Phonological awareness training and phonological therapy approaches for specific language impairment children with speech sound disorders: a comparative outcome study.

PURPOSE: Children with specific language impairment (SLI) might present with speech sound disorder (SSD) and phonological awareness (PA) deficits which put them at risk of potential reading problems. This work aimed to organize an intervention program in Arabic for phonological training and to assess the effect of PA training versus the phonological therapy (PT) for children with SLI and SSD. METHODS: The study was carried out on 60 children with comorbid SLI and SSD, aged 5-7 years. Children were equally divided into two groups; each group received language therapy combined with (PT or PA training). Measures of language development, phonological output, and PA were taken before therapy and at 4 month post-therapy for all children. RESULTS: The two therapy groups made nearly the same amount of progress in the development of language and phonological production, with no significant differences regarding language age and percent of consonants correct (PCC). The PA training group progressed more on the PA skills than children who received PT over the same time. CONCLUSIONS: PA training could facilitate the development of phonological skills by targeting the child's awareness of phonemes and improving the production of sound patterns.

Subtract Before You Add: Toward the Development of a De-Implementation Approach in School-Based Speech Sound Therapy.

PURPOSE: It is often difficult for school-based speech-language pathologists (SLPs) to prioritize implementing new practices for children with speech sound disorders (SSDs), given burgeoning caseloads and the myriad of other workload tasks. We propose that de-implementation science is equally as important as implementation science. De-implementation science is the recognition and identification of areas that are of "low-value and wasteful." Critically, the idea of de-implementation suggests that we first remove something from a clinician's workload before requesting that they learn and implement something new. METHOD: Situated within the Sustainability in Healthcare by Allocating Resources Effectively (SHARE) framework, we review de-implementation science and current speech sound therapy literature to understand the mechanisms behind continuous use of practices that are no longer supported by science or legislation. We use vignettes to highlight real-life examples that clinicians may be facing in school-based settings and to provide hypothetical solutions, resources, and/or next steps to these common challenges. RESULTS: By focusing on Phase 1 of the SHARE framework, we identified four primary practices that can be de-implemented to make space for new evidence-based techniques and approaches. These four practices were determined based on an in-depth review of SLP-based survey research: (a) overreliance on speech sound norms for eligibility determinations, (b) the omission of phonological processing skills within evaluations, (c) homogeneity of service delivery factors, and (d) the use of only one treatment approach for all children with SSDs. CONCLUSIONS: De-implementation will take work and may lead to some difficult discussions. Implementing a framework, such as SHARE, can guide SLPs toward a reduction in workloads and improved outcomes for children with SSDs.

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.

Shared characteristics of intervention techniques for oral vocabulary and speech comprehensibility in preschool children with co-occurring features of developmental language disorder and a phonological speech sound disorder: protocol for a systematic review with narrative synthesis.

INTRODUCTION: Evidence suggests that over one-third of young children with developmental language disorder (DLD) or speech sound disorder (SSD) have co-occurring features of both. A co-occurring DLD and SSD profile is associated with negative long-term outcomes relating to communication, literacy and emotional well-being. However, the best treatment approach for young children with this profile is not understood. The aim of the proposed review is to identify intervention techniques for both DLD and SSD, along with their shared characteristics. The findings will then be analysed in the context of relevant theory. This will inform the content for a new or adapted intervention for these children. METHODS AND ANALYSIS: This search will build on a previous systematic review by Roulstone et al (2015) but with a specific focus on oral vocabulary (DLD outcome) and speech comprehensibility (SSD outcome). These outcomes were identified by parents and speech and language therapists within the prestudy stakeholder engagement work. The following databases will be searched for articles from January 2012 onwards: Ovid Emcare, MEDLINE Complete, CINAHL, APA PsycINFO, Communication Source and ERIC. Two reviewers will independently perform the title/abstract screening and the full-text screening with the exclusion criteria document being revised in an iterative process. Articles written in languages other than English will be excluded. Data will be extracted regarding key participant and intervention criteria, including technique dosage and delivery details. This information will then be pooled into a structured narrative synthesis. ETHICS AND DISSEMINATION: Ethical approval is not needed for a systematic review protocol. Dissemination of findings will be through peer-reviewed publications, social media, and project steering group networks. PROSPERO REGISTRATION NUMBER: CRD4202237393.

Consensus on an assessment protocol for children with speech sound disorders in Sri Lanka.

BACKGROUND: Speech sound disorders (SSDs) are the most common form of communication disorders in children. SSD have an impact on children's abilities to make themselves understood to their listeners and can influence a child's social and emotional well-being as well as their academic achievements. Therefore, it is important to identify children with an SSD early, in order to provide appropriate intervention. A wealth of information on best practice in the assessment of children with SSD is available in countries where the speech and language therapy profession is well established. In Sri Lanka, there is a paucity of research evidence supporting assessment practices that are culturally and linguistically appropriate in SSDs. Therefore, clinicians rely on informal assessment methods. There is a need to understand more about how clinicians in Sri Lanka assess this caseload in order to get general agreement regarding comprehensive and consistent procedures for assessment of paediatric SSD in Sri Lanka. This would support speech and language therapists' (SLTs') clinical decision-making in relation to choice of appropriate goals and intervention for this caseload. AIM: To develop and gain consensus on an assessment protocol for Sri Lankan children with SSD that is culturally appropriate and based on existing research. METHOD: A modified Delphi method was utilised to gather data from clinicians currently working in Sri Lanka. The research involved three rounds of data collection, exploring current assessment practices in Sri Lanka, ranking these in order of priority and establishing consensus on a proposed assessment protocol. The proposed assessment protocol was based on the results of the first and second rounds as well as previously published best practice guidelines. OUTCOME AND RESULTS: The proposed assessment protocol achieved consensus in relation to content, format and cultural appropriateness. SLTs affirmed the usefulness of the protocol within the Sri Lankan context. Further research is required to assess the feasibility and effectiveness of this protocol in practice. CONCLUSIONS & IMPLICATIONS: The assessment protocol supports practicing SLTs with a general guide to assessing children with suspected SSDs in Sri Lanka. The application of this protocol built upon consensus enables clinicians to improve their individual practice patterns based on best practice recommendations in the literature and the evidence on culturally and linguistically appropriate practices. This study has identified the need for further research in this area, including the development of culturally and linguistically specific assessment tools that would complement the use of this protocol. WHAT THIS PAPER ADDS: What is already known on the subject The assessment of children with speech sound disorders (SSDs) requires a comprehensive and holistic approach due to their heterogeneous nature. Although there is evidence to support the assessment of paediatric SSDs in many countries where the profession of speech and language therapy is established, there is limited evidence to support the assessment of children with SSDs in Sri Lanka. What this study adds This study provides information about current assessment practices in Sri Lanka and consensus on a proposed culturally appropriate protocol for the assessment of children with SSDs in this country. What are the clinical implications of this work? The proposed assessment protocol provides speech and language therapists in Sri Lanka with a guide for assessment of paediatric SSDs to support more consistent practice in this area. Future evaluation of this preliminary protocol is required; however, the methodology used in this research could be applied to the development of assessment protocols for other range of practice areas in this country.

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

PURPOSE: Ultrasound biofeedback therapy (UBT) is a relatively new type of technology-assisted speech-language therapy and has shown promise in remediating speech sound disorders. However, there is a current lack of understanding of the barriers and benefits that may influence the usage behavior and clinical decision making for the implementation of UBT from a clinician perspective. In this qualitative study, we explore the perspectives of speech-language pathologists (SLPs) who have used ultrasound biofeedback in programs of speech sound therapy using the unified theory of acceptance and use of technology (UTAUT) model. METHOD: Seven SLPs who had clinical experience treating speech sound disorders with UBT participated. Semistructured in-depth interviews were conducted and video-recorded. Two coders coded and categorized the transcribed data, with consensus established with a third coder. Using thematic analysis, the data were exploratorily grouped into themes along components of the UTAUT model. RESULTS: The highest number of codes was sorted into the "effort expectancy" theme, followed by "performance expectancy," "social influence," and "facilitating conditions" themes of the UTAUT model. Clinicians identified multiple perceived barriers and benefits to the use of ultrasound technology. The top identified barrier was limited accessibility, and the top benefit was the ability to visualize a client's articulatory response to cues on a display. CONCLUSIONS: Clinicians prioritized "effort expectancy" and "performance expectancy" when reflecting on the use of ultrasound biofeedback for speech sound disorders. Clinicians spoke favorably about using UBT for speech sound disorder treatment but acknowledged institutional barriers and limitations at organizational and social levels.

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.

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.

Music and musical elements in the treatment of childhood speech sound disorders: A systematic review of the literature.

PURPOSE: Music-based interventions are used in the treatment of childhood speech sound disorders (SSDs). Hypotheses on working mechanisms are being developed, focussing on shared neural processes. However, evidence of the effect of treatment with musical elements in SSDs in children is lacking. This study reviews the literature regarding the use of music-based interventions in the treatment of childhood SSDs. METHOD: A systematic search in six databases was conducted, yielding 199 articles, eight of which met the inclusion criteria. Included articles were reviewed on study characteristics, patient characteristics, interventions, outcomes and methodological quality. RESULT: This review included four case studies, three single-subject design studies and one cohort study. Seven studies reported positive outcomes on speech production, but outcome measures in the four studies with experimental design were not all aimed at the level of speech (motor) processes. Methodological quality was sufficient in one study. CONCLUSION: Seven out of eight studies in this review report positive outcomes of music-based interventions in the treatment of SSDs. However, these outcomes are not sufficiently supported by evidence due to insufficient methodological quality. Suggestions for improving methodological quality in future research are presented.

A temporal-based therapy for children with inconsistent phonological disorder: A case-series.

Deficits in temporal auditory processing, and in particular higher gap detection thresholds have been reported in children with inconsistent phonological disorder (IPD). Here we hypothesized that providing these children with extra time for phoneme identification may in turn enhance their phonological planning abilities for production, and accordingly improve not only consistency but also accuracy of their speech. We designed and tested a new temporal-based therapy, inspired by Core Vocabulary Therapy and called it T-CVT, where we digitally lengthened formant transitions between phonemes of words used for therapy. This allowed to target both temporal auditory processing and word phonological planning. Four preschool Persian native children with IPD received T-CVT for eight weeks. We measured changes in speech consistency (% inconsistency) and accuracy (percentage of consonants correct PCC) to assess the effects of the intervention. Therapy significantly improved both consistency and accuracy of word production in the four children: % inconsistency decreased from 59% on average before therapy to 2% post-T-CVT, and PCC increased from 61% to 92% on average. Consistency and accuracy were furthermore maintained or even still improved at three-month follow-up (2% inconsistency and 99% PCC). Results in a nonword repetition task showed the generalization of these effects to non-treated material: % inconsistency for nonwords decreased from 67% to 10% post-therapy, and PCC increased from 63% to 90%. These preliminary findings support the efficacy of the T-CVT intervention for children with IPD who show temporal auditory processing deficits as reflected by higher gap detection thresholds.

Word-final complexity in speech sound intervention: two case studies.

In speech sound intervention, consonant clusters promote generalisation (i.e. improvement in untreated sounds and words), ostensibly due to their relative complexity compared to other phonological targets. However, our understanding of clusters as intervention targets is largely restricted to those in word-initial position (e.g. [fl-], flip). The present study extends available work to consider the effects of word-final consonant cluster targets (e.g. [-ks]). Phonologically complex word-final clusters may be morphologically simple (e.g. mix) or morphologically complex (e.g. packs, inflected with third-person singular) - yet this cross-domain complexity remains an understudied phenomenon. Presently, two case studies provide an initial investigation of word-final cluster intervention targets for children with phonologically based speech sound disorders. Intervention targets for both Anna (3;7 [years;months]) and David (4;1) featured the phonologically complex word-final cluster [-ks], with Anna's target being morphologically simple and David's being morphologically complex. Intervention was provided in 45-minute, individual sessions three times per week for a maximum of 18 sessions. Both children demonstrated high target accuracy by intervention's end. Following intervention, both children demonstrated progress in intelligibility and ability to produce word-final consonant clusters; David further demonstrated generalisation across multiple measures. Results are interpreted with consideration of individual differences and existing research on complexity in phonological intervention. Overall, present findings motivate continued research, as manipulation of word-final complexity allows for emphasis on a context that is relevant for children with speech sound disorders, for peers with difficulties in morphology (including word-final grammatical morphemes) and for the substantial proportion of children demonstrating weaknesses in both domains.

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

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

A survey of interventions used by speech-language pathologists for children with speech sound disorders in the Middle East.

PURPOSE: While many examples of speech pathology intervention approaches for children with speech sound disorders (SSDs) exist in English and some other European languages, approaches with children in other languages are largely unknown. The aim was to determine current speech-language pathologists (SLPs) intervention practices with children with SSDs in the ME, and to then compare these with international practices. METHODS: Data were collected by online questionnaire using Qualtrics. One hundred and eighty-nine SLPs completed the survey. Participants were required to be Arabic first language speaking SLPs practicing in the ME (e.g. Kuwait, Saudi Arabia, UAE, and Egypt), working with children with SSDs. RESULTS: The respondents reported a frequent use of phonological awareness, traditional articulation therapy, auditory discrimination, minimal pairs, and whole language therapy approaches in the treatment of children with SSDs, like their counterparts in Australia, the USA, UK, and Portugal. Gaps between research recommendations for evidence-based practice and actual clinical practice are identified, and discussed. CONCLUSIONS: Future research should investigate the efficacy of speech-therapy approaches to improve service delivery for Arabic-speaking children with SSDs in the ME.

The impact of age on the treatment of late-acquired sounds in children with speech sound disorders.

The question of 'when' to treat speech sounds is often posed in the context of normative data. The new normative data suggest that speech sounds such as /ɹ/ and /l/ are acquired earlier than previously thought. The present study compared the treatment of late-acquired sounds between two age groups of English-speaking children: Young children (4-5) and Old children (7-8). Eight monolingual children with speech sound disorder (SSD) participated in the study. Each child received a criterion-based, standardised, two-phase therapy protocol. Treatment efficacy was measured by examining children's accuracy on real world speech probes. Treatment efficiency was measured by calculating the number of sessions required to meet the exit criterion and the mean session duration. For treatment efficacy, young children learned treated sounds as effectively as oldchildren did. For treatment efficiency, both groups required a comparable number of sessions, but young children required longer sessions than old children. The results suggest that delaying treatment of individual speech sounds is unnecessary and that a range of sounds should be considered as potential treatment targets.

Phonological processing skills in children with speech sound disorder: A multiple case study approach.

BACKGROUND: Children with speech sound disorder (SSD) are at increased risk of reading difficulties due to poor phonological processing skills. However, the extent to which children with SSD demonstrate weaknesses on specific or all phonological processing tasks is not well understood. AIMS: To examine the phonological processing abilities of a clinically identified sample of children with SSD, with and without reading difficulties. To determine the extent to which the proportion of children with concomitant SSD and reading difficulties exhibited weaknesses in specific areas of phonological processing, or a more general phonological deficit. METHODS & PROCEDURES: Data were obtained from 157 school-aged children (Mage = 77 months, SD = 7.01) in receipt of school-based speech therapy. Approximately 25% of the sample was identified as poor readers, based on a standardized measure of word decoding. We compared the proportion of children who scored at or below 1 SD below the mean, or the bottom 16th percentile, on measures of phonological awareness, rapid automatized naming and verbal short-term memory among those identified as poor readers and good readers. OUTCOMES & RESULTS: Children with SSD demonstrated a range of phonological processing difficulties, particularly on the measure of verbal short-term memory. No specific skill differentiated groups of children with SSD with and without reading difficulties; however, those classified as poor readers on the word-decoding measure exhibited more widespread difficulties, even after controlling for language ability. CONCLUSIONS & IMPLICATIONS: Results support a cumulative risk model such that children with SSD and reading difficulties are likely to demonstrate generally poor phonological processing abilities. WHAT THIS PAPER ADDS: What is already known on the subject Children with SSD are at heightened risk of reading difficulties, particularly if their SSD persists into school age. However, not all children with SSD experience reading problems. Research aimed at determining which children are at the highest risk is mixed as to how best to identify which children with SSD are most likely to experience reading difficulties. What this paper adds to existing knowledge The study used a multiple case study approach to determine if performance on phonological processing skills might differentiate children with SSD who were poor readers from those who were good readers. As a group, children with SSD exhibited poor verbal short-term memory but relatively intact rapid automatized naming skills. No one phonological processing skill differentiated children who were poor readers from good readers. However, children with reading difficulties appeared to experience more general difficulties across phonological processing tasks, even after controlling for language abilities. What are the potential or actual clinical implications of this work? A single deficit (i.e., speech sound production) is not sufficient data to make a complete diagnosis or treatment decisions. Multiple sources of data, including several aspects of phonological processing, should be obtained to understand reading risk in children with SSD.

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.

Predictors of Speech Severity and Inconsistency Over Time in Children With Token-to-Token Inconsistency.

PURPOSE: The aim of this study was to describe and explain changes in severity of speech sound disorder (SSD) and token-to-token inconsistency in children with high levels of inconsistency. METHOD: Thirty-nine children (aged 4;6-7;11 [years;months]) with SSDs and high levels of token-to-token inconsistency were assessed every 6 months for 2 years (i.e., five assessment points). Growth modeling was used to assess relations among therapy support, receptive vocabulary, severity, and inconsistency over time. RESULTS: Children with the most severe SSDs and highest levels of token-to-token inconsistency showed the smallest improvements in speech accuracy over time. Therapy support did not predict changes in speech accuracy or token-to-token inconsistency over time. Receptive vocabulary (measured at the outset of the study) was also a significant predictor of speech accuracy and inconsistency. CONCLUSIONS: These findings suggest that an immediate start to intervention (rather than a wait-and-see approach) is recommended for children with inconsistent speech error patterns. The results also highlight the value of developing vocabulary knowledge in addition to improving speech accuracy for some children with inconsistent speech production.

Treating Concomitant Language and/or Phonology Impairment in Children Who Stutter.

Stuttering can co-occur with phonological and/or language impairment in a nontrivial number of children. This article provides a framework for addressing concomitant phonology/language impairment and stuttering through the application of the World Health Organization's International Classification of Functioning, Disability and Health (ICF) framework. Described is a multifactorial approach to understanding stuttering, the application of the ICF to treating children who stutter with concomitant disorders, and models for structuring-related therapy. A case study is explored to illustrate this process and includes a sample treatment plan with goals, short-term objectives, and sample activities.

Introduction: Innovations in Treatment for Children With Speech Sound Disorders.

PURPOSE: There is a clear need for effective and efficient interventions for children with speech sound disorder (SSD) that can be implemented in both clinical and school-based settings. METHOD: This forum was created for any clinician who treats SSDs. We asked the invited authors to include immediately actionable information, such as therapy activities, tips for goal writing or progress monitoring, assessment processes, and frameworks for conversations with parents. RESULTS: We have curated nine scientifically based articles that highlight the heterogeneity of SSDs and how various subpopulations require uniquely tailored interventions. Some children with SSDs require treatment approaches that are more heavily embedded in phonological theories (e.g., maximal or multiple oppositions) or that extend beyond speech production and include speech perception and phonological awareness skills. Clinicians also need to be mindful of not only which sounds are affected, but which kinds of errors a child is making. For instance, lateral lisps and residual speech sound errors should be evaluated and treated differently from other kinds of speech sound errors. There are certainly subpopulations of children with SSDs for whom there is extremely limited data upon which speech-language pathologists can base clinical decisions, such as children under the age of 3 years or children who are multilingual. Finally, there is a crucial need to better understand the social-emotional impacts of SSDs. Tools to aid in including social-emotional data within assessment and intervention outcomes are also included in this forum. CONCLUSION: The traditional articulation approach is the most commonly used approach in school-based settings; however, there are many children for whom this approach is not appropriate. We hope to provide a robust resource for busy school-based speech-language pathologists who treat children with SSD-specifically, we hope clinicians embrace the opportunity to "think outside the box" of traditional articulation therapy.

Characterizing sensorimotor profiles in children with residual speech sound disorder: a pilot study.

PURPOSE: Children with speech errors who have reduced motor skill may be more likely to develop residual errors associated with lifelong challenges. Drawing on models of speech production that highlight the role of somatosensory acuity in updating motor plans, this pilot study explored the relationship between motor skill and speech accuracy, and between somatosensory acuity and motor skill in children. Understanding the connections among sensorimotor measures and speech outcomes may offer insight into how somatosensation and motor skill cooperate during speech production, which could inform treatment decisions for this population. METHOD: Twenty-five children (ages 9-14) produced syllables in an /ɹ/ stimulability task before and after an ultrasound biofeedback treatment program targeting rhotics. We first tested whether motor skill (as measured by two ultrasound-based metrics of tongue shape complexity) predicted acoustically measured accuracy (the normalized difference between the second and third formant frequencies). We then tested whether somatosensory acuity (as measured by an oral stereognosis task) predicted motor skill, while controlling for auditory acuity. RESULTS: One measure of tongue shape complexity was a significant predictor of accuracy, such that higher tongue shape complexity was associated with lower accuracy at pre-treatment but higher accuracy at post-treatment. Based on the same measure, children with better somatosensory acuity produced /ɹ/ tongue shapes that were more complex, but this relationship was only present at post-treatment. CONCLUSION: The predicted relationships among somatosensory acuity, motor skill, and acoustically measured /ɹ/ production accuracy were observed after treatment, but unexpectedly did not hold before treatment. The surprising finding that greater tongue shape complexity was associated with lower accuracy at pre-treatment highlights the importance of evaluating tongue shape patterns (e.g., using ultrasound) prior to treatment, and has the potential to suggest that children with high tongue shape complexity at pre-treatment may be good candidates for ultrasound-based treatment.