Treating tricky /r/ errors? Start with ultrasound visual biofeedback

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Every SLP has a bag of tricks for treating persistent /r/ errors. Increasingly, that might include high-tech visual biofeedback tools like ultrasound that allow children to see what their articulators are doing in real time. We’ve talked before about ultrasound as an up-and-coming tool to target speech production, and a new study gives us more evidence that it works.

The study looked at traditional vs. ultrasound visual biofeedback treatment for vocalic /r/ errors in older children (age 9–14). One group of children did 8 ultrasound sessions and then 8 traditional sessions, and the other group did the opposite. In both types of session, the SLP used the usual techniques (shaping, modeling, feedback), but in the ultrasound sessions, children could place the ultrasound under their chin to view their tongue placement.

Nine of the 12 children improved their /r/ productions following treatment. Traditional and ultrasound treatment both worked, but ultrasound treatment worked a little better, and children who had ultrasound treatment first did slightly better than those who had traditional treatment first.

This study tells us that ultrasound visual biofeedback treatment can help with persistent /r/ errors for most children. It also suggests that, instead of using ultrasound as a last resort, it might be better to start with ultrasound practice, giving children detailed feedback and establishing a good production.

Also—this systematic review of ultrasound studies for speech was recently published as well! It doesn’t include the newest studies (like the one, above), but overall the take-home is that ultrasound is an emerging technique (needs more evidence) with some promising results. Especially for, “…individuals whose speech errors persist despite previous intervention.”

Editor’s Note: Are you wondering, “Who has access to ultrasound equipment for speech?!” Many private practices and schools ARE starting to get this equipment! We wouldn’t cover this research yet if they weren’t. Expand the comments, below, and share your experiences with us, so we can all get a feel for what implementation is looking like.

 

Preston, J. L., McAllister, T., Phillips, E., Boyce, S., Tiede, M., Kim, J. S., & Whalen, D. H. (2019). Remediating residual rhotic errors with traditional and ultrasound-enhanced treatment: A single-case experimental study. American Journal of Speech-Language Pathology. doi:10.1044/2019_AJSLP-18-0261.

Sugden, E., Lloyd, S., Lam, J., & Cleland, J. (2019). Systematic review of ultrasound visual biofeedback in intervention for speech sound disorders. International Journal of Language and Communication Disorders. doi: 10.1111/1460-6984.12478.

Differences in how teachers and SLPs see DLD

Teachers and SLPs* are supposed to collaborate to support children with developmental language disorder (DLD). Right?! Yet, it seems to infrequently happen successfully. This paper helps us identify why by capturing similarities and differences in how our fields view and support DLD.

Some highlights:

  1. SLPs conceptualize DLD as a language learning impairment; teachers more commonly label it as a learning disability.

  2. SLPs assess DLD in order to identify what areas of language are a weakness, with plans to directly target those language areas, and quantify outcomes based on language performance. However, teachers assess in order to guide classroom instruction, with plans to change the classroom environment, and measure educational achievement.

  3. SLPs tend to prescribe intervention that is added on to classroom instruction, whereas teachers are looking at how they can tailor instruction within the classroom curriculum.

  4. SLPs tend to value language as a critical skill in and of itself, whereas teachers don’t tend to conceptualize language in isolation. Instead, their focus is overall educational achievement (and of course they recognize that language skills are embedded within that, but they don’t usually think of language as a target).

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Overall, this paper is a really good exercise in perspective-taking for SLPs. It highlights fundamental differences in how speech–language professionals and teachers are taught, what their research literature focuses on, and how their practice mindsets can be very different. And understanding all this could be really useful in framing discussions on inter-professional collaboration.

 

*SLTs in the UK; this is an Irish paper

Gallagher, A.L., Murphy, C-.A.,  Conway, P., Perry, A. (2019). Consequential differences in perspectives and practices concerning children with developmental language disorders: an integrative review. International Journal of Language and Communication Disorders. doi: 10.1111/1460-6984.12469.

Throwback (2012): One way to support your older students with DLD

If you serve students with developmental language disorders (DLD) in middle or high school, you’ve probably grappled with most of these problems: large caseloads, the impossible Tetris-game of scheduling pull-out sessions, a disconnect between therapy and classroom activities, time diverted to supporting missed or misunderstood class assignments, and difficulty connecting with general education teachers to co-plan or co-teach… to name just a few. So how do we navigate these hurdles to make meaningful changes for our students?

Back in 2012, Starling et al. took a novel approach to improving the language skills of a group of middle-grade students* (Australian Year 8, corresponding to the same grade in the U.S.) with language disorders: teaching the students’ teachers to modify their instructional language. This is taking a systemic approach to supporting students by targeting their environment and some of their most impactful communication partners—the ones delivering core academic instruction.

Teacher training addressed a few different areas, focusing on “practical and useable techniques”

  1. Modifying teacher’s written language in worksheets by breaking up large chunks of information, adding visuals, giving descriptions of vocab terms, and putting questions on the same page as the text they refer to.

  2. Modifying oral language by making directions explicit, giving extra processing time, rephrasing/repeating important points, and looking at the class when speaking.

  3. Visual strategies like lesson outlines, mind maps, and anchor charts/posters that the whole class participated in making.

  4. Vocabulary instruction techniques using the 3-tier system, adding extra opportunities to work with new words, and breaking down new words into roots and affixes.

Teachers met weekly individually or in small groups with the SLP for 10 weeks, and the SLP sat in on a few of each teachers’ lessons during that time to monitor how they put the strategies into practice. Click through to the article for specific examples of how lessons were modified based on the coaching process.

(An aside: We hear you, secondary-school SLP friends. This is WAY more access to gen-ed teachers than any of us are likely to have. Despite that, there are probably creative ways to implement something similar in your setting, even if you can’t follow the same schedule. If your school uses Professional Learning Communities, invests in peer coaching, or has other, regularly-occurring chances for professional development, you might be able to squirrel your way right in there! Administrators in charge of professional development stuff love coaching models—that’s how adults often learn best, after all—especially when they aren’t paying for an expensive outside consultant to deliver them.)

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Compared to another school, randomly chosen to wait until the next term for the intervention, trained teachers successfully adopted the new strategies and kept up with them, even after the coaching was ended. Even better, their students with identified language disorders improved in a standardized measure of listening comprehension and written expression compared to the students at the other school, and maintained those gains after three months. Similar improvements didn’t show up in oral expression or reading comprehension, though. The authors acknowledge that this teacher-focused intervention isn’t enough for students with significant language needs—of course it’s not. Many (most… all…) of them will still benefit from individualized instruction in some areas. But this can be one layer in a “comprehensive model of service delivery in supporting secondary students with [language disorders].” And bonus? These kinds of teaching practices have benefits for ALL students, not just the ones with disabilities. If your school or district follows RTI/MTSS or Universal Design for Learning, SLP-delivered teacher coaching fits perfectly with those values.

 

*An important note: English learners were not included in the target student group.

Starling, J., Munro, N., Togher, L., & Arciuli, J. (2012). Training Secondary School Teachers in Instructional Language Modification Techniques to Support Adolescents With Language Impairment: A Randomized Controlled Trial. Language, Speech, and Hearing Services in Schools. doi:10.1044/0161-1461(2012/11-0066)

Rhetorical competence: Anaphors, organizational signals, and refutation cues. Oh my!

If you’re an SLP who works with older elementary children and above, you’re probably already targeting strategies to improve reading comprehension. And you likely already know the differences between narrative texts and expository (informational) texts. But are you targeting rhetorical competence to improve expository text comprehension? Have you... even heard of rhetorical competence (RC)? Don’t panic if this is foreign to you—we’ve got a handy breakdown of some common rhetorical devices, based on this new article.

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Anaphors/Connectives:

  • Direct readers to think about an earlier referent in the text

  • e.g. Students are getting hurt because of unsafe playground equipment. A potential solution for this problem

Organizational Signals:

  • Help readers create a mental representation of the main ideas and text structure

  • e.g. “A second issue to consider is…” or “The first reason…

Refutation Cues:

  • Signal to readers that an incorrect belief is being asserted and then refuted

  • Many people think that ____, but actually ____

Now that you’re up to speed, on to the study*. The authors examined (1) how RC develops between 3rd and 6th grades, (2) how RC contributes to comprehension of expository texts, even beyond skills such as decoding and inferencing, and (3) if the relationship between RC and comprehension is moderated by grade level and other reader characteristics. The findings are detailed and dense, so here are the results that you, the practicing SLP, should focus on:

  • All measures of RC were correlated with improved comprehension of expository text. (Strong RC and strong text comprehension tended to go together.)

  • RC contributes to a student’s expository comprehension above and beyond that student’s inferencing skills, decoding ability, prior knowledge, and working memory. This means that the ability to use rhetorical devices makes a unique contribution to comprehension.

  • RC develops slowly over time and was not even complete in the 6th graders included in this study, meaning it is a skill you can target across several grade levels.

Sadly, this study didn’t tackle how to target rhetorical devices. But as the communication expert, you are uniquely positioned to explicitly draw attention to rhetorical devices in text, especially with readers who may already struggle with comprehension. Keep your eyes open for these features in the texts you’re already using, giving you the perfect opportunity to build rhetorical competence!

*Keep in mind, this sample featured typically-developing Spanish students, but there are enough similarities in text structure that the findings apply to English-speaking students as well.

García, J. R., Sánchez, E., Cain, K., & Montoya, J. M. (2019). Cross-sectional study of the contribution of rhetorical competence to children’s expository texts comprehension between third- and sixth-grade. Learning and Individual Differences. doi:10.1016/j.lindif.2019.03.005

Helping older students with DLD gain language skills

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Most research on language treatment looks at younger children, but we know that kids with developmental language disorder (DLD) are likely to struggle with oral language skills in middle school and beyond. This study looked at the effectiveness of narrative and vocabulary treatment for older students with DLD. 

Researchers assigned 12-year-olds (year 7 students in the UK) to one of four groups: narrative treatment, vocabulary treatment, both narrative and vocabulary treatment, or a wait-listed control group. Teaching assistants (similar to paraprofessionals in the US) led treatment sessions with small groups of 2–6 students. Sessions lasted 45–60 minutes and took place 3 times a week for 6 weeks. The assistants used lessons from commercially available narrative and vocabulary treatment programs. Narrative lessons focused on story structure, comprehension, and generation; vocabulary lessons focused on educationally-relevant words taught through categorization, mind-mapping, and word association tasks.

After the six weeks, students in all 3 treatment groups improved on standardized tests of narrative skill, and students in the narrative and combined groups improved on some of the study narrative measures. There was no difference among the groups on standardized vocabulary tests, but on researcher-developed assessments similar to the treatment activities, vocabulary skills improved with intervention too.

These findings suggest that a short period of group treatment delivered by teaching assistants has the potential to improve language skills in older children with DLD. This is a big deal because we don’t have a lot of well-designed studies showing that language therapy actually works for older kids. Even better? The intervention model used here (treatment delivered to groups by paraprofessionals) should be feasible for most school settings.

 

Joffe, V. L., Rixon, L., & Hulme, C. (2019). Improving storytelling and vocabulary in secondary school students with language disorder: A randomized controlled trial. International Journal of Language and Communication Disorders. doi:10.1111/1460-6984.12471