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.

Efficacy of Electropalatography for Treating Misarticulation of /r/.

PURPOSE: The purpose of the present study was to document the efficacy of electropalatography (EPG) for the treatment of rhotic errors in school-age children. Despite a growing body of literature using EPG for the treatment of speech sound errors, there is little systematic evidence about the relative efficacy of EPG for rhotic errors. METHOD: Participants were 5 English-speaking children aged 6;10 to 9;10, who produced /r/ at the word level with < 30% accuracy but otherwise showed typical speech, language, and hearing abilities. Therapy was delivered in twice-weekly 30-min sessions for 8 weeks. RESULTS: Four out of 5 participants were successful in achieving perceptually and acoustically accurate /r/ productions during within-treatment trials. Two participants demonstrated generalization of /r/ productions to nontreated targets, per blinded listener ratings. CONCLUSIONS: The present findings support the hypothesis that EPG can improve production accuracy in some children with rhotic errors. However, the utility of EPG is likely to remain variable across individuals. For rhotics, EPG training emphasizes one possible tongue configuration consistent with accurate rhotic production (lateral tongue contact). Although some speakers respond well to this cue, the narrow focus may limit lingual exploration of other acceptable tongue shapes known to facilitate rhotic productions.

Enhancing Intervention for Residual Rhotic Errors Via App-Delivered Biofeedback: A Case Study.

Purpose: Recent research suggests that visual-acoustic biofeedback can be an effective treatment for residual speech errors, but adoption remains limited due to barriers including high cost and lack of familiarity with the technology. This case study reports results from the first participant to complete a course of visual-acoustic biofeedback using a not-for-profit iOS app, Speech Therapist's App for /r/ Treatment. Method: App-based biofeedback treatment for rhotic misarticulation was provided in weekly 30-min sessions for 20 weeks. Within-treatment progress was documented using clinician perceptual ratings and acoustic measures. Generalization gains were assessed using acoustic measures of word probes elicited during baseline, treatment, and maintenance sessions. Results: Both clinician ratings and acoustic measures indicated that the participant significantly improved her rhotic production accuracy in trials elicited during treatment sessions. However, these gains did not transfer to generalization probes. Conclusions: This study provides a proof-of-concept demonstration that app-based biofeedback is a viable alternative to costlier dedicated systems. Generalization of gains to contexts without biofeedback remains a challenge that requires further study. App-delivered biofeedback could enable clinician-research partnerships that would strengthen the evidence base while providing enhanced treatment for children with residual rhotic errors. Supplemental Material: https://doi.org/10.23641/asha.5116318.

Perceptual, durational and tongue displacement measures following articulation therapy for rhotic sound errors.

Outcomes of articulation therapy for rhotic errors are usually assessed perceptually. However, our understanding of associated changes of tongue movement is limited. This study described perceptual, durational and tongue displacement changes over 10 sessions of articulation therapy for /ɹ/ in six children. Four of the participants also received ultrasound biofeedback of their tongue shape. Speech and tongue movement were recorded pre-therapy, after 5 sessions, in the final session and at a one month follow-up. Perceptually, listeners perceived improvement and classified more productions as /ɹ/ in the final and follow-up assessments. The durations of VɹV syllables at the midway point of the therapy were longer. Cumulative tongue displacement increased in the final session. The average standard deviation was significantly higher in the middle and final assessments. The duration and tongue displacement measures illustrated how articulation therapy affected tongue movement and may be useful for outcomes research about articulation therapy.

Direction of attentional focus in biofeedback treatment for /r/ misarticulation.

BACKGROUND: Maintaining an external direction of focus during practice is reported to facilitate acquisition of non-speech motor skills, but it is not known whether these findings also apply to treatment for speech errors. This question has particular relevance for treatment incorporating visual biofeedback, where clinician cueing can direct the learner's attention either internally (i.e., to the movements of the articulators) or externally (i.e., to the visual biofeedback display). AIMS: This study addressed two objectives. First, it aimed to use single-subject experimental methods to collect additional evidence regarding the efficacy of visual-acoustic biofeedback treatment for children with /r/ misarticulation. Second, it compared the efficacy of this biofeedback intervention under two cueing conditions. In the external focus (EF) condition, participants' attention was directed exclusively to the external biofeedback display. In the internal focus (IF) condition, participants viewed a biofeedback display, but they also received articulatory cues encouraging an internal direction of attentional focus. METHODS & PROCEDURES: Nine school-aged children were pseudo-randomly assigned to receive either IF or EF cues during 8 weeks of visual-acoustic biofeedback intervention. Accuracy in /r/ production at the word level was probed in three to five pre-treatment baseline sessions and in three post-treatment maintenance sessions. Outcomes were assessed using visual inspection and calculation of effect sizes for individual treatment trajectories. In addition, a mixed logistic model was used to examine across-subjects effects including phase (pre/post-treatment), /r/ variant (treated/untreated), and focus cue condition (internal/external). OUTCOMES & RESULTS: Six out of nine participants showed sustained improvement on at least one treated /r/ variant; these six participants were evenly divided across EF and IF treatment groups. Regression results indicated that /r/ productions were significantly more likely to be rated accurate post- than pre-treatment. Internal versus external direction of focus cues was not a significant predictor of accuracy, nor did it interact significantly with other predictors. CONCLUSIONS: The results are consistent with previous literature reporting that visual-acoustic biofeedback can produce measurable treatment gains in children who have not responded to previous intervention. These findings are also in keeping with previous research suggesting that biofeedback may be sufficient to establish an external attentional focus, independent of verbal cues provided. The finding that explicit articulator placement cues were not necessary for progress in treatment has implications for intervention practices for speech-sound disorders in children.

Multiple phonetically trained-listener comparisons of speech before and after articulatory intervention in two children with repaired submucous cleft palate.

Cleft Palate (CP) assessments based on phonetic transcription are the "gold standard" therapy outcome measure, despite reliability difficulties. Here we propose a novel perceptual evaluation, applied to ultrasound-visual biofeedback (U-VBF) therapy and therapy using visual articulatory models (VAMs) for two children with repaired submucous CP. Three comparisons were made: post VAM, post U-VBF and overall pre- and post-therapy. Twenty-two phonetically-trained listeners were asked to determine whether pre- or post-therapy recordings sounded "closer to the English target", using their own implicit phonological knowledge (prompted via orthographic representation). Results are compared with segment-oriented percent target consonant correct (PTCC) derived from phonetic transcriptions. Listener judgements and PTCC suggest that both children made improvements using both VAM and U-VBF. Statistical analysis showed listener agreement in each comparison, though agreement was weak. However, perceptual evaluation offers a straightforward method of evaluating the effectiveness of interventions and can be used by phonetically trained or lay listeners.

Using ultrasound visual feedback to remediate velar fronting in preschool children: A pilot study.

Anecdotally, velar fronting can be difficult to remediate in some children. This pilot study examined the use of ultrasound visual feedback in remediating velar fronting in typically developing children. A single-case, multiple-baseline across-subjects experimental design was used to examine acquisition, retention and generalisation of velar treatment targets. Two otherwise typically developing children (P1, aged 4;0; P3, aged 4;11) completed the study. The productions of /k/ and /É¡/ at syllable level were targeted during treatment. P1 improved her productions of /k/ and /É¡/ at syllable level during the treatment period and achieved correct production at word level during follow-up. P3 made no improvements in his productions of velar targets. This study suggests that ultrasound visual feedback may be an option for remediating velar fronting in some preschoolers. Further study is required.

Programa de intervenção práxico-produtivo para crianças com transtorno fonológico / Praxis-productive intervention program for children with phonological disorder

A fala é definida como a representação motora da Linguagem, a partir da coordenação de três processos neurológicos: organização de conceitos, formulação e expressão simbólica; programação do ato motor envolvido na produção da fala e a sua própria produção motora. O controle motor da fala, que ordena a contração muscular para a sua execução de praxias, inclui o planejamento, a preparação de movimentos e a execução de planos, com vistas a contrações musculares e deslocamentos de estruturas que culminarão na articulação da fala. Os trabalhos científicos nacionais e internacionais vislumbram um novo campo de atuação fonoaudiológica para o trabalho com a fala alterada, com a estimulação da praxias não verbais. Os objetivos deste trabalho centram-se na elaboração de um Programa de Intervenção Práxico-produtivo e aplicação em crianças com transtorno fonológico, para verificar sua aplicabilidade na clínica fonoaudiológica. O trabalho foi dividido em 2 etapas. A 1ª etapa contou com a revisão, na bibliografia nacional e internacional, do tratamento dado às praxias orais e não verbais e suas aplicações clínicas no âmbito fonoaudiológico, por meio de busca nas bases de dados PubMed, Lilacs e Scielo. Os artigos mostraram que a praxia não verbal pode ser estimulada para o trabalho clínico com a fala, no entanto, não há descrição do trabalho fonoaudiológico, tampouco um detalhamento de exercícios em sequência que poderiam ser usados. Nenhum artigo referiu o modo pelo qual as praxias não verbais deveriam ser trabalhadas, nem mesmo como se deve estimular a programação motora para a fala. Baseados nessa revisão, este estudo propôs um programa de estimulação das praxias não verbais de lábios e língua e dos aspectos fonológicos em 12 sessões pré-determinadas. Após elaboração do programa, aplicouse o material em 12 crianças, com idades entre 6 e 8 anos, com transtorno fonológico, que se enquadravam nos critérios de inclusão do estudo, para mostrar sua aplicabilidade na clínica. Os resultados apontaram melhora da realização da fala em todos os sujeitos, no tempo estipulado pelo instrumento, com escores superiores nas provas avaliativas de fonologia e praxias orais pós-intervenção, quando comparadas aos scores da pré-intervenção. O Programa de Intervenção Práxico-produtivo mostrou-se útil, simples, de fácil aplicação pelo fonoaudiólogo e de bom entendimento pelos participantes, com respostas favoráveis à aquisição dos fonemas.(AU)

Speech is defined as the motor representation of language from the coordination of three neurological processes: organization of concepts, formulation and symbolic expression; programming of motor act involved in speech production and its own motor production. The speech motor control, which orders the muscle contraction for its execution, includes the planning, preparation of movements and execution of plans, with a view to muscle contractions and movements of structures that will culminate in speech. National and international scientific papers envision a new field of speech therapy to work with altered speech with the stimulation of non-verbal praxis. The objectives of the present study focuses on the development of a Program of Praxis- Productive Intervention and its application in children with phonological disorder in order to verify its usability in speech therapy. The study was defined in 2 parts. The 1st stage included a review of the national and international literature for the treatment of oral and non-verbal praxis and its clinical applications in the area of speech by searching in the PubMed, Lilacs and Scielo databases. The articles showed that nonverbal praxis can be stimulated for clinical work with speech, however, there is no description of speech therapy work, nor a breakdown of exercises in sequence that could be used. No article referred to the way in which non-verbal praxis should be worked, not even how to stimulate motor programming for speech. Based on this review, the present study proposed a stimulation program of non-verbal praxis of the lips and tongue and the phonological aspects in 12 predetermined sessions. After drawing up the program, the material was applied to 12 children, aged between 6 and 8 years with phonological disorder that met the inclusion criteria of the study in order to show their applicability in practice. The results showed improvement in the realization of Speech in all subjects at the time stipulated by the instrument, with higher scores on the evaluative evidence of Phonology and Oral Praxis post-intervention compared to the scores of pre-intervention. The Praxis-productive intervention program was useful, simple, easy to apply by the speech patologist and had a good understanding by the participants with favorable responses for the acquisition of phonemes.(AU)

Efeitos do treinamento auditivo computadorizado em crianças com distúrbio do processamento auditivo e sistema fonológico típico e atípico / Effects of computerized auditory training in children with auditory processing disorder and typical and atypical phonological system

RESUMO Objetivo: Investigar os efeitos do treinamento auditivo computadorizado (TAC) por meio da análise do desempenho em testes comportamentais e da Escala de Funcionamento Auditivo (SAB), em crianças com distúrbio do processamento auditivo (DPA) e sistema fonológico típico e atípico. Métodos: Participaram 14 crianças com DPA, sete crianças com DPA e aquisição fonológica típica (G1) e sete com DPA e aquisição fonológica atípica (G2). Foi realizada a avaliação comportamental do processamento auditivo com o Teste de Detecção de Intervalo Aleatório (RGDT), Teste de Inteligibilidade Pediátrica (PSI), Teste Dicótico Não Verbal (TDNV) e Escala de Funcionamento Auditivo (SAB). Para composição dos grupos realizou-se a Avaliação Fonológica da Criança. A intervenção terapêutica foi realizada por meio do software Escuta Ativa, com 12 sessões, duas vezes por semana. Utilizou-se testes estatísticos adequados. Resultados: No desempenho nos testes comportamentais do processamento auditivo (PA), pré-TAC e pós-TAC, o resultado foi significativo no RGDT e TDNV, etapa de escuta direcionada à esquerda em ambos os grupos e TDNV à direita apenas no G2. Houve correlação positiva entre SAB e algumas condições de escuta do teste PSI em ambos os grupos, tanto pré-TAC quanto pós-TAC, além de correlação negativa entre a SAB e o teste RGDT pós-TAC, no grupo com aquisição fonológica típica e DPA. A SAB mostrou-se um instrumento útil para mensurar o efeito do TAC. Conclusão: O TAC mostrou-se eficaz para melhorar/adequar os processos gnósicos auditivos em escolares dos grupos estudados. Houve correlação entre os testes comportamentais e o escore na SAB.

ABSTRACT Purpose: To investigate the effects of computerized auditory training (CAT) through performance analysis of behavioral tests and Scale of Auditory Behaviors (SAB), in children with Auditory Processing Disorder (APD) and typical and atypical phonological system. Methods: Forteen children with APD, seven children with APD and typical phonological acquisition (G1) and seven with APD and atypical phonological acquisition (G2) participated. It was performed an auditory processing behavioral evaluation with Random Gap Detection Test (RGDT), Pediatric Speech Intelligibility test (PSI), Nonverbal Dichotic Test (NVDT) and SAB. For composition of the groups it was performed a Child Phonological Assessment. The therapeutic intervention was performed using the Escuta Ativa software, with 12 sessions held twice a week. Appropriate statistical tests were used. Results: In the performance in behavioral tests of auditory processing (AP), pre-and post-CAT, there was a significant result in RGDT and NVDT, hearing stage directed to the left in both groups and NVDT to the right only in G2. There was a positive correlation between SAB and some listening conditions of the PSI test in both groups, including pre and post-CAT. Moreover, there was a negative correlation between SAB and the RGDT test post-CAT in the group with typical phonological acquisition and APD. SAB proved to be a useful tool to measure the effect of CAT. Conclusion: CAT was effective to improve/adapt the gnosis auditory processes in the studied school groups. There was a correlation between behavioral tests and the score in the SAB.

Non-speech oral motor treatment for children with developmental speech sound disorders.

BACKGROUND: Children with developmental speech sound disorders have difficulties in producing the speech sounds of their native language. These speech difficulties could be due to structural, sensory or neurophysiological causes (e.g. hearing impairment), but more often the cause of the problem is unknown. One treatment approach used by speech-language therapists/pathologists is non-speech oral motor treatment (NSOMT). NSOMTs are non-speech activities that aim to stimulate or improve speech production and treat specific speech errors. For example, using exercises such as smiling, pursing, blowing into horns, blowing bubbles, and lip massage to target lip mobility for the production of speech sounds involving the lips, such as /p/, /b/, and /m/. The efficacy of this treatment approach is controversial, and evidence regarding the efficacy of NSOMTs needs to be examined. OBJECTIVES: To assess the efficacy of non-speech oral motor treatment (NSOMT) in treating children with developmental speech sound disorders who have speech errors. SEARCH METHODS: In April 2014 we searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (R) and Ovid MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Education Resources Information Center (ERIC), PsycINFO and 11 other databases. We also searched five trial and research registers, checked the reference lists of relevant titles identified by the search and contacted researchers to identify other possible published and unpublished studies. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials that compared (1) NSOMT versus placebo or control; and (2) NSOMT as adjunctive treatment or speech intervention versus speech intervention alone, for children aged three to 16 years with developmental speech sound disorders, as judged by a speech and language therapist. Individuals with an intellectual disability (e.g. Down syndrome) or a physical disability were not excluded. DATA COLLECTION AND ANALYSIS: The Trials Search Co-ordinator of the Cochrane Developmental, Psychosocial and Learning Problems Group and one review author ran the searches. Two review authors independently screened titles and abstracts to eliminate irrelevant studies, extracted data from the included studies and assessed risk of bias in each of these studies. In cases of ambiguity or information missing from the paper, we contacted trial authors. MAIN RESULTS: This review identified three studies (from four reports) involving a total of 22 children that investigated the efficacy of NSOMT as adjunctive treatment to conventional speech intervention versus conventional speech intervention for children with speech sound disorders. One study, a randomised controlled trial (RCT), included four boys aged seven years one month to nine years six months - all had speech sound disorders, and two had additional conditions (one was diagnosed as "communication impaired" and the other as "multiply disabled"). Of the two quasi-randomised controlled trials, one included 10 children (six boys and four girls), aged five years eight months to six years nine months, with speech sound disorders as a result of tongue thrust, and the other study included eight children (four boys and four girls), aged three to six years, with moderate to severe articulation disorder only. Two studies did not find NSOMT as adjunctive treatment to be more effective than conventional speech intervention alone, as both intervention and control groups made similar improvements in articulation after receiving treatments. One study reported a change in postintervention articulation test results but used an inappropriate statistical test and did not report the results clearly. None of the included studies examined the effects of NSOMTs on any other primary outcomes, such as speech intelligibility, speech physiology and adverse effects, or on any of the secondary outcomes such as listener acceptability.The RCT was judged at low risk for selection bias. The two quasi-randomised trials used randomisation but did not report the method for generating the random sequence and were judged as having unclear risk of selection bias. The three included studies were deemed to have high risk of performance bias as, given the nature of the intervention, blinding of participants was not possible. Only one study implemented blinding of outcome assessment and was at low risk for detection bias. One study showed high risk of other bias as the baseline characteristics of participants seemed to be unequal. The sample size of each of the included studies was very small, which means it is highly likely that participants in these studies were not representative of its target population. In the light of these serious limitations in methodology, the overall quality of the evidence provided by the included trials is judged to be low. Therefore, further research is very likely to have an important impact on our confidence in the estimate of treatment effect and is likely to change the estimate. AUTHORS' CONCLUSIONS: The three included studies were small in scale and had a number of serious methodological limitations. In addition, they covered limited types of NSOMTs for treating children with speech sound disorders of unknown origin with the sounds /s/ and /z/. Hence, we judged the overall applicability of the evidence as limited and incomplete. Results of this review are consistent with those of previous reviews: Currently no strong evidence suggests that NSOMTs are an effective treatment or an effective adjunctive treatment for children with developmental speech sound disorders. Lack of strong evidence regarding the treatment efficacy of NSOMTs has implications for clinicians when they make decisions in relation to treatment plans. Well-designed research is needed to carefully investigate NSOMT as a type of treatment for children with speech sound disorders.

Using ultrasound visual biofeedback to treat persistent primary speech sound disorders.

Growing evidence suggests that speech intervention using visual biofeedback may benefit people for whom visual skills are stronger than auditory skills (for example, the hearing-impaired population), especially when the target articulation is hard to describe or see. Diagnostic ultrasound can be used to image the tongue and has recently become more compact and affordable leading to renewed interest in it as a practical, non-invasive visual biofeedback tool. In this study, we evaluate its effectiveness in treating children with persistent speech sound disorders that have been unresponsive to traditional therapy approaches. A case series of seven different children (aged 6-11) with persistent speech sound disorders were evaluated. For each child, high-speed ultrasound (121 fps), audio and lip video recordings were made while probing each child's specific errors at five different time points (before, during and after intervention). After intervention, all the children made significant progress on targeted segments, evidenced by both perceptual measures and changes in tongue-shape.

Enhancing generalisation in biofeedback intervention using the challenge point framework: a case study.

Biofeedback intervention can help children achieve correct production of a treatment-resistant error sound, but generalisation is often limited. This case study suggests that generalisation can be enhanced when biofeedback intervention is structured in accordance with a "challenge point" framework for speech-motor learning. The participant was an 11-year-old with residual /r/ misarticulation who had previously attained correct /r/ production through a structured course of ultrasound biofeedback treatment but did not generalise these gains beyond the word level. Treatment difficulty was adjusted in an adaptive manner following predetermined criteria for advancing, maintaining, or moving back a level in a multidimensional hierarchy of functional task complexity. The participant achieved and maintained virtually 100% accuracy in producing /r/ at both word and sentence levels. These preliminary results support the efficacy of a semi-structured implementation of the challenge point framework as a means of achieving generalisation and maintenance of treatment gains.

Retroflex versus bunched in treatment for rhotic misarticulation: evidence from ultrasound biofeedback intervention.

PURPOSE: To document the efficacy of ultrasound biofeedback treatment for misarticulation of the North American English rhotic in children. Because of limited progress in the first cohort, a series of two closely related studies was conducted in place of a single study. The studies differed primarily in the nature of tongue-shape targets (e.g., retroflex, bunched) cued during treatment. METHOD: Eight participants received 8 weeks of individual ultrasound biofeedback treatment targeting rhotics. In Study 1, all 4 participants were cued to match a bunched tongue-shape target. In Study 2, participants received individualized cues aimed at eliciting the tongue shape most facilitative of perceptually correct rhotics. RESULTS: Participants in Study 1 showed only minimal treatment effects. In Study 2, all participants demonstrated improved production of rhotics in untreated words produced without biofeedback, with large to very large effect sizes. CONCLUSIONS: The results of Study 2 indicate that with proper parameters of treatment, ultrasound biofeedback can be a highly effective intervention for children with persistent rhotic errors. In addition, qualitative comparison of Studies 1 and 2 suggests that treatment for the North American English rhotic should include opportunities to explore different tongue shapes, to find the most facilitative variant for each individual speaker.

A multi-modal approach to intervention for one adolescent's frontal lisp.

An adolescent with a persistent frontal lisp participated in a two-part 11-session intervention case study. The first phase used ultrasound imagery and acoustic, phonetic and voice education to provide information about articulatory setting (AS) and general awareness of the speech production process. The second phase used traditional articulation therapy, online visual-acoustic biofeedback and fluency strategies to target the frontal lisp directly (specifically /s/, /z/, /ʃ/ and /ʧ/). Trained listener evaluations of pre-intervention, post-phase 1 and post-phase 2 assessments showed no improvement after phase 1, but notable improvement in all treatment targets immediately after phase 2. These improvements were substantially maintained at assessment 4 months post-intervention. The outcomes suggest that direct training was more effective than the AS approach; however, the client's ability to self-monitor in phase 2, rapid acquisition of the targets and maintenance at 4 months post-intervention possibly reflected the knowledge gained in phase 1 about AS.

Investigating the use of traditional and spectral biofeedback approaches to intervention for /r/ misarticulation.

PURPOSE: Misarticulation of /r/ is among the most challenging developmental speech errors to remediate. Case studies suggest that visual biofeedback treatment can establish perceptually accurate /r/ in clients who have not responded to traditional treatments. This investigation studied the response of children with persistent /r/ misarticulation to a course of traditional treatment and a course of biofeedback treatment. METHOD: Eleven children with /r/ misarticulation completed 10 weeks of individual treatment consisting of 4-6 weeks of traditional treatment followed by 4-6 weeks of biofeedback treatment. Progress was measured by tracking correct /r/ productions within treatment and probing /r/ in words at 3 time points. RESULTS: At the group level, there was no difference in independent judges' ratings of /r/ sounds produced by the children before and after traditional treatment. However, /r/ sounds produced after biofeedback treatment were significantly more likely to be rated by the judges as perceptually correct. Eight of the 11 children made measurable gains in the accuracy of isolated /r/ produced within treatment, with 4 showing significant generalization to untreated /r/ in words. CONCLUSION: This descriptive study shows that treatment incorporating spectral biofeedback can facilitate accurate /r/ production in children with treatment-resistant errors. A follow-up period using traditional intervention methods may be necessary to encourage generalization.

Research and clinical findings--a wholistic view.

Valuable information is available to clinicians both from research articles, and reports from clinicians. Both sources have limitations. Research, with the exception of longitudinal studies, tends to isolate a variable or two from the whole, limiting its usefulness. Clinical techniques reported are sometimes biased, and perform well for certain therapists in certain settings, and not so well for others. Interrelationships are important among variables such as dentition, anatomy, physiology, oral muscle functions, oral rest postures, eating, and speech. Each affects the others. Equally important are interrelationships among all the specialists who treat patients with orofacial myofunctional disorders. A wholistic approach to the evaluation and treatment of orofacial disorders is advocated.

Speech therapy for errors secondary to cleft palate and velopharyngeal dysfunction.

Individuals with a history of cleft lip/palate or velopharyngeal dysfunction may demonstrate any combination of speech sound errors, hypernasality, and nasal emission. Speech sound distortion can also occur due to other structural anomalies, including malocclusion. Whenever there are structural anomalies, speech can be affected by obligatory distortions or compensatory errors. Obligatory distortions (including hypernasality due to velopharyngeal insufficiency) are caused by abnormal structure and not by abnormal function. Therefore, surgery or other forms of physical management are needed for correction. In contrast, speech therapy is indicated for compensatory articulation productions where articulation placement is changed in response to the abnormal structure. Speech therapy is much more effective if it is done after normalization of the structure. When speech therapy is appropriate, the techniques involve methods to change articulation placement using standard articulation therapy principles. Oral-motor exercises, including the use of blowing and sucking, are never indicated to improve velopharyngeal function. The purpose of this article is to provide information regarding when speech therapy is appropriate for individuals with a history of cleft palate or other structural anomalies and when physical management is needed. In addition, some specific therapy techniques are offered for the elimination of common compensatory articulation productions.

Palatal training appliances in children with mild to moderate oral dysfunctions.

OBJECTIVE: The objective of the study was to evaluate the efficacy of palatal training appliances on speech articulation and orofacial functions in children undergoing speech therapy. STUDY DESIGN: The material consisted of 134 boys and 34 girls who were referred by speech and language therapists to the Public Dental Health Service in Vantaa due to mild to moderate problems with speech articulation or in oral motor skills. The mean age of the children at the start of the palatal plate therapy was 6.4 years (SD 1.9). The articulation assessment was performed by five speech and language therapist while the palatal plate therapy was carried out by an experienced dentist. The mean treatment time with the oral plates was 4.4 months (SD 2.3). RESULTS: An improvement in speech articulation was observed by the speech and language therapists in 51% of the children. Tongue movements improved in 47%, and lip closure in 38% of the participants. Drooling decreased in 54% of the cases. A multiple logistic regression model revealed that with respect to speech articulation the best improvement was found in children with /r/-disorder and in those with a crossbite. CONCLUSIONS: Palatal training appliances during speech therapy seemed to be an efficient way to improve speech articulation and tongue movements in children with mild to moderate problems in orofacial functions.

Horns, whistles, bite blocks, and straws: a review of tools/objects used in articulation therapy by Van Riper and other traditional therapists.

The use of tools and other objects in articulation therapy has been bundled into new groups of activities called "nonspeech oral motor exercises" (NSOME) and 'nonspeech oral motor treatments' (NSOMT) by some authors. The purveyors of these new terms suggest that there is no proof that such objects aid speech learning, and they have cautioned students and professionals about their use. Speech-language pathologists are trying to reconcile these cautions with basic Van Riper type therapy routines. The purpose of this literature review was to summarize the ways in which tools/objects were used by Van Riper and other speech professionals between 1939 and 1968. Fourteen textbooks were selected for review. Van Riper and other developers of traditional articulation therapy regularly used a wide variety of tools/objects in articulation therapy. Tools/objects were used when other auditory, linguistic, and cognitive means failed to stimulate correct phoneme productions. To call these activities "non-speech" methods seems to misrepresent the historic purpose objects have served in articulation therapy. More empirical research is required in this area.

Electropalatographic therapy for children and young people with Down's syndrome.

Articulation disorders in Down's syndrome (DS) are prevalent and often intractable. Individuals with DS generally prefer visual to auditory methods of learning and may therefore find it beneficial to be given a visual model during speech intervention, such as that provided by electropalatography (EPG). In this study, participants with Down's syndrome, aged 10:1 to 18:9, received 24 individualized therapy sessions using EPG. Simultaneous acoustic and EPG recordings were made pre- and post-intervention during 10 repetitions of a word list containing lingua-palatal consonants. Participants also completed the DEAP phonology sub-test at both time points. Post-treatment, all participants showed qualitative and quantifiable differences in EPG patterns and improvements in DEAP percentage consonants correct. EPG assessment and therapy appears a positive approach for identifying and improving articulatory patterns in children with DS.