Functional speech assessment for children with CP

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Although there’s a lot of information out there about children with cerebral palsy (CP) who use AAC, what about those who are verbal? The speech of children with CP presents uniquely, with at least half having dysarthria. Because of the myriad presentations of dysarthria (flashback to motor speech disorders in grad school!) it can be difficult to differentiate between dysarthria and other speech/sound disorders. Detecting motor speech disorders at the youngest age possible is vital to ensuring that we are using the most appropriate, evidence-based treatment.

Hustad et al. used measures of functional speech in an attempt to differentiate five-year-old children with CP who have motor speech involvement (i.e. dysarthria) and those who do not. Those functional measures of speech included intelligibility, speech rate, and intelligible words per minute (a measure of speech efficiency). Children’s speech was measured using delayed imitation, so that evaluators knew the target words. However, these measures could be used with just about any speech sample! Below is a little review for how to calculate these handy measurements:

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All three measures readily differentiated children with dysarthria from children without dysarthria (with both typical development and CP). Furthermore, they even differentiated children with CP but without dysarthria from typically developing children, showing that even kids with CP who appear to have typical speech may have borderline to mild speech difficulties. Intelligibility was the strongest differentiator, with 90% of typically developing five-year-olds falling at 87% intelligibility or greater. See Figure 1 in the article for the hard data, including cutoff scores for differential diagnosis of dysarthria in kids with CP.

Note: Although this study focused on children with CP, functional measures of speech can be useful for any speech evaluation. These measurements, along with other assessment tools, can help us both to identify speech disorders at the earliest possible age and to make decisions regarding intervention and the use of AAC.

 

Hustad, K.C., Sakash, A., Broman, A.T., & Rathouz, P.J. (2019). Differentiating typical from atypical speech production in 5-Year-Old children with cerebral palsy: A comparative analysis. American Journal of Speech–Language Pathology. doi: 10.1044/2018_AJSLP-MSC18-18-0108.

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.

Quantifying unintelligible speech

Evaluations for children with speech sound disorders (SSDs) are pretty standard across the board. We take a speech sample through imitated words, picture naming, and/or free conversation. We measure which consonants they produce correctly vs. incorrectly, do an oral mech exam, and call it a day. But when children have long stretches of unintelligible speech, things can get complicated. How can we analyze speech if we have no idea what the child is saying? Öster et al. attempts to help us quantify unintelligible speech using a measure called percentage of intelligible correct syllables (PICS).  

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SLPs measured intelligible correct syllables by listening to a short sample of connected speech in children ages 4–10 with SSD (approximately 100 words). Since syllables are still evident in unintelligible speech, the SLPs were able to measure the number of accurate syllables divided by the total number of syllables in the sample to obtain the percentage of correct syllables. Furthermore, children’s’ PICS scores were correlated with their percentage of correct consonants (PCC) showing us that PICS can be used as a valid measure for assessing speech sounds. For those tricky children who are unintelligible more often than not, PICS could provide a baseline from which to measure progress.  

These researchers also used a novel method for collecting a connected speech sample. Using concurrent commenting, children watched a silent video, typically a clip from a children’s TV episode, and were instructed to describe the ongoing events of the video to a listener. This procedure allows SLPs to gain a sample of narration, which usually contains more linguistically complex and longer utterances compared to conversational speech. The video also provides contextual clues for the SLP to use when transcribing the sample.

Ready to jump in? Check out the article for even more details on how to assess a child using PICS and concurrent commenting. Both are handy tools to consider using when assessing highly unintelligible children.

 

Öster, C.A.M., Ode, C., & Strömbergsson, S. (2019). Dealing with the unknown—addressing challenges in evaluating unintelligible speech. Clinical Linguistics and Phonetics. doi:10.1080/02699206.2019.1622787.

Speech homework: The parents’ perspective

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If you are an SLP who works with children with speech sound disorders (SSD), you are aware of: (1) how important home practice is, and (2) how difficult it is to ensure it happens. You send home cute activities and worksheets only to find out they’re never being done. You email parents with suggestions but wonder how much parents actually use them.

Some researchers decided to interview parents about their experiences with home practice in order to better understand their perspective. They wanted to hear from parents how SLPs could better support and encourage their attempts!

The researchers interviewed six parents of children aged 3–6 who had participated in speech–language therapy for an SSD. Several themes emerged throughout the conversations. They boiled them down these: 

Evolution over time

Parents expressed that their experiences with home practice changed over time. At the beginning, parents often felt confused, overwhelmed, and unsure of how to complete the activities. Over time, parents felt increasingly confident in the activities and what was expected of them.

Different roles

Parents saw the SLP as the expert who could provide materials and instruction, but saw themselves as ultimately responsible for supporting their child’s speech and language.

Importance

Parents stressed the importance of several things to them: their child’s speech and communication growth, their own role and involvement in therapy, consistent home practice, and rapport with the SLP. They felt that when there was rapport, they and their child were more motivated to do home practice and they saw more progress.

Managing the practicalities of home practice

Parents expressed difficulty with the logistics of home practice. All parents reported that it was challenging to find the time to do the activities and most admitted that they did not complete the full amount of time suggested by the SLP. Parents described receiving activities that were not motivating to their child or did not suit them as a family. They were often also unsure of how to complete the activities or how to do the technical components of therapy.

Taken together, these findings leave us SLPs with some helpful takeaways. First, it’s important for parents and SLPs to have a clear discussion about both of their expectations at the beginning of therapy. These parents spoke about how their expectations did not always match the realities of what therapy looked like and it took a while for them to adjust and figure out the ropes. Second, it may be beneficial to regularly share data about the child’s progress, as parents found that when their child made progress, they were more motivated to continue home practice. Last, SLPs should work with the family to provide family-appropriate materials as well as sufficient training and clear instructions for how to complete them.

 

Sugden, E., Munro, N., Trivette, C.M., Baker, E., Williams, A.L. (2019) Parents’ experiences of completing home practice for speech sound disorders. Journal of Early Intervention. doi: 10.1177/1053815119828409.

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.

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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