Ultrasound visual biofeedback: a new tool for treating SSD?

Have a student (...or 50?) on your caseload with articulation goals? Have some of them been there for a long time? While some of our kids with speech sound disorders (SSD) make quick progress with traditional methods, what can we try with those whose errors persist despite treatment? One new—and cool— option is ultrasound visual biofeedback (u-VBF).

“Wait, what? Ultrasound??”

Yes, it’s actually been an active area of research for both assessment and intervention for many years, with positive or mixed outcomes reported. Ultrasound is non-invasive and uses high-frequency sound waves to make an image of the tongue, which clients can see as they speak, in real-time. This technology is most helpful for place errors involving the tongue, since labial sounds can be seen using a mirror. And while it sounds super-expensive, ultrasound units have actually become so affordable that we’re starting to see clinics and even school districts jump on board!

This newest study from Cleland et al. used u-VBF to treat a diverse range of children who presented with a range of SSDs, comorbid conditions like DLD or ASD, and different speech targets. (Note: /r/ was excluded as a possible target in this particular study.) The authors conducted a thorough assessment for each child to determine errors and stimulability, which guided the target selection for each child (check out the article for a cool flow chart illustrating this). After an initial baseline phase, 10–12 treatment sessions were conducted, following procedures you can find in this resource manual from the same authors.


Most children made some improvement toward their speech sound, although those without a co-occurring diagnosis made the most improvements, which the authors took to mean that children with comorbidities might benefit from higher dosage. These results show us that ultrasound can be used to treat lingual articulation errors in a wide range of SSDs. Given the design and sample size, we can’t say much about treatment of specific targets or client subtypes at this point. And since this paper didn’t address the dreaded /r/, see here, here, and here for more on that.

Cleland, J., Scobbie, J. M., Roxburgh, Z., Heyde, C., & Wrench, A. (2019). Enabling new articulatory gestures in children with persistent speech sound disorders using ultrasound visual biofeedback. Journal of Speech, Language, and Hearing Research. doi:10.1044/2018_JSLHR-S-17-0360

On intelligibility: why use it, and options for measurement

It’s been suggested that we use intelligibility as part of comprehensive speech assessment, and measurement of treatment outcomes. Why? Well, because intelligibility is kind of the point of speech therapy in the first place, right? Also, intelligibility can pick up on phonological changes that other measures (like percent consonants correct, PCC) can’t.

So which intelligibility measures are we supposed to be using, exactly? Or, more appropriately—what are our options?

First, there are many ways to measure intelligibility. We can use rating scales, single word measures, or connected speech; and raters may include the clinician, family, peers, or unfamiliar listeners. Each of these have their own pros and cons in terms of reliability, validity, and compatibility with clinical practice. But the gold standard has been to calculate the percent of words understood, by unfamiliar listeners, in a connected speech sample (Gordan-Brannan & Hodson, 2010).

And while speech samples + few unfamiliar listeners as raters may be ideal, that carries a time burden for clinicians. Further, we also really want data on how the child is functioning in his or her everyday life. These considerations are what make the Intelligibility in Context Scale (ICS) particularly enticing—developed and measured over the past several years from (ongoing) research by McLeod and colleagues.

What is the ICS? It’s a brief, 7-item rating scale, completed by the parents of preschool and school-aged children. It can supplement other clinical measures for a nice look at functional speech. The scale can be found here (also on the last page of this article). Additional things to know about it:


Multilingual populations: It’s been translated into 60 languages (free, online!), and being multilingual doesn’t affect the scores (McLeod et al., 2015). It’s recommended that you use a separate sheet for each language the child speaks.

Screening: Use for preschool screening would be appropriate, especially as additional normative data is collected by future research. For now, this article can help you identify appropriate scores for your environment. You’ll extrapolate to your clinical population by looking at the scores they found in their sample of 4- and 5-year-olds (see Table 3 of the study). Do keep in mind the limitations of their study (read Limitations section). But basically, the scores in this study are relatively conservative, so children are generally likely to require further speech evaluation if their scores are lower than that 2015 study.

Psychometric properties: You can find this data throughout several of their articles; in particular, this one, which provides support for the ICS as a valid and reliable measurement of preschool children’s intelligibility.

Though we started by looking at the McLeod et al., 2015 paper, research for this Throwback review ended up sending us toward several papers on intelligibility, linked out above. Enjoy!

And more

Hwa-Froelich & Matsuo found that children who were adopted internationally had pragmatic skills within the average range, yet their scores were lower than their non-adopted, typically-developing peers. Understanding the language skill profiles of children adopted internationally is important so that we don’t over-refer or misdiagnose these kids. P.S. We’ve reviewed this team’s research with this same population before here.

In the largest study of its kind to date, Potter, Nievergelt, & VanDam found that children with speech sound disorders have similar tongue strength as their typically-developing peers. This study adds to the evidence base that disputes the use of non-speech oral motor exercises in speech therapy.

Rivera Pérez et al. wondered whether monolingual SLPs could use audio prompting (i.e., pre-recorded stimuli in the home language) to facilitate vocabulary learning in Spanish–English bilingual preschoolers with typical language abilities. Children were taught vocabulary in either English only or in both English and audio prompt-delivered Spanish. All children learned English vocabulary, and only the group receiving audio prompting improved on Spanish vocabulary measures, suggesting audio prompting may help improvement in the home language. We should note that their design didn’t compare the English-only and English-plus-audio-prompting conditions and participants were typically developing children taught by SLPs. Still, more research like this could help identify ways SLPs can better serve their bilingual students. Exciting! 

Roberts et al. found positive effects of teaching preschoolers (including some dual language learners) letter name and letter–sound correspondence. No surprise there—we know how important that skill is! It is interesting that they found no advantage for teaching letter names before letter sounds: the jury’s still out on whether one should be taught before the other.

A study by Sue et al. reminds us to consider generalization not only across contexts but across receptive–expressive language modalities. In a single case design on vocabulary training in children with ASD, where children were taught a set of words either receptively or expressively, they found that some but not all of those words taught were acquired in the untrained modality. More expressive-to-receptive transfer was noted—which makes a lot of sense. There are still open questions about the optimal teaching order (if there is one) and what the implications are for dosage.


Hwa-Froelich, D. A., & Matsuo, H. (2019). Pragmatic language performance of children adopted internationally. American Journal of Speech–Language Pathology. doi:10.1044/2018_AJSLP-18-0075

Potter, N. L., Nievergelt, Y., & VanDam, M. (2019). Tongue strength in children with and without speech sound disorders. American Journal of Speech–Language Pathology. doi:10.1044/2018_AJSLP-18-0023

Rivera Pérez, J. F., Creaghead, N. A., Washington, K., Guo, Y., Raisor-Becker, L., & Combs, S. (2019). Using Audio Prompting to Assist Monolingual Speech–Language Pathologists to Teach English–Spanish Vocabulary to English Learners. Communication Disorders Quarterly. doi:10.1177/2F1525740118819659

Roberts, T. A., Vadasy, P. F., & Sanders, E. A. (2019). Preschoolers’ alphabet learning: Cognitive, teaching sequence, and English proficiency influences. Reading Research Quarterly. doi:10.1002/rrq.242

Su, P. L., Castle, G., & Camarata, S. (2019). Cross-modal generalization of receptive and expressive vocabulary in children with autism spectrum disorder. Autism & Developmental Language Impairments. doi:10.1177/2F2396941518824495

And more...

Baylis and Shriberg found that 14 of 17 children (82.4%) with 22q11.2 deletion syndrome (aka DiGeorge syndrome and velocardiofacial syndrome) had comorbid motor speech disorders. Speech motor delay and childhood dysarthria were more common than CAS. These initial prevalence estimates add to a growing body of evidence that helps us better understand the profile of 22q syndrome.

Glover et al. found that young children (preschool through 3rd grade) had more negative attitudes toward stuttering than their parents. By 5th grade, those attitudes improved and were similar to attitudes of parents.

Hammarström et al. found that an intense treatment (4 sessions per week for 6 weeks) was effective for a 4 year old, Swedish-speaking child with a severe speech sound disorder. Treatment incorporated multiple approaches—integral stimulation, nonlinear phonology, and a core vocabulary approach. After therapy, the child produced more target words, word shapes, and consonants correctly.

Kraft et al. replicated an earlier study to find that effortful control (an aspect of temperament) was the most important factor predicting stuttering severity in children. They recommend addressing self-regulation as part of the holistic treatment of stuttering.

Lancaster and Camarata set out to explain the heterogeneity of language skills in kids with DLD. At this time, it’s looking like a spectrum model (think autism!) fits best, versus labeling kids by subtypes or chalking up the differences to unique, individual profiles; but lots more data is needed. For now, the evidence suggests we should assess and treat kids with DLD based on level of severity *and* individual needs—which is probably what you’re doing already. 

Lane et al. profiled the communication skills of children with Sotos Syndrome using a parent-report measure. They found that most of the children had a language impairment (with issues in both structure and pragmatics), with a relative strength in verbal vs. nonverbal communication and a weakness in using context. These children are likely to need support in peer relationships, too. 

Sutherland et al. found that a standardized language test (the CELF-4) can be reliably administered via telehealth to children with autism. The specific children they tested were between 9 and 12 years old and mostly mainstreamed.


Baylis, A. L., & Shriberg, L. D. (2018). Estimates of the prevalence of speech and motor speech disorders in youth with 22q11.2 deletion syndrome. American Journal of Speech-Language Pathology. doi:10.1044/2018_AJSLP-18-0037

Glover, H. L., St Louis, K. O., & Weidner, M. E. (2018). Comparing stuttering attitudes of preschool through 5th grade children and their parents in a predominately rural Appalachian sample. Journal of Fluency Disorders. Advance online publication. doi:10.1016/j.jfludis.2018.11.001

Hammarström, I. L., Svensson, R., & Myrberg, K. (2018). A shift of treatment approach in speech language pathology services for children with speech sound disorders – a single case study of an intense intervention based on non-linear phonology and motor-learning principles. Clinical Linguistics & Phonetics. Advance online publication. doi:10.1080/02699206.2018.1552990 

Kraft, S. J., Lowther, E., & Beilby, J. (2018). The Role of Effortful Control in Stuttering Severity in Children: Replication Study. American Journal of Speech-Language Pathology. Advance online publication. doi: 10.1044/2018_AJSLP-17-0097

Lancaster, H. S., & Camarata, S. (2018). Reconceptualizing developmental language disorder as a spectrum disorder: Issues and evidence. International Journal of Language and Communication Disorders. Advance online publication. doi:10.1111/1460-6984.12433

Lane, C., Van Herwegen, J., & Freeth, M. (2018). Parent-Reported Communication Abilities of Children with Sotos Syndrome: Evidence from the Children’s Communication Checklist-2. Journal of Autism and Developmental Disorders. Advance online publication. doi:10.1007/s10803-018-3842-0

Sutherland, R., Trembath, D., Hodge, M. A., Rose, V., & Roberts, J. (2018). Telehealth and autism: Are telehealth language assessments reliable and feasible for children with autism? International Journal of Language & Communication Disorders. Advance online publication. doi:10.1111/1460-6984.12440

Random, reading, or rendof: What type of target words maximize treatment gains?

Ah, the age-old question—what words should we use in therapy for kids with speech sound disorders? There are a number of choices, each with some good arguments in its favor:


This study checked out differences in treatment success for each of these three word types for 24 children ages 3 to 7. Therapy for each kid focused on one, word-initial complex phoneme (/r/, /l/, “th” or “ch”), with five target words (either high-frequency, academic vocab, or nonwords, depending on which group the child was assigned to). The article describes the activities within each 50-minute intervention session, and supplemental treatment materials are available on a lab website (woo!). Each child’s progress was compared with his own performance in a baseline condition.

So, the winner? It’s the best possible news for clinicians, really. All the kids improved their phonological skills, with no significant differences among the words types. The authors point out that in reality, you’ll probably want to incorporate multiple types of words into your sessions. Like starting with nonwords for that “clean slate” effect, then moving to academic vocabulary words after a while to help boost those skills. But either way, the initial familiarity of the words likely won’t make or break your therapy. 

A second research question looked at treatment intensity. By splitting their subject pool in half (which, keep in mind, meant the number of kids per condition was pretty small), they found a large effect of treatment after 19 sessions (accuracy of target sounds in new words), and a medium effect after 11. I doubt anyone here is shocked—shocked!—that more therapy leads to better outcomes, but the size of the difference was actually pretty surprising. As we know, many kids don’t just make slow and steady progress, but need to get to that point where things start to “click.” It’s good to realize that the “clicking” place might be a little further away than we think.


Cummings, A., Hallgrimson, J., & Robinson, S. (2018). Speech Intervention Outcomes Associated With Word Lexicality and Intervention Intensity. Language, Speech, and Hearing Services in Schools. Advance online publication. doi: 10.1044/2018_LSHSS-18-0026.

The speech disorder we aren’t paying attention to

Q: What congenital syndrome…

  • May be more than twice as prevalent as autism?

  • Is often misdiagnosed or not spotted at all?

  • Results in a speech impairment for 90% of affected children?


A: It’s fetal alcohol spectrum disorder (FASD). And while all of us probably learned the hallmark physical features and cognitive/behavioral consequences (Do you know how often “philtrum” comes up on Jeopardy? It’s a lot!), the particulars of the speech impairment haven’t been well studied. Traditionally it’s talked about as a speech delay, but clinical SLPs have found the situation to be more… complicated than that.

Speech delay, disorder, or both? It matters, since you’ll approach treatment differently. But some research is missing to connect the dots and guide our intervention. This study begins that work by analyzing the speech of a group of boys* with FASD and comparing it with another group of typically-developing children. The boys with FASD had:

  • Slightly lower overall intelligibility

  • More consonant errors and some differences in order of mastery (in Dutch, FYI)

  • Extra difficulties with nonword repetition

  • Difficulties with auditory discrimination

  • Difficulties with oral motor skills (especially tongue control), causing issues with specific consonants

  • Speech errors related to craniofacial anomalies (e.g., high palate → denasalization errors)

The takeaways for SLPs? Speech in this population seems to be both delayed and disordered. It may be that motor planning and processing deficits are causing many of the speech issues we see. Beyond that, specific characteristics, such as hearing loss, tongue control issues, high arched palates, and phonological impairments (all of which some, but not all children with FASD will have) have additional effects on speech. Clinicians need to evaluate these underlying differences and difficulties and use that to guide treatment. And remember: These kids need a lot of repetition and practice to learn and generalize skills.

Unfortunately, there are no easy solutions for this population. They need “long-term dedicated treatment that is tailored to the individual profile under the guidance of SLPs who are trained in working with these children.” 

*Why just boys? Evidently no families of girls with FASD were willing to participate. Interesting.  So... sex-related differences in the FASD population are still an open question.


Terband, H., Spruit, M., & Maassen, B. (2018). Speech Impairment in Boys With Fetal Alcohol Spectrum Disorders. American Journal of Speech-Language Pathology / American Speech-Language-Hearing Association, 27(4), 1405–1425.

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. Advance online publication. doi: 10.1044/2018_LSHSS-17-0159.

Teasing out morphology vs. speech skills in preschoolers

Researchers 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?


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:

  • No SSD/DLD

  • SSD only

  • 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. Advance online publication. doi: 10.1016/j.lindif.2018.05.001