age children with speech sound disorders. Supplemental Material https://osf.io/5jmf9/.

Treatment for Residual Rhotic Errors With High- and Low-Frequency Ultrasound Visual Feedback: A Single-Case Experimental Design

PURPOSE

The aim of this study was to explore how the frequency with which ultrasound visual feedback (UVF) is provided during speech therapy affects speech sound learning.

METHOD

Twelve children with residual speech errors affecting /ɹ/ participated in a multiple-baseline across-subjects design with 2 treatment conditions. One condition featured 8 hr of high-frequency UVF (HF; feedback on 89% of trials), whereas the other included 8 hr of lower-frequency UVF (LF; 44% of trials). The order of treatment conditions was counterbalanced across participants. All participants were treated on vocalic /ɹ/. Progress was tracked by measuring generalization on /ɹ/ in untreated words.

RESULTS

After the 1st treatment phase, participants who received the HF condition outperformed those who received LF. At the end of the 2-phase treatment, within-participant comparisons showed variability across individual outcomes in both HF and LF conditions. However, a group level analysis of this small sample suggested that participants whose treatment order was HF-LF made larger gains than those whose treatment order was LF-HF.

CONCLUSIONS

The order HF-LF may represent a preferred order for UVF in speech therapy. This is consistent with empirical work and theoretical arguments suggesting that visual feedback may be particularly beneficial in the early stages of acquiring new speech targets.

Intensive Treatment for Persisting Rhotic Distortions: A Case Series

PURPOSE

The study explored changes in accuracy of American English rhotics as a result of an intensive 1-week therapy program for adolescents and young adults with residual speech sound errors that had not resolved with previous therapy.

METHOD

Four case reports are presented of individuals aged 13, 17, 21, and 22 years with residual /ɹ/ distortions. Each participant attended a 1-week intensive program consisting of pretreatment assessments, 14 hr of therapy, and posttreatment assessment. Treatment sessions included structured motor-based practice, ultrasound visual feedback of the tongue, and auditory speech perception training. To assess generalization, untreated words and sentences with rhotics were recorded before and after therapy; these were rated by listeners who were blind to when the recordings were taken.

RESULTS

All participants showed measurable and statistically significant improvement in speech sound accuracy. Averaged across the 4 participants, rhotic accuracy at the word level improved from 35% to 83%. At the sentence level, rhotic accuracy increased from 11% pretreatment to 66% posttreatment in 1 week.

CONCLUSION

The promise of an intensive treatment program that includes motor-based practice, biofeedback, and auditory perception training is illustrated by the case presentations in which substantial improvements in speech sound accuracy were observed.

SUPPLEMENTAL MATERIALS

https://doi.org/10.23641/asha.5561254.

A Framework for Generalization in Disordered Phonology

Generalization is an important outcome of treatment for phonological disorders. However, generalization often fails to occur. When it does not occur spontaneously, modifications must be made in the treatment program. In this article, a framework is provided for types of generalization that are potential results of treatment. The framework includes stimulus generalization (across materials, activities, people, settings) and response generalization (across word position, phonetic context, sounds, linguistic level). Within this framewor described which can increase the potential for generalization to occur. Guidelines are also given for measurement of generalization.

The Application of Motor Learning Concepts to the Treatment of Children with Compensatory Speech Sound Errors

Children with cleft palate frequently present with compensatory speech sound errors, which are generally targeted in treatment. Often, treatment consists of different phonetic teaching methods and procedures that are delivered via an operant learning paradigm; however, there are other theoretical models of learning that may prove more efficacious for modifying compensatory errors. Motor learning is a teaching/learning methodology that has an extensive body of research to support its use in the acquisition and development of motor skills. Currently, researchers are using motor learning paradigms in the treatment of different speech disorders and evidence on efficacy is being collected. This paper will discuss motor learning as a methodology for treating compensatory speech sound errors in an effective and efficient manner.

The use of ultrasound in remediation of North American English /r/ in 2 adolescents

PURPOSE

Ultrasound can provide images of the tongue during speech production. The present study set out to examine the potential utility of ultrasound in remediation of North American English /r/.

METHOD

The participants were 2 Canadian English-speaking adolescents who had not yet acquired /r/. The study included an initial period without ultrasound and 13 treatment sessions, each 1 hr long, using ultrasound. Speech samples were recorded at screening and immediately before and after treatment. Samples were analyzed acoustically and with listener judgments. Ultrasound images were obtained before, during, and after the treatment period.

RESULTS

Three speech-language pathologists unfamiliar with the participants rated significantly more posttreatment tokens as accurate [r]s in single words and some phrases. Acoustic analyses showed an expected lowering of the third formant after treatment. A qualitative observation of posttreatment ultrasound images for accurate [r] tokens showed tongue shapes to be more similar to those of typical adults than had been observed before treatment. Participants needed continued practice of their newly acquired skills in sentences and conversation.

CONCLUSION

Two-dimensional dynamic ultrasound appears to have potential utility for remediation of /r/ in speakers with residual /r/ impairment. Further research is needed with larger numbers of participants to establish the relative efficacy of ultrasound in treatment.

Comparison of two training methods to enhance awareness of the oral cavity

This investigation assessed two training methods to heighten awareness of the oral cavity in normal adult speakers of English. A pretest-posttest design was used. 40 subjects (M age=25.6 yr., SD=8.7) who passed a speech and hearing screening were placed into two equal-sized groups. Each group received 10 hr. of training over 3 wk. The Experimental group received verbal instructions regarding how the phonemes of English are produced, including tongue height, location, and contact with other structures in the oral cavity. Subjects in the Experimental group also used a tongue blade to enhance lingual awareness. The Control group received instructions in articulatory placement only. The Lingual Awareness Test required subjects to imitate 7 English syllables and answer 4 multiple-choice questions regarding lingual contact for each syllable. Posttest scores for the Experimental group were significantly better for one phoneme. The Control group made no significant improvement.

Speech and language therapy interventions for children with primary speech and language delay or disorder

BACKGROUND

It is thought that approximately 6% of children have speech and language difficulties of which the majority will not have any other significant developmental difficulties. Whilst most children's difficulties resolve, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialisation, behaviour and school attainment.

OBJECTIVES

To examine the effectiveness of speech and language interventions for children with primary speech and language delay/disorder.

SEARCH STRATEGY

The following databases were searched: The Cochrane Controlled Trials Register (Cochrane Library, CENTRAL: 2002/3), CINAHL (1982 - July 2002), EMBASE (1980 - Sept Week 4 2002), ERIC (1965 - 2002), MEDLINE (1966 - Sept Week 3 2002), PsycINFO (1872 - 2002/10 Week 2), The National Research Register (2002/3). In addition to this references were taken from reviews of the literature and reference lists from articles.

SELECTION CRITERIA

The review considered randomised controlled trials of speech and language therapy interventions for children or adolescents with primary speech and language delay/disorder.

DATA COLLECTION AND ANALYSIS

Titles and abstracts were identified and assessed for relevance, before the full text version was obtained of all potentially relevant articles. The data were categorised depending on the nature of the control group and considered in terms of the effects of intervention on expressive and receptive phonology, syntax and vocabulary. The outcomes used in the analysis were dependent on the focus of the study with only the primary effects of therapy being considered in this review.

MAIN RESULTS

The results of twenty-five studies were used in the meta-analysis. The results suggest that speech and language therapy is effective for children with phonological (SMD=0.44, 95%CI: 0.01,0.86) or vocabulary difficulties (SMD=0.89, 95%CI: 0.21,1.56), but that there is less evidence that interventions are effective for children with receptive difficulties (SMD=-0.04, 95%CI: -0.64,0.56). Mixed findings were found concerning the effectiveness of expressive syntax interventions (n=233; SMD=1.02, 95%CI: 0.04-2.01). No significant differences were shown between clinician administered intervention and intervention implemented by trained parents, and studies did not show a difference between the effects of group and individual interventions (SMD=0.01, 95%CI: -0.26,1.17). The use of normal language peers in therapy was shown to have a positive effect on therapy outcome (SMD=2.29, 95%CI: 1.11,3.48).

REVIEWER'S CONCLUSIONS

The review shows that overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. The evidence for expressive syntax difficulties is more mixed, and there is a need for further research to investigate intervention for receptive language difficulties. There is a large degree of heterogeneity in the results, and the sources of this need to be investigated.

Constructivist Strategies in Phonological Intervention

This tutorial describes an instructional approach for school-age children who have difficulty achieving phonological carryover. Behavioral, cognitive, and constructivist instructional strategies are examined in regard to their usefulness during the establishment, transfer, and carryover phases of phonological intervention. The advantages of using constructivist strategies to facilitate carryover are presented. A model of self-regulated learning is then applied to constructivist carryover activities (performances) so that children who have difficulty attaining carryover might develop metacognitive abilities similar to those of children who easily achieve carryover. Ideas for implementing a constructivist approach to facilitating self-regulated carryover are presented and examples are provided.

Factors associated with speech-sound stimulability

Speech-sound stimulability as a clinical procedure has been used in speech-language pathology for more than 60 years although review of the archival literature on this clinical construct provides little information on what factors may be associated with it. In this study, the factors found to relate to stimulability were articulation visibility, the child's age, the family's socioeconomic status, and the child's overall imitative abilities. Perception, severity, otitis media history, language abilities, consistency of productions, amount of stimulations provided, and willingness to self-correct were not associated with stimulability. Potential explanations are provided on the basis of prior research.

Visual feedback in treatment of residual phonological disorders

The use of visual biofeedback in the treatment of individuals who have Residual Phonological Errors is discussed. This type of treatment was used with clients who had not improved through traditional auditory/production based treatments. Biofeedback is conceptualized as a cognitive treatment that requires the client's analysis of visual information. The information is used in developing correct productions of Residual Phonological Errors. The reported results indicate that visual feedback is a viable alternative treatment for those who have been unable to develop correct sound production through traditional methods.

Self-Monitoring and Generalization in Preschool Speech-Delayed Children

Self-monitoring and generalization were observed as eight preschool children progressed in management programs for their developmental phonological disorders. Changes in the production of target and non-target sounds and behaviors presumed to reflect self-monitoring were tallied as they occurred concurrently in conversational speech samples. With some notable exceptions, generalization data for target and non-target sound changes were consistent with linguistic patterns reported in the literature. Self-monitoring behaviors were observed to vary in type, frequency, and point of onset in relation to generalization data. A consistent observation across children was that self-monitoring behaviors neither always nor only occurred in temporal association with generalization. Alternative hypotheses concerning the occurrence of self-monitoring behaviors in stimulus and response generalization are considered.

Changes in Apparent Extent of Misarticulation during Successive Repetitions of a Word

This study investigated the variability of judgments of correct and misarticulated /r/ words. Correct, moderate, and severely distorted /r/ words were each repeated 90 times on individual audio tapes and judged by listeners from one of three groups ( N = 33). Subjects in each group showed shifts in judgment but the group which evaluated the severely distorted /r/ word demonstrated the most frequent shifts in judgment.

Awareness of certain articulatory gestures in normal-speaking and articulatory-defective children

A comparison of the awareness of articulatory gestures between normal-speaking children and those with articulation disorders was undertaken. The articulation-disorders group included children receiving speech training, and others placed on an observation list. The results indicate that the groups did not differ with respect to their awareness of articulatory gestures. The majority of the responses from both groups reflected accurate execution of the task.