Speech Sound Disorders
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Articulation therapy is the bread-and-butter for many pediatric and school-based SLPs, but when was the last time you checked in on current research and methods in treating speech sound disorders (SSDs)? With all due respect to Van Riper (and plenty is due), we’re willing to bet you’ll find some new ideas and question some old ones after reading this collection of research reviews, covering 16 articles published between 2013 and 2018:
Ready to break up with your +/- data tally method, for a finer-grained measure that might help you show progress?
Need tips for collecting language samples from your students with severe SSDs?
Has it never occurred to you to examine polysyllabic words in your evaluations?
Need some method behind your madness when picking target words for therapy?
Geeking out at the thought of using high-tech methods to tackle the dreaded /r/ once and for all?
We’ve got you covered, and more. There is also a set of reviews discussing influential treatment approaches for Childhood Apraxia of Speech, including an evidence-based program with freely available training materials (Huzzah!) and the first dive into the efficacy of the well-known Kaufman approach. Ready to learn something new? Let's go!
On “Treating children ages 3–6 who have speech sound disorder: a survey”
This article surveys SLPs to identify knowledge gaps in the treatment of speech sound disorders. The authors then make recommendations on techniques the SLPs should know, but are missing.
Many trends and issues are covered, but perhaps the most interesting finding is that most SLPs don't know enough about phonological treatment. They found that SLPs tend to use traditional articulation methods for children with speech sound disorders, instead of phonological methods. Traditional articulation treatment is "directed at correcting isolated speech sounds” and “phonological interventions... are directed at improving the speech sound system”. The authors state that “… it is unclear why traditional intervention, especially the more advanced steps in the sequence [e.g. targeting sounds in sentences], was used for preschoolers with phonological disorders...” They highlight studies in which phonological interventions have been “shown to be more efficacious than traditional intervention”. They also point out which methods have procedure manuals published, which is SUPER useful, because that means you don't have to hunt those down yourself, and can more readily implement the technique.
To do a quick check of whether this article will teach you something, take a quick look at their Table 1. It lists all the interventions they surveyed. What do you think? Do you now these? Or even half of them? We bet you find at least a few techniques to add to your list!
Predicting resolution of speech sound errors
Producing speech sound errors early in development is normal. Many children make errors in the preschool years that they simply grow out of in early elementary school. However, some kids don’t grow out of their errors. These are the kids that need speech–language pathologists’ attention, but how do we know which kids these are?
This study aimed to answer exactly that question—which kids just need time, and which kids need speech therapy? They examined 93 children at age four (all “identified as speech impaired” with the GFTA-2 or DEAP), categorized the children’s error types, then looked again at age seven, and found the following:
Total number of errors didn’t predict spontaneous resolution of SSD.
Type of errors, however did! Kids with speech sound errors best described as “phonologically delayed” (that is, those who use error patterns consistent with younger children, e.g. stopping or cluster reduction) were nearly twice as likely to spontaneously resolve as kids with speech sound errors best described as “atypical” (e.g. backing or initial consonant deletion). The kids who made the fewest atypical errors were most likely to improve over time.
What does this mean for SLPs? First, looking at the types of errors kids make may make more sense than counting the number of consonant errors. This may aid us in predicting who is more or less likely to grow out of their speech errors!
But, then what to do? Should we prioritize services for children with atypical errors, and wait it out for kids with more typical error patterns? Ehhh…. not so fast. First, we have to be cautious making decisions that apply to entire caseloads or entire school districts (as many of our supervisors want so badly to do!) To think on this, we also need to look more closely at the actual percentages, here: The authors state, “67% of phonologically delayed children had resolved by seven years (of age) compared to 35% of children making atypical speech errors.” So… if 67% of phonologically delayed children resolve, that’s great—but what about the 33% who don’t? Even though the authors have some nice data, here, categorizing kids this way clearly isn’t a perfect predictor of the future. There may be slightly better methods that are even more predictive than what was done in the current study (yay for more science!). Also—resolution of speech sound errors isn’t all that matters, here, when kids with phonological delay may be experiencing other difficulties as well (e.g. literacy). Clearly more data and more discussions are needed, before we attempt to make widespread procedural decisions. But this is a really good start!
Oh, and BTW—are you looking for research to justify working on speech sound errors at a young age, or single speech sound errors, because you have administrators who think the “speech kids” don’t need your attention? In the background of this paper, they review research on why we shouldn’t be framing this as just an articulation problem—“Children’s school achievement is often adversely affected (Hayiou-Thomas et al., 2016) as are their peer relationships, due to social, emotional and behavioral difficulties (Murphy et al., 2014). Persistent impairment in adolescence affects literacy, mental health and employment (Law et al., 2017).” You can get some real gems from the background of this paper!
Dodd, B., Ttofari-Eecen, K., Brommeyer, K., Ng, K., Reilly, S., Morgan, A. (2017). Delayed and disordered development of articulation and phonology between four and seven years. Child Language Teaching and Therapy. doi: 10.1177/0265659017735958.
Early speech and language disorders affect later spelling
SLPs are well-aware that speech, language, and literacy are all interconnected, but we’re also aware that they’re not necessarily interconnected in a nice, clear, easy-to-understand way. This study helped to sharpen our vision on whether we should expect later spelling difficulty in children with early speech and language disorders.
First, a quick refresher. There are a couple of skills kids need in order to have good spelling skills. One is phonological awareness. The other is RAN, or rapid automatized naming (e.g., naming a set of colors or animals as fast as possible). While RAN is usually studied in the context of reading, it can also affect spelling, and can predict spelling difficulty in children, especially for irregular words (see here for more on RAN and spelling). In addition to the skills associated with spelling, there is also a genetic factor: spelling difficulty (and reading, learning, language, etc.) can run in families. On top of all of that, we know from existing research and clinical experience that children with speech sound and language disorders are at risk for later reading and spelling impairments.
The authors tested participants from a large longitudinal study to explore how these factors contribute to spelling ability in middle- and high-school students. Children who were tested between 4- and 6-years of age were split into groups* based on diagnosis:
SSD + DLD
CAS (these children also all had DLD)
All children were assessed again at middle school or high school age on phonological awareness, RAN, reading decoding, and spelling. Interestingly, the results indicated that having SSD alone was not associated with spelling difficulty in later school years, but children with SSD + DLD and children with CAS (who also met criteria for DLD) showed continued spelling difficulty into middle- and high-school. Taking a closer look at the underlying skills needed for spelling, phonological awareness was related to spelling scores at middle- and high-school, but RAN was only related to spelling scores in the high school group.
The authors also looked at heritability of spelling skills. Heritability looks at the probability that differences in a trait (in this case, spelling) occur because of genetic reasons and not because of environmental factors or by chance. Controlling for diagnosis and socio-economic status, the authors found strong heritability only in the high school group, meaning that genetic factors are probably more important in later spelling skills while environmental factors are more at play in the earlier years. Based on the results of the study, authors suggest we should keep a close eye on children with early SSD and DLD and intervene for those students who are showing early signs of spelling and reading difficulty.
*SSD = speech sound disorder; DLD = developmental language disorder; CAS = childhood apraxia of speech)
Lewis, B. A., Freebairn, L., Tag, J., Benchek, P., Morris, N. J., Iyengar, S. K., …, & Stein, C., M. (2018). Heritability and longitudinal outcomes of spelling skills in individuals with histories of early speech and language disorders. Learning and Individual Differences. doi: 10.1016/j.lindif.2018.05.001
Using a visual analog scale to characterize speech
“...there is much variability in children’s speech that is less easily captured using phonetic transcription.”
In this study, the authors examined whether a visual analog scale (VAS; as below, but with speech sounds) can be used to perceptually characterize speech variability within phonetic categories. A group of adults (not SLPs) listened to /s/ and /θ/ syllables extracted from words produced by 2–5-year-old children. Their task was to place the sounds on a continuum from /s/ vs. /θ/. The scale was found to be quite useful, in that its measures correlated “…with a variety of continuous measures of children’s production…”.
This study represents an initial step in a larger goal of identifying when and how visual analog scales could be used to accurately characterize speech. Would similar results be obtained for sounds other than /s/ vs. /θ/?
For SLPs, this could be a great option for charting clients’ progress, and the authors have research underway specifically looking at this. For our purposes, transcription sometimes isn’t enough to capture subtle changes in speech that occur during the course of therapy. We'll need to know whether SLP use of the scale produces the same results as lay people's use of the scale, how the scale works for other speech sounds, and whether the measure is reliable over the course of weeks or months.
Schellinger, S.K., Munson, B., & Edwards, J. (2016). Gradient perception of children's productions of /s/ and /θ/: a comparative study of rating methods. Clinical Linguistics and Phonetics. doi: 10.1080/02699206.2016.1205665.
How to evaluate young children’s polysyllable productions
Think about the last time you assessed a young child’s speech— did you look at polysyllables (i.e., words with three or more syllables)? There are often only a small number of polysyllable targets on speech-sampling assessments, which is problematic because polysyllable production is related to both phonological processing and later literacy development. In this article, Masso and colleagues provide tools for analyzing longer words in order to enhance our evaluations and to provide better descriptions of children’s speech.
Literature Review. The authors reviewed 53 studies that explored a variety of polysyllable sampling and analysis methods with either typically developing (TD) children or children with speech sound disorders (SSD). There was more information relating to polysyllable development in TD children vs. those with SSD, but even more research is still needed.
Tools and Analysis Methods. Simplifying things for SLPs, the Word-Level Analysis of Polysyllables (WAP) captures the 7 polysyllable analysis categories including substitution, deletion, addition, etc. The WAP can be applied to any polysyllable word list, so SLPs can select one of the 19 lists in Table 1 to meet the needs of the children you support. Be sure to also check out the WAP Short Form to use during analysis. SLPs can then use the Framework of Polysyllable Maturity (Figure 1) to interpret and visualize the child’s polysyllable productions on a continuum.
Sound complex? There’s a tutorial! The authors guide SLPs through the case study of a 4 year, 10-month old girl with SSD, first analyzing her polysyllable productions using the WAP and then interpreting the results using the Framework. The tutorial compares these results with those obtained using the DEAP, a standardized speech assessment.
The bottom line: Although we need more research on how to actually treat polysyllable production, assessing it will increase the depth and richness of your analysis of children’s speech.
Choosing the right words in speech sound treatment: (aka: No, seriously—is there a deck for this?)
When treating a young child with a speech sound disorder, how do you choose which words to work on? Many of us choose words we predict to be most meaningful to the child and most likely used on a regular basis (e.g. targeting /s/ in “sick” instead of “soot”). The author agrees that functional communication often motivates SLPs’ choices. Also convenience—for example, using a ready-made deck of cards, regardless of what words are in it, as long as it has the right target sounds in the right position(s).
In this paper, however, the author summarizes research to show that choosing stimuli this way is inadequate. Instead, lexical properties of words must be considered because of their significant impact on phonological learning. She suggests two things that we should be considering:
WORD FREQUENCY: For the greatest learning benefit to both treated and untreated sounds and words, use words that are more frequently-occurring in the language
PHONOLOGICAL NEIGHBORHOOD DENSITY (PND) and PHONOTACTIC PROBABILITY (PP): Recall that a word’s “phonological neighbors” are those that differ from the word by only one phoneme (e.g. neighbors of ‘dog’ would include ‘fog, log, dot, dig…’). A “dense neighborhood” is exactly what it sounds like—lots of phonological neighbors. Phonotactic probability refers to the frequency of sounds or sound sequences in a language. The author points out that “PND and PP tend to be highly correlated”, so groups them together for consideration. Words that have a high phonological neighborhood density and high phonotactic probability should be used as stimuli.
The author also points out that using words that satisfy both criteria (1) and (2) are best.
Resources are provided within the article for websites with phonological neighborhood density calculators.
Also—even though it’s not a major focus of the article, the author also points to research on the use of phototactically legal nonwords in therapy. Even though these are a word frequency of zero, evidence indicates that they may have a unique benefit for phonological instruction (see Cummings & Barlow, 2011; Gierut & Morrisette, 2010; Gierut et al., 2010).
Teasing out morphology vs. speech skills in preschoolers
We tend to talk about speech OR language impairment, when in reality, we know that it’s rarely so simple. Two studies this month looked at morphology skills in preschoolers with speech sound disorders, and ways to untangle the effects of each.
Murray et al. looked at assessment data from studies of preschoolers with childhood apraxia of speech (CAS) who all were given the CELF-P2. They found that children with CAS had lower expressive than receptive language skills overall. Morphology was particularly difficult for children with CAS, and errors were inconsistent across the same morphemes. While some morpheme errors were speech-based, others were language-based. Unfortunately, assessing morphology skills independently of speech skills is difficult, especially in connected speech.
The takeaway is that morphological skills should be part of our assessment process for children with CAS, but we need to consider whether children’s speech skills are causing the morpheme errors we see.
So, how can we do that? Howland et al. have some suggestions. They looked at grammatical morpheme production in preschoolers with phonological impairment (defined as speech sound disorder with pattern-based errors). They found that, for these kids:
Past tense –ed was harder than all other morphemes. Morphemes like third person singular -s were harder than morphemes like plural or possessive -s.
Morphemes in clusters (e.g., wants) were harder than morphemes in singletons (e.g., sees) or syllables (e.g., washes).
Children who could produce final clusters in single-morpheme words (e.g., waste) were more likely to use morphemes correctly overall.
So basically, children’s speech skills affect their ability to use morphemes. We can try to see whether the issue is caused by phonology or morphology by sampling sounds and clusters in single-morpheme vs. multi-morpheme words. Standardized tests don’t necessarily do this well, so it’s worth our time to do more probe testing to tease it out. What could this look like? Check out the example word pairs below. We’re asking, is it clusters that this child can’t do? Or morphemes?
Howland, C., Baker, E., Munro, N. & McLeod, S. (2018). Realisation of grammatical morphemes by children with phonological impairment. Clinical Linguistics & Phonetics. doi: 10.1080/02699206.2018.1518487.
Murray, E., Thomas, D. & McKechnie, J. (2018). Comorbid morphological disorder apparent in some children aged 4-5 years with childhood apraxia of speech: findings from standardised testing. Clinical Linguistics & Phonetics. doi: 10.1080/02699206.2018.1513565.
How do you interpret “educational performance”?
We don’t have to remind you of all the challenges facing children with speech sound disorders (SSD), especially since roughly 90% of school-based SLPs serve students with SSDs. Although we have that in common, we’re pretty different in how we (and our districts/states) interpret “educational performance,” a key phrase from IDEA. These differences have a huge impact on which students ultimately get services—and which students don’t.
By surveying SLPs nationwide, the authors of this article found a lot of variability. The guidelines we use come from different agencies (states, districts, state speech–language–hearing associations, etc.), but at least some of the differences are due to our individual decision making, because the survey found that “SLPs are familiar with their state guidelines but do not consistently use them as evidenced by considerable variability within and between states.”
Essentially, we are taking different factors into account when looking for the impact (or lack thereof) of SSDs on kids’ school success. Are you looking at only at grades? Do you weigh access to the curriculum, oral participation in class, or spelling? Do you take social-emotional adjustment into the mix? Consider how you determine educational impact now, and how either a narrower or broader view of the concept would change your practice. Would you have more artic/phono students? Fewer? Would they get services earlier, or keep them longer? Would you do your evals differently? Having the most possible students in therapy isn’t really the goal (must think least restrictive environment), but under-serving these students is definitely a problem.
Big takeaway here: other SLPs out there are likely making decisions very differently from how you are—and it’s time we talked more about it. As you reflect on the questions above, talk with your SLP coworkers and friends—even consider the conversations you might have with administrators, policy makers, and your local and state agencies. Small changes in policy (or how you and your coworkers apply the policy) could help ensure kids with SSDs get the services they need in the schools.
Farquharson, K., & Boldini, L. (2018). Variability in interpreting “educational performance” for children with speech sound disorders. Language, Speech, and Hearing Services in the Schools. doi: 10.1044/2018_LSHSS-17-0159.
Evidence-based treatment of childhood apraxia of speech
This is an exciting article to include, because it’s arguably the most thorough evaluation of childhood apraxia of speech (CAS) treatment options to date. When someone says, “I need a research study to help me decide among treatment strategies for CAS”, send them this!
This systematic review covers “…all levels of evidence that may be critical to inform clinical practice…” from the 1970s through 2012. From over 1000 studies, detailed inclusion/exclusion criteria were employed to narrow it down to 23. One issue that arose across studies was consistency in the definition of CAS (see ASHA’s 2007 consensus). The authors found that, “The most commonly overlooked CAS characteristic across studies was dysprosody…” Other studies were excluded for lack of clearly-reported treatment outcomes. Of the final 23 studies, most were motor approaches, with some linguistic and two AAC approaches. All delivered treatment individually, with a range in treatment schedule and dose.
So, what did the authors of this systematic review conclude? They found that:
“… currently two motor treatments (Integral Stimulation/DTTC and ReST [Rapid Syllable Transition]) and one linguistic treatment (Integrated Phonological Awareness Intervention) are best suited to interim clinical use…”
And, voilà—from there you start. Want another paper? Try this one. Maas et al. also examined the evidence behind several treatment approaches, and suggest that, “At present, a DTTC-type integral stimulation approach has the strongest evidence base…”
So—exciting as it is to know where you should start with these clients, I know what you all are thinking: Do either of these articles tell me how to "do" these techniques? How do I implement DTTC in the therapy room? Well... unfortunately, that's beyond the purpose of these papers (<sigh>). But, I know you all need this. So let's talk where to go next in the comments section (see here). We'll show you what we've found, and you all chime in, too! We should be able to crowd-source some of the best current resources for SLPs (extra credit for web-based continuing ed courses, folks!)
Murray, E., McCabe, P., & Ballard, K.J. (2014). A systematic review of treatment outcomes for children with childhood apraxia of speech. American Journal of Speech-Language Pathology. doi: 10.1044/2014_AJSLP-13-0035.
Teletherapy for CAS using Rapid Syllable Transitions
This article is a good one, not only because it’s a nice example of telepractice via online video conferencing (not many of those!), but also because it uses a treatment technique that you should know about, as well. Rapid Syllable Transitions (ReST) has been studied before, here and here, among others. It is “a relatively new treatment for CAS [childhood apraxia of speech] that uses pseudo-word targets with varying lexical stress patterns to target... articulatory accuracy, fluent transitions between syllables, and lexical stress” (Thomas et al., 2016).
The current study is small (five kids, age 5–11) and the first of its kind (so interpret with caution), but demonstrates “significant… generalization of the treatment effect to untreated imitated pseudo-words and real words”. Therapy was delivered four times per week for three weeks, so high intensity and short duration. The authors point out that ReST doesn’t require hands-on cueing and tends to work best for clients with milder forms of CAS, and thus may be well-suited for teletherapy.
Thomas, D. C., McCabe, P., Ballard, K. J. and Lincoln, M. (2016), Telehealth delivery of Rapid Syllable Transitions (ReST) treatment for childhood apraxia of speech. International Journal of Language & Communication Disorders. doi: 10.1111/1460-6984.12238
Is the Kaufman Speech to Language Protocol effective for children with CAS? (Spoiler: We don’t know)
Sometimes the popularity of a treatment program doesn’t match the evidence supporting it. Enter the Kaufman Speech to Language Protocol (K-SLP) for treating children with childhood apraxia of speech (CAS; aka: Kaufman cards, Kaufman kit) which Gomez et al. point out “is a treatment program that, anecdotally, is widely used by clinicians despite the lack of theory to support the approach.”
To test the K-SLP, the authors conducted a small experimental study. Two children with CAS, ages 4 and 5, received 3 weeks of treatment, with four 1-hour sessions per week. As prescribed by the K-SLP, treatment focused on successive word approximations. The K-SLP was also modified slightly; the children had to match the correct prosody for the words, and the authors incorporated principles of motor learning.
After treatment, the authors compared children’s performance on treated words to untreated control words. This is where it gets tricky—children’s baseline performance on control words was not consistent, likely because inconsistent productions are a hallmark of CAS. Both children’s average percent phonemes correct (PPC) increased, but only one child showed generalization by improving production of similar but untreated words. Both children’s PPC went down after treatment was withdrawn, but had not returned to baseline levels at 3 months post-treatment.
So, does the K-SLP work? This study is too small and preliminary to answer that question, and it’s the first published experimental study to ask it. It also doesn’t tell us how the K-SLP compares to other treatments, or which children it might work best for. In the meantime, there are other treatments for CAS with more evidence.
Gomez, M., McCabe, P., Jakielski, K., & Purcell, A. (2018). Treating childhood apraxia of speech with the Kaufman Speech to Language Protocol: A Phase I pilot study. Language, Speech, and Hearing Services in Schools. doi: 10.1044/2018_LSHSS-17-0100.
Speech treatment for children with Down syndrome
This study of 51 children with Down Syndrome (ages 5–12) compared the treatment technique Broad Target Speech Recasts (BTSR) to a comparison technique, Easy Does It (EDI). They sought to improve speech comprehensibility, or “the extent to which an unfamiliar listener can understand what the speaker says (Hanson, Yorkston, & Beukelman, 2004)”. BTSR may be roughly described as a technique that uses primarily speech recasts* and doesn’t target specific phonological patterns, while EDI uses elicited imitation to target specific phonological patterns.
Results indicate that BTSR is superior to EDI in improving speech comprehensibility for students with DS who have above-sample-average verbal imitation skills (but still low comprehensibility), and that this effect is driven by cumulative number of speech recasts. The authors predict that this is because students with DS who have adequate verbal memory and motor capacity (decent verbal imitation skills in the first place) benefit from their SLP providing frequent correct speech models that they can immediately compare to their own productions.
The authors also spend some time explaining why speech comprehensibility (instead of, or in addition to, speech accuracy) should be a standard outcome measure for speech therapy. These authors also published another paper in this month’s JSLHR describing how to perform these measures reliably.
*A speech recast is “an adult utterance that immediately follows a child’s 'platform' utterance, gives a neutral or positive evaluation of the meaning of the child’s utterance, and is an exact or reduced imitation of the word(s) that the child attempted to say but uses adult pronunciation”. e.g CHILD: “Da tu bid” ... ADULT RESPONSE: “That’s too big.”
Yoder, P.J., Camarata, S., Woynaroski, T. (2016). Treating Speech Comprehensibility in Students with Down Syndrome. Journal of Speech, Language, and Hearing Research. doi: 10.1044/2015_JSLHR-S-15-0148.
LSA for children with severe speech sound disorders
In this study, the authors aimed to evaluate whether language sample analysis (LSA) can accurately capture the expressive language profile of preschool children with severe speech impairment. The children in the sample were 3–5 years old, with receptive language within normal limits, but very low language comprehensibility (< 50%; no-context).
An approximately 20-minute language sample of 50–100 utterances was taken (most had 100+ utterances) and analyzed by two trained students. Results indicate that you can use LSA for severe speech impairment—even in children with very low comprehensibility. Of course, you can't use all the same analyses, but you can still analyze some things, so the tool shouldn't be avoided.
Between the two transcribers, exact word agreement was often low—meaning, one person thought the child said ‘where’, while the other transcriber thought she said ‘here’. But there was excellent agreement for word and syllable presence. From this, one can analyze mean length of utterance in words (MLUw) and mean syllables per utterance, which provide the clinician insight into the child’s expressive language ability. The authors additionally summarize which standardized and non-standardized scores correlated closely with LSA measures, so the clinician may weigh various options for testing. The authors do note that there will be children for whom modified LSA still doesn’t adequately capture their expressive language skills—e.g. those kids whose verbal expressive language is extremely minimal, but who are able to form multi-word utterances using AAC.
The authors remind us that many “severe speech” kids require language therapy—and we need to know what language to be treating, even though their speech is difficult to understand. We can’t simply work on semantics and single-word utterances if these children are capable of producing much longer utterances. Without good measurement tools, clinicians are at risk of setting language goals either too low or too high for these children.
EPG for treatment of articulation errors: “r”
Wouldn’t it be great if there were some sort of fancy biofeedback device that could be used for the treatment of articulation disorders? There is! One example is electropalatography (EPG) devices like the SmartPalate, now commercially available, increasingly affordable by clinics and school districts, and marketed for the correction of speech sound errors (“r” in particular).
But, do we have evidence to support that EPG devices work for speech? That’s exactly what Hitchcock et al. attempt to tackle. Five elementary-aged children—all with very low accuracy for “r”, four previously treated for “r” and one with no treatment history—were provided twice-weekly EPG therapy sessions for two months, using SmartPalate. At the end of treatment, all of the children made some gains with “r”, but it was quite variable, with only some of the children generalizing what’s they’d learned to untreated “r” targets.
So, what do we do with this information? Well, the good news is we know it can work for some kids! The bad news is this study is very small, and represents only the beginning of the type of data that needs to be collected in order to make truly informed decisions about the need for such technology. We have no idea how EPG biofeedback fares compared to other types of biofeedback, including ultrasound biofeedback (like this or this) and visual–acoustic biofeedback (seeing visual representations of acoustic features, e.g. on a computer screen). And, realistically, what is best may vary per child characteristics and treatment target—that is, acoustic biofeedback versus tongue shape biofeedback (as in ultrasound) versus tongue-to-palate contact information (as in EPG) could all be more or less ideal depending on what speech sound you’re working on. For example, with EPG treatment of “r”, the child is getting feedback about lateral bracing only (what’s lateral bracing? Read this). However, “…articulatory imaging has shown that speakers produce English rhotics using a variety of different tongue shapes…”
Hitchcock, E.R., Byun, T.A., Swartz, M., & Lazarus, R. (2017). Efficacy of Electropalatography for Treating Misarticulation of /r/. American Journal of Speech-Language Pathology. doi:10.1044/2017_AJSLP-16-0122.
A bit more!
Swaminathan & Farquharson asked 575 school-based SLPs whether they used an RTI (“Response to Intervention”) model with children with speech sounds disorders (SSD). SLPs with smaller caseloads were more likely to use RTI, even though those with larger caseloads could potentially benefit the most from the model. They also found a lot of inconsistency in how RTI was interpreted and used. If you’re questioning using this model, the article does a nice job of RTI applied to SSD!
Sudgen et al. (2018) review on the intensity of treatment for speech sound disorders shows that, in our research literature, intensity is generally: "... intervention two to three times per week in individual sessions... lasting 30–60 minutes..." Note that this review doesn't address what's best; rather, what the norm is. If you’re interested in more info on treatment intensity, check out our Evidence Answer on this topic!
Swaminathan, D., & Farquharson, K. (2018). Using Response to Intervention for Speech Sound Disorders: Exploring Practice Characteristics and Geographical Differences. Perspectives of the ASHA Special Interest Groups, 3(SIG 16), 53–66.
Sudgen, E., Baker, E., Munro, N., Williams, L., Trivette, C.M. (2018) Service delivery and intervention intensity for phonology‐based speech sound disorders. International Journal of Language and Communication Disorders. Advance online publication. doi: 10.1111/1460-6984.12399.
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