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

PURPOSE: Children with residual speech sound disorders (RSSD) have shown differences in neural function for speech production, as compared to their typical peers; however, information about how these differences may change over time and relative to speech therapy is needed. To address this gap, we used functional magnetic resonance imaging (fMRI) to examine functional activation and connectivity on adaptations of the syllable repetition task (SRT-Early Sounds and SRT-Late Sounds) in children with RSSD before and after a speech therapy program. METHOD: Sixteen children with RSSD completed an fMRI experiment before (Time 1) and after (Time 2) a speech therapy program with ultrasound visual feedback for /ɹ/ misarticulation. Progress in therapy was measured via perceptual ratings of productions of untreated /ɹ/ word probes. To control for practice effects and developmental change in patterns of activation and connectivity, 17 children with typical speech development (TD) completed the fMRI at Time 1 and Time 2. Functional activation was analyzed using a region-of-interest approach and functional connectivity was analyzed using a seed-to-voxel approach. RESULTS: Children with RSSD showed a range of responses to therapy. After correcting for multiple comparisons, we did not observe any statistically significant cross-sectional differences or longitudinal changes in functional activation. A negative relationship between therapy effect size and functional activation in the left visual association cortex was on the SRT-Late Sounds after therapy, but it did not survive correction for multiple comparisons. Significant longitudinal changes in functional connectivity were observed for the RSSD group on SRT-Early Sounds and SRT-Late Sounds, as well as for the TD group on the SRT-Early Sounds. RSSD and TD groups showed connectivity differences near the left insula on the SRT-Late Sounds at Time 2. CONCLUSION: RSSD and treatment with ultrasound visual feedback may thus be associated with neural differences in speech motor and visual association processes recruited for speech production.

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

PURPOSE: Both Rapid Syllable Transition Treatment (ReST) and ultrasound biofeedback are effective approaches to treating childhood apraxia of speech (CAS). The purpose of the study was to compare outcomes from these two motor-based treatment approaches for school-age children with CAS. METHOD: In a single site, single blind randomized control trial, 14 children with CAS ages 6-13 years were randomly assigned to 12 sessions over 6 weeks of either of ultrasound biofeedback treatment (with a speech motor chaining practice structure) or ReST. Treatment was delivered at The University of Sydney by students trained and supervised by certified speech-language pathologists. Transcriptions from blinded assessors were used to compare the two groups on speech sound accuracy (percent phonemes correct) and prosodic severity (lexical stress errors and syllable segregation) in untreated words and sentences at three time points: pretreatment, immediately posttreatment, and 1-month posttreatment (i.e., retention). RESULTS: Both groups showed significant improvement on treated items indicating a treatment effect. At no time was there a difference between groups. Both groups showed a significant improvement in speech sound accuracy on untreated words and sentences from pre to post and neither group showed an improvement in prosody pre-post. Changes to speech sound accuracy were retained by both groups at 1-month follow-up. Significant improvement in prosodic accuracy was reported at the 1-month follow-up. CONCLUSIONS: ReST and ultrasound biofeedback were equally effective. Either ReST or ultrasound biofeedback may be viable treatment options for school-age children with CAS. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.22114661.

Tutorial: Using Visual-Acoustic Biofeedback for Speech Sound Training.

PURPOSE: This tutorial summarizes current practices using visual-acoustic biofeedback (VAB) treatment to improve speech outcomes for individuals with speech sound difficulties. Clinical strategies will focus on residual distortions of /ɹ/. METHOD: Summary evidence related to the characteristics of VAB and the populations that may benefit from this treatment are reviewed. Guidelines are provided for clinicians on how to use VAB with clients to identify and modify their productions to match an acoustic representation. The clinical application of a linear predictive coding spectrum is emphasized. RESULTS: Successful use of VAB requires several key factors including clinician and client comprehension of the acoustic representation, appropriate acoustic target and template selection, as well as appropriate selection of articulatory strategies, practice schedules, and feedback models to scaffold acquisition of new speech sounds. CONCLUSION: Integrating a VAB component in clinical practice offers additional intervention options for individuals with speech sound difficulties and often facilitates improved speech sound acquisition and generalization outcomes. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.21817722.

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

PURPOSE: This study aimed to identify predictors of response to treatment for residual speech sound disorder (RSSD) affecting English rhotics. Progress was tracked during an initial phase of traditional motor-based treatment and a longer phase of treatment incorporating ultrasound biofeedback. Based on previous literature, we focused on baseline stimulability and sensory acuity as predictors of interest. METHOD: Thirty-three individuals aged 9-15 years with residual distortions of /ɹ/ received a course of individual intervention comprising 1 week of intensive traditional treatment and 9 weeks of ultrasound biofeedback treatment. Stimulability for /ɹ/ was probed prior to treatment, after the traditional treatment phase, and after the end of all treatment. Accuracy of /ɹ/ production in each probe was assessed with an acoustic measure: normalized third formant (F3)-second formant (F2) distance. Model-based clustering analysis was applied to these acoustic measures to identify different average trajectories of progress over the course of treatment. The resulting clusters were compared with respect to acuity in auditory and somatosensory domains. RESULTS: All but four individuals were judged to exhibit a clinically significant response to the combined course of treatment. Two major clusters were identified. The "low stimulability" cluster was characterized by very low accuracy at baseline, minimal response to traditional treatment, and strong response to ultrasound biofeedback. The "high stimulability" group was more accurate at baseline and made significant gains in both traditional and ultrasound biofeedback phases of treatment. The clusters did not differ with respect to sensory acuity. CONCLUSIONS: This research accords with clinical intuition in finding that individuals who are more stimulable at baseline are more likely to respond to traditional intervention, whereas less stimulable individuals may derive greater relative benefit from biofeedback. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.20422236.

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

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

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

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

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

BACKGROUND: Speech sound disorder in childhood poses a barrier to academic and social participation, with potentially lifelong consequences for educational and occupational outcomes. While most speech errors resolve by the late school-age years, between 2 and 5% of speakers exhibit residual speech errors (RSE) that persist through adolescence or even adulthood. Previous findings from small-scale studies suggest that interventions incorporating visual biofeedback can outperform traditional motor-based treatment approaches for children with RSE, but this question has not been investigated in a well-powered randomized controlled trial. METHODS/DESIGN: This project, Correcting Residual Errors with Spectral, ULtrasound, Traditional Speech therapy Randomized Controlled Trial (C-RESULTS RCT), aims to treat 110 children in a parallel randomized controlled clinical trial comparing biofeedback and non-biofeedback interventions for RSE affecting the North American English rhotic sound /ɹ/. Eligible children will be American English speakers, aged 9-15 years, who exhibit RSE affecting /ɹ/ but otherwise show typical cognitive-linguistic and hearing abilities. Participants will be randomized, with stratification by site (Syracuse University or Montclair State University) and pre-treatment speech production ability, to receive either a motor-based treatment consistent with current best practices in speech therapy (40% of participants) or treatment incorporating visual biofeedback (60% of participants). Within the biofeedback condition, participants will be assigned in equal numbers to receive biofeedback in the form of a real-time visual display of the acoustic signal of speech or ultrasound imaging of the tongue during speech. The primary outcome measure will assess changes in the acoustics of children's production of /ɹ/ during treatment, while a secondary outcome measure will use blinded listeners to evaluate changes in the perceived accuracy of /ɹ/ production after the completion of all treatment. These measures will allow the treatment conditions to be compared with respect to both efficacy and efficiency. DISCUSSION: By conducting the first well-powered randomized controlled trial comparing treatment with and without biofeedback, this study aims to provide high-quality evidence to guide treatment decisions for children with RSE. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT03737318, November 9, 2018.

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.

Tongue shapes for rhotics in school-age children with and without residual speech errors.

Speakers of North American English use variable tongue shapes for rhotic sounds. However, quantifying tongue shapes for rhotics can be challenging, and little is known about how tongue shape complexity corresponds to perceptual ratings of rhotic accuracy in children with residual speech sound errors (RSE). In this study, 16 children aged 9-16 with RSE and 14 children with typical speech (TS) development made multiple productions of 'Let Robby cross Church Street'. Midsagittal ultrasound images were collected once for children with TS and twice for children in the RSE group (once after 7 h of speech therapy, then again after another 7 h of therapy). Tongue contours for the rhotics in the four words were traced and quantified using a new metric of tongue shape complexity: the number of inflections. Rhotics were also scored for accuracy by four listeners. During the first assessment, children with RSE had fewer tongue inflections than children with TS. Following 7 h of therapy, there were increases in the number of inflections for the RSE group, with the cluster items cross and Street reaching tongue complexity levels of those with TS. Ratings of rhotic accuracy were correlated with the number of inflections. Therefore, the number of inflections in the tongue, an index of tongue shape complexity, was associated with perceived accuracy of rhotic productions.

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.

Variable Practice to Enhance Speech Learning in Ultrasound Biofeedback Treatment for Childhood Apraxia of Speech: A Single Case Experimental Study.

PURPOSE: The purpose of this study was to evaluate the role of practice variability, through prosodic variation during speech sound training, in biofeedback treatment for children with childhood apraxia of speech. It was hypothesized that variable practice would facilitate speech sound learning. METHOD: Six children ages 8-16 years with persisting speech sound errors due to childhood apraxia of speech participated in a single-subject experimental design. For each participant, 2 speech sound targets were treated with ultrasound visual feedback training: one with prosodic variation (i.e., practicing sound targets in words and phrases spoken fast, slow, loud, as a question, command, and declarative), and one without prosodic variation. Each target was treated for half of the 1-hr session for 14 treatment sessions. RESULTS: As measured by standardized effect sizes, all participants showed greater change on generalization probes for sound targets treated under the prosodic variation condition with mean effect sizes (d2) of 14.5 for targets treated with prosodic variation and 8.3 for targets treated without prosodic variation. The average increase in generalization scores was 38% in the prosodic variation condition compared to 31% without. CONCLUSIONS: Ultrasound visual feedback may facilitate speech sound learning and learning may be enhanced by treating speech sounds with explicit prosodic variation. SUPPLEMENTAL MATERIALS: https://doi.org/10.23641/asha.5150119.

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.

Limited acquisition and generalisation of rhotics with ultrasound visual feedback in childhood apraxia.

Ultrasound visual feedback of the tongue is one treatment option for individuals with persisting speech sound errors. This study evaluated children's performance during acquisition and generalisation of American English rhotics using ultrasound feedback. Three children aged 10-13 with persisting speech sound errors associated with childhood apraxia of speech (CAS) were treated for 14 one-hour sessions. Two of the participants increased the accuracy of their rhotic production during practise trials within treatment sessions, but none demonstrated generalisation to untreated words. Lack of generalisation may be due to a failure to acquire the target with sufficient accuracy during treatment, or to co-existing linguistic weaknesses that are not addressed in a motor-based treatment. Results suggest a need to refine the intervention procedures for CAS and/or a need to identify appropriate candidates for intervention to optimise learning.

Ultrasound biofeedback treatment for persisting childhood apraxia of speech.

PURPOSE: The purpose of this study was to evaluate the efficacy of a treatment program that includes ultrasound biofeedback for children with persisting speech sound errors associated with childhood apraxia of speech (CAS). METHOD: Six children ages 9-15 years participated in a multiple baseline experiment for 18 treatment sessions during which treatment focused on producing sequences involving lingual sounds. Children were cued to modify their tongue movements using visual feedback from real-time ultrasound images. Probe data were collected before, during, and after treatment to assess word-level accuracy for treated and untreated sound sequences. As participants reached preestablished performance criteria, new sequences were introduced into treatment. RESULTS: All participants met the performance criterion (80% accuracy for 2 consecutive sessions) on at least 2 treated sound sequences. Across the 6 participants, performance criterion was met for 23 of 31 treated sequences in an average of 5 sessions. Some participants showed no improvement in untreated sequences, whereas others showed generalization to untreated sequences that were phonetically similar to the treated sequences. Most gains were maintained 2 months after the end of treatment. The percentage of phonemes correct increased significantly from pretreatment to the 2-month follow-up. CONCLUSION: A treatment program including ultrasound biofeedback is a viable option for improving speech sound accuracy in children with persisting speech sound errors associated with CAS.

Identification of conductive hearing loss in young infants using tympanometry and wideband reflectance.

OBJECTIVE: The goal of the study was to evaluate the effectiveness of tympanometry and wideband reflectance (WBR) in detecting conductive hearing loss (CHL) in young infants. METHODS: Type of hearing loss was determined using auditory brainstem response using air- and bone-conducted tone bursts in 84 ears from 70 infants (median age = 10 weeks). Of these 84 ears, 60 are included in the current analysis: 43 with normal hearing (NH) and 17 with CHL. Tympanometry was measured using probe tone frequencies of 226, 678, and 1000 Hz. Tympanograms were evaluated in two ways: (1) Acoustic middle ear admittance (Ya, in millimhos); and (2) two-category classification (normal/abnormal), as described by Baldwin (2006). Measures of Ya were evaluated in two ways: by admittance-magnitude tympanograms and calculated admittance magnitude from subcomponents (conductance and susceptance). WBR was measured in response to a chirp stimulus after probe calibration. WBR was analyzed into thirteen 1/3 octave bands. Tests for statistical differences for two-category classification were analyzed using Chi-squared and Ya, and WBR were analyzed using repeated-measures analyses of variances. Cohen's d and likelihood ratios were computed for comparison with statistically significant differences. RESULTS: Ya measured with 678- and 1000 Hz probe tones was significantly different between ears with CHL and NH. Two-category classification of tympanograms using a 1000 Hz probe tone was significantly different between ears with CHL and NH. Neither two-category classification nor Ya was significantly different between ears identified with CHL and NH using a 226 Hz probe tone. WBR was significantly higher in the frequency bands 800 to 2500 Hz and in the frequency band centered at 6300 Hz in infants with CHL. Effect sizes (Cohen's d) were greater than 2 for several WBR frequency bands and Ya measured with 1000 Hz probe tones. The results were similar for calculations of Ya from admittance-magnitude and subcomponent tympanograms. Positive likelihood ratios for WBR ranged between 8.1 and 38, and those for Ya using 1000 Hz ranged between 12.5 and 32. CONCLUSIONS: CHL in young infants can be detected well with WBR or tympanometry using probe frequencies of 678 and 1000 Hz.