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.

Speech sound disorder or DLD (phonology)? Towards a consensus agreement on terminology.

BACKGROUND: The publication of phase 2 of the CATALISE project in 2017 clarified terminology for children with developmental language disorder (DLD) or delay but unintentionally muddied the water for children with unintelligible speech. A diagnostic label of DLD (phonology) indicates poor prognosis and phonological disorder that persists into middle childhood. However, in contrast to other diagnostic labels that fall under the overarching term of speech sound disorder (SSD), DLD (phonology) does not elucidate the characteristics of the child's speech nor does it point us in the direction of appropriate intervention. AIMS: The aim of this paper is to discuss terminology in SSD leading to an evidence-based model which builds on the model of DLD developed in CATALISE, supports descriptive diagnosis and signposts intervention. METHODS: Following a focused review of literature proposing or describing terminology for SSD, an expert group of researchers in developmental SSD proposed a revised model of existing terminology. Groups of UK speech and language therapists (SLTs) who provide services for children with SSD were asked to comment on its acceptability and feasibility. DISCUSSION: A three-level terminology model was developed. This comprised an overarching Level 1 term; Level 2 terms that differentiated SSD of unknown origin from SSD with associated or underlying conditions; and specific diagnostic terms at Level 3 to support further assessment and intervention decisions. Consulted SLTs generally expressed agreement with the proposed terminology and a willingness to adopt it in practice. CONCLUSIONS: Existing terminology for childhood SSD provides a good basis for clinical decision-making. A modified version of Dodd's (2005) terminology was found to be acceptable to UK SLTs. There is an evident overlap of SSD with CATALISE terminology. However more detailed and specialist terminology than 'DLD (phonology)' is required to support clinical decision-making. It is proposed that endorsement by the UK Royal College of Speech and Language Therapists would obviate the need for a Delphi process. WHAT THIS PAPER ADDS: What is already known on this subject Over nearly a hundred years, as our knowledge and understanding of speech sound disorder (SSD) has increased, so has the terminology that is used to describe those disorders. Current terminology not only describes subtypes of SSD but can also signpost us to effective interventions. With the publication, in 2017, of phase 2 of CATALISE a new term of 'developmental language disorder (DLD) (phonology)' was introduced with the unintentional consequence of challenging more specific descriptive terms for SSD. What this paper adds In the context of CATALISE and DLD (phonology), the history and nature of SSD terminology are reappraised. Building on the model of DLD developed in CATALISE, a tiered model that supports descriptive diagnosis and signposts intervention is proposed for discussion. Clinical implications of this study The proposed model of terminology for SSD provides descriptive and detailed labels that will support accuracy in differential diagnosis of developmental SSD by speech and language therapists. Furthermore, a decision-making tree for SSD demonstrates the pathway from diagnostic use of the terminology to the selection of evidence-based, effective interventions.

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.

Clinical application of usage-based phonology: Treatment of cleft palate speech using usage-based electropalotography.

PURPOSE: To investigate whether a novel electropalatography (EPG) therapy, underpinned by usage-based phonology theory, can improve the accuracy of target speech sounds for school-aged children and adults with persistent speech sound disorder (SSD) secondary to cleft palate +/- lip. METHOD: Six consecutively treated participants (7-27 years) with long-standing speech disorders associated with cleft palate enrolled in a multiple baseline (ABA) within-participant case series. The usage-based EPG therapy technique involved high-volume production of words. Speech was assessed on three baselines prior to therapy, during weekly therapy, at completion of therapy, and 3 months post-therapy. Percent correct of target phonemes in untreated words and continuously connected speech were assessed through acoustic phonetic transcription. Intra- and inter-transcriber agreement was determined. RESULT: Large to medium treatment effect sizes were shown for all participants following therapy (15-33 sessions). Percentage of targets correct for untreated words improved from near 0% pre-therapy, to near 100% for most target sounds post-therapy. Generalisation of target sounds to spontaneous connected speech occurred for all participants and ranged from 78.95-100% (M = 90.66; SD = 10.14) 3 months post-therapy. CONCLUSION: Clinically significant speech change occurred for all participants following therapy. Response to the novel therapeutic technique is encouraging and further research is indicated.

Tongue Shape Complexity in Children With and Without Speech Sound Disorders.

PURPOSE: This study investigates the hypothesis that younger speakers and speakers with more severe speech sound disorders are more likely to use simpler (undifferentiated) tongue gestures due to difficulties with, or immaturity of, lingual motor control. METHOD: The hypothesis is tested using cross-sectional secondary data analysis of synchronous audio and high-speed ultrasound recordings from children with idiopathic speech sound disorders (n = 30, aged 5;0-12;11 [years;months]) and typically developing children (n = 29, aged 5;8-12;10), producing /a/, /t/, /ɹ/, /l/, /s/, and /ʃ/ in an intervocalic /aCa/ environment. Tongue shape complexity is measured using NINFL (Number of INFLections) and modified curvature index (MCI) from splines fitted to ultrasound images at the point of maximal lingual gesture. Age, perceived accuracy, and consonant are used as predictors. RESULTS: The results suggest that as age increases, children with speech sound disorders have lower MCI compared to typically developing children. Increase in age also led to decrease of MCI for the typically developing group. In the group of children with speech sound disorders, perceptually incorrect /ɹ/ productions have lower MCI than correct productions, relative to /a/. CONCLUSIONS: There is some evidence of systematic tongue shape complexity differences between typically developing children and children with speech sound disorders when accounting for increase in age. Among children with speech sound disorders, increase in age and perceptually incorrect consonant realizations are associated with decreasing tongue shape complexity.

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.

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

INTRODUCTION: 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 list of assessments, interventions or outcomes exists.The objective of this paper is to provide a rigorous and detailed protocol for an umbrella review of assessments, interventions and outcomes that target SSD in children. The protocol details the development of a search strategy and trial of an extraction tool. METHODS AND ANALYSES: The umbrella review has been registered with PROSPERO (CRD42022316284). Papers included can use a review methodology of any sort but must include children of any age, with an SSD of unknown origin. In accordance with the Joanna Briggs Institute scoping review methods guidelines, an initial search of the Ovid Emcare and Ovid Medline databases was conducted. Following this, a final search strategy for these databases were produced. A draft extraction form was developed. ETHICS AND DISSEMINATION: Ethical approval is not needed for an umbrella review protocol. Following the systematic development of an initial search strategy and extraction form, an umbrella review of this topic can take place. Dissemination of findings will be through peer-reviewed publications, social media, and patient and public engagement.

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.

Translation and validation of the Intelligibility in Context Scale into Sinhala for adolescents in Sri Lanka with cleft lip and palate.

The Intelligibility in Context Scale (ICS) is a parent-report screening tool used to measure parents' perceptions of children's functional intelligibility. This tool has been translated into over 60 languages and found to have a good reliability and validity. The purpose of the current study was to translate the ICS into Sinhala (the ICS-SIN), the main language spoken by the Sinhalese people in Sri Lanka, and to validate it with both typically developing (TD) children and children with repaired cleft lip and/or palate (CLP). The translation process followed the forward-backward-forward method. A total of 88 parents of TD children and children with CLP aged 12-15 years old (TD n = 50, CLP n = 38) completed the ICS-SIN questionnaire. Parents of TD and CLP children reported their children's speech as most intelligible to parents and least intelligible to strangers. The ICS-SIN had high internal consistency for both groups (TD α = 0.87, p < 0.05, CLP α = 0.97, p < 0.05). The ICS-SIN total scores and item scores showed significant correlations, indicating a good construct validity. TD participant group's ICS-SIN average mean scores (M = 4.88, SD = 0.29) were significantly higher compared to the CLP ICS-SIN average mean scores (M = 4.64, SD = 0.67) and varied according to gender in both groups, suggesting good discriminant validity. The ICS-SIN has overall good psychometric properties. Therefore, this tool has the potential to be used as a valid parent-rating screening tool for clinical and research purposes in Sri Lanka.

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.

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.

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.

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 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.

The Impact of Real-Time Articulatory Information on Phonetic Transcription: Ultrasound-Aided Transcription in Cleft Lip and Palate Speech.

OBJECTIVE: This study investigated whether adding an additional modality, namely ultrasound tongue imaging (UTI), to perception-based phonetic transcription impacted on the identification of compensatory articulations and on interrater reliability. PATIENTS AND METHODS: Thirty-nine English-speaking children aged 3-12 years with cleft lip and palate (CLP) were recorded producing repetitions of /aCa/ for all places of articulation with simultaneous audio recording and probe-stabilized ultrasound (US). Three types of transcriptions were performed: (1) descriptive observations from the live US by the clinician recording the data, (2) US-aided transcription (UA) by two US-trained clinicians, and (3) traditional phonetic transcription by two CLP specialists from audio recording. We compared the number of consonants identified as in error by each transcriber and then classified errors into eight different subcategories. RESULTS: Both UA and traditional transcription yielded similar error detection rates; however, these were significantly higher than the observations recorded live in the clinic. Interrater reliability for the US transcribers was substantial (κ = 0.65) compared to moderate (κ = 0.47) for the traditional transcribers. US transcribers were more likely to identify covert errors such as double articulations and retroflexion than the audio-only transcribers. CONCLUSION: UTI is a useful complement to traditional phonetic transcription for CLP speech.

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

BACKGROUND: As cost and access barriers to ultrasound technology have decreased, interest in using ultrasound visual biofeedback (U-VBF) as a tool for remediating speech sound disorders (SSD) has increased. A growing body of research has investigated U-VBF in intervention for developmental SSD; however, diversity in study design, participant characteristics, clinical methods and outcomes complicate the interpretation of this literature. Thus, there is a need for a synthesis and review of the evidence base for using U-VBF in intervention for SSD. AIMS: To synthesise and evaluate the research evidence for U-VBF in intervention for developmental SSD. METHODS: A systematic review was conducted. Eight electronic databases were searched for peer-reviewed articles published before 2018. Details about study design, participants, intervention procedures, service delivery, intervention intensity and outcomes were extracted from each study that met the inclusion criteria. The included studies were rated using both a critical appraisal tool and for their reporting of intervention detail. MAIN CONTRIBUTIONS: Twenty-eight papers, comprising 29 studies, met the inclusion criteria. The most common research design was single-case experimental design (44.8% of studies). The studies included between one and 13 participants (mean = 4.1) who had a mean age of approximately 11 years (range = 4;0-27 years). Within the research evidence, U-VBF intervention was typically provided as part of, or as an adjunct to, other articulatory-based therapy approaches. A range of lingual sounds were targeted in intervention, with 80.6% of participants across all reviewed studies receiving intervention targeting rhotics. Outcomes following therapy were generally positive with the majority of studies reporting that U-VBF facilitated acquisition of targets, with effect sizes ranging from no effect to a large effect. Difficulties with generalisation were observed for some participants. Most studies (79.3%) were categorised as efficacy rather than effectiveness studies and represented lower levels of evidence. Overall, the reviewed studies scored more highly on measures of external validity than internal validity. CONCLUSIONS: The evidence base for U-VBF is developing; however, most studies used small sample sizes and lower strength designs. Current evidence indicates that U-VBF may be an effective adjunct to intervention for some individuals whose speech errors persist despite previous intervention. The results of this systematic review underscore the need for more high-quality and large-scale research exploring the use of this intervention in both controlled and community contexts.

Enabling New Articulatory Gestures in Children With Persistent Speech Sound Disorders Using Ultrasound Visual Biofeedback.

Purpose This study evaluated ultrasound visual biofeedback treatment for teaching new articulations to children with a wide variety of speech sound disorders. It was hypothesized that motor-based intervention incorporating ultrasound would lead to rapid acquisition of a range of target lingual gestures with generalization to untreated words. Method Twenty children aged 6-15 years with a range of mild to severe speech disorders affecting a variety of lingual targets enrolled in a case series with replication. Of these, 15 children completed the intervention. All of the children presented with a variety of errors. We therefore employed a target selection strategy to treat the most frequent lingual error. These individual speech targets were treated using ultrasound visual biofeedback as part of ten to twelve 1-hr intervention sessions. The primary outcome measure was percentage of target segments correct in untreated wordlists. Results Six children were treated for velar fronting; 3 children, for postalveolar fronting; 2 children, for backing alveolars to pharyngeal or glottal place; 1 child, for debuccalization (production of all onsets as [h]); 1 child, for vowel merger; and 2 children, for lateralized sibilants. Ten achieved the new articulation in the 1st or 2nd session of intervention, despite no children being readily stimulable for their target articulation before intervention. In terms of generalization, effect sizes for percentage of target segments correct ranged from no effect (5 children), small effect (1 child), medium effect (4 children), and large effect (5 children). Conclusions Ultrasound visual biofeedback can be used to treat a wide range of lingual errors in children with various speech sound disorders, from mild to severe. Visual feedback may be useful for establishing new articulations; however, generalization is more variable.

Use of electropalatography in the treatment of speech disorders in children with Down syndrome: a randomized controlled trial.

BACKGROUND: Electropalatography (EPG) records details of the location and timing of tongue contacts with the hard palate during speech. It has been effective in treating articulation disorders that have failed to respond to conventional therapy approaches but, until now, its use with children and adolescents with intellectual/learning disabilities and speech disorders has been limited. AIMS: To evaluate the usefulness of EPG in the treatment of speech production difficulties in children and adolescents with Down syndrome (DS) aged 8-18 years. METHODS & PROCEDURES: A total of 27 children with DS were assessed on a range of cognitive and speech and language measures and underwent additional EPG assessment. Participants were randomly allocated to one of three age-matched groups receiving either EPG therapy, EPG-informed conventional therapy or 'treatment as usual' over a 12-week period. The speech of all children was assessed before therapy using the Diagnostic Evaluation of Articulation and Phonology (DEAP) and reassessed immediately post- and 3 and 6 months post-intervention to measure percentage consonants correct (PCC). EPG recordings were made of the DEAP assessment items at all time points. Per cent intelligibility was also calculated using the Children's Speech Intelligibility Measure (CSIM). OUTCOMES & RESULTS: Gains in accuracy of production immediately post-therapy, as measured by PCC, were seen for all groups. Reassessment at 3 and 6 months post-therapy revealed that those who had received therapy based directly on EPG visual feedback were more likely to maintain and improve on these gains compared with the other groups. Statistical testing showed significant differences between groups in DEAP scores across time points, although the majority did not survive post-hoc evaluation. Intelligibility across time points, as measured by CSIM, was also highly variable within and between the three groups, but despite significant correlations between DEAP and CSIM at all time points, no statistically significant group differences emerged. CONCLUSIONS & IMPLICATIONS: EPG was an effective intervention tool for improving speech production in many participants. This may be because it capitalizes on the relative strength of visual over auditory processing in this client group. The findings would seem to warrant an increased focus on addressing speech production difficulties in current therapy.

Covert contrast and covert errors in persistent velar fronting.

Acoustic and articulatory studies demonstrate covert contrast in perceptually neutralised phonemic contrasts in both typical children and children with speech disorders. These covert contrasts are thought to be relatively common and symptomatic of phonetic speech disorders. However, clinicians in the speech therapy clinic have had no easy way of identifying this covertness. This study uses ultrasound tongue imaging to compare tongue contours for /t/and /k/in seven children with persistent velar fronting. We present a method of overlaying tongue contours to identify covert contrast at the articulatory level. Results show that all seven children, contrary to expectations, produced both /t/and /k/with near-identical tongue shapes showing no evidence of covert contrast. However, further analysis of one of the participants showed highly variable tongue shapes for /t/and /k/, including retroflex productions of both. Although not phonologically conditioned, this covert error is evidence of speech disorder at the phonetic level.