Random versus blocked practice in treatment for childhood apraxia of speech

A Goal-Writing Framework for Motor-Based Intervention for Childhood Apraxia of Speech

PURPOSE

There are multiple frameworks for goal writing that are applicable to the practice of speech-language pathology. Motor-based speech disorders are a subset of speech sound disorders that are thought to require specific elements of intervention that are typically not addressed in the traditional frameworks used in the clinical setting. The purpose of this tutorial is to review general approaches of goal writing and suggest additional elements that may be used to improve the efficiency and effectiveness of treatment for childhood motor speech disorders, specifically childhood apraxia of speech (CAS).

METHOD

Existing models of goal writing were reviewed to ascertain elements common to most of these models. A basic framework was chosen and modified to include behaviors, conditions, and approaches to goal measurement tailored to the clinical needs of children with CAS. A resource for clinical decision making for children with CAS was developed to inform goal writing at the onset of treatment and adaptations that occur over the course of treatment. Case studies are presented to demonstrate how the presented framework can be applied to writing goals for motor-based treatment for two different children with CAS.

DISCUSSION

Children with CAS require a specialized approach to intervention, which requires goals to reflect the unique clinical needs of this population. This tutorial offers resources that use the best available research evidence and current understanding of effective treatment practices for CAS to guide clinical decision making for motor-based intervention and goal writing. This tutorial is intended to guide treatment planning across varied settings to facilitate progress and optimize treatment outcomes for children with CAS.

Listening like a speech-training app: Expert and non-expert listeners' goodness ratings of children's speech

Speech training apps are being developed that provide automatic feedback concerning children's production of known target words, as a score on a 1-5 scale. However, this 'goodness' scale is still poorly understood. We investigated listeners' ratings of 'how many stars the app should provide as feedback' on children's utterances, and whether listener agreement is affected by clinical experience and/or access to anchor stimuli. In addition, we explored the association between goodness ratings and clinical measures of speech accuracy; the Percentage of Consonants Correct (PCC) and the Percentage of Phonemes Correct (PPC). Twenty speech-language pathologists and 20 non-expert listeners participated; half of the listeners in each group had access to anchor stimuli. The listeners rated 120 words, collected from children with and without speech sound disorder. Concerning reliability, intra-rater agreement was generally high, whereas inter-rater agreement was moderate. Access to anchor stimuli was associated with higher agreement, but only for non-expert listeners. Concerning the association between goodness ratings and the PCC/PPC, correlations were moderate for both listener groups, under both conditions. The results indicate that the task of rating goodness is difficult, regardless of clinical experience, and that access to anchor stimuli is insufficient for achieving reliable ratings. This raises concerns regarding the 1-5 rating scale as the means of feedback in speech training apps. More specific listener instructions, particularly regarding the intended context for the app, are suggested in collection of human ratings underlying the development of speech training apps. Until then, alternative means of feedback should be preferred.

Childhood Apraxia of Speech: A Descriptive and Prescriptive Model of Assessment and Diagnosis

Childhood apraxia of speech (CAS) represents a significant diagnostic and therapeutic challenge within the field of clinical neuropsychology, characterized by its nuanced presentation and multifactorial nature. The aim of this study was to distil and synthesize the broad spectrum of research into a coherent model for the assessment and diagnosis of CAS. Through a mixed-method design, the quantitative phase analyzed 290 studies, unveiling 10 clusters: developmental apraxia, tabby talk, intellectual disabilities, underlying speech processes, breakpoint localization, speech characteristics, functional characteristics, clinical practice, and treatment outcome. The qualitative phase conducted a thematic analysis on the most cited and recent literature, identifying 10 categories: neurobiological markers, speech motor control, perceptual speech features, auditory processing, prosody and stress patterns, parent- and self-report measures, intervention response, motor learning and generalization, comorbidity analysis, and cultural and linguistic considerations. Integrating these findings, a descriptive and prescriptive model was developed, encapsulating the complexities of CAS and providing a structured approach for clinicians. This model advances the understanding of CAS and supports the development of targeted interventions. This study concludes with a call for evidence-based personalized treatment plans that account for the diverse neurobiological and cultural backgrounds of children with CAS. Its implications for practice include the integration of cutting-edge assessment tools that embrace the heterogeneity of CAS presentations, ensuring that interventions are as unique as the children they aim to support.

Treatment for Childhood Apraxia of Speech: Past, Present, and Future

PURPOSE

The purposes of this review article were to provide an introduction to and "bird's-eye" overview of the current evidence base for treatment of childhood apraxia of speech (CAS), identify some gaps and trends in this rapidly growing literature, and formulate some future research directions, in order to advance the evidence base and clinical practice for children with CAS.

METHOD

Following a brief introduction outlining important concepts, a narrative review of the CAS treatment literature is provided, and trends and future directions are identified based on this review. The review is organized around four fundamental treatment research questions: (a) "Does Treatment X work?", (b) "Does Treatment X work better than Treatment Y?", (c) "For whom does Treatment X work?", and (d) "What does 'work' mean, anyway?"

RESULTS

A wide range of CAS treatments with varying degrees of evidence for efficacy exists. Research is beginning to emerge that compares different treatments and seeks to determine optimal treatment parameters. Few studies to date have explored child-level predictors of treatment response, and the evidence base currently is limited in scope with respect to populations and outcomes studied.

CONCLUSIONS

A growing evidence base supports the efficacy of a number of treatments for CAS. However, many important gaps in the literature were identified that warrant redoubled and sustained research attention. Research is beginning to emerge that addresses treatment optimization, comparison, candidacy, and outcomes. Suggestions for future research are offered, and the concept of a hypothesized pathway was applied to CAS to illustrate how components of an intervention can effect change in a clinical goal and can help guide development and refinement of treatments for children with CAS.

Dynamic Temporal and Tactile Cueing in Young Children With Childhood Apraxia of Speech: A Multiple Single-Case Design

PURPOSE

Childhood apraxia of speech (CAS) is a multivariate motor speech disorder that requires a motor-based intervention approach. There is limited treatment research on young children with CAS, reflecting a critical gap in the literature given that features of CAS are often in full expression early in development. Dynamic Temporal and Tactile Cueing (DTTC) is a treatment approach designed for children with severe CAS, yet the use of DTTC with children younger than 3 years of age has not been examined.

METHOD

A multiple single-case design was employed to examine the use of DTTC in seven children with CAS (aged 2.5-5 years) over the course of 6 weeks of intervention. Changes in word accuracy were measured in treated words from baseline to posttreatment and from baseline to maintenance (6 weeks posttreatment). Generalization of word accuracy changes to matched untreated words was also examined. A linear mixed-effects model was used to estimate the change in word accuracy for treated and untreated words across all children from baseline to posttreatment and to maintenance. A quasi-Poisson regression model was used to estimate mean change and calculate effect sizes for treated and untreated words.

RESULTS

Group-level analyses revealed significant changes in word accuracy for treated and untreated words at posttreatment and maintenance. At the child level, six of seven children displayed medium-to-large effect sizes where word accuracy increased in an average of 3.4/5 words across all children. Each child displayed some degree of generalization to untreated targets, specifically for words with the same syllable shape as the treated words.

CONCLUSIONS

These results demonstrate that DTTC can yield positive change in some young children with CAS. Key differences in each child's performance are highlighted.

Traditional and Visual-Acoustic Biofeedback Treatment via Telepractice for Residual Speech Sound Disorders Affecting /ɹ/: Pilot study

Purpose

This study aimed to examine the feasibility of telepractice delivery of a treatment package including visual-acoustic biofeedback and motor-based treatment for residual speech sound disorder affecting /ɹ/ in school-age children. The overall study used a single-case randomization design; however, this preliminary report will simply quantify changes in accuracy before and after completion of the treatment package. The present analysis did not differentiate between the relative contributions of biofeedback and motor-based treatments.

Method

Seven children aged 9-14 received speech therapy for /ɹ/ distortions via telepractice. The study design consisted of three phases: baseline (four sessions), treatment (20 sessions), and post-treatment (three sessions). Treatment included two sessions weekly for a duration of 10 weeks. The participants received one motor-based/non-biofeedback session and one visual-acoustic biofeedback session per week. The order of treatment within each week was randomly determined prior to the start of therapy. Overall progress was assessed using untrained listeners' ratings of word probes administered in the baseline and posttreatment phases.

Results

Findings revealed that six of the seven participants showed a clinically significant response to the overall treatment package, although the magnitude of individual responses varied across speech contexts (consonantal and vocalic) and participants.

Conclusion

The present results suggest that a treatment combining visual-acoustic biofeedback and motor-based treatment for residual /ɹ/ errors treatment can be effectively delivered via telepractice. Considerations for technology setup and treatment protocols are provided.

A Comparison of Sound Production Treatment and Metrical Pacing Therapy for Apraxia of Speech: A Single-Case Experimental Design

PURPOSE

The purpose of this investigation was to compare the effects of two specific treatment protocols for acquired apraxia of speech (AOS): Sound Production Treatment (SPT) and Metrical Pacing Therapy (MPT), and to examine changes in communicative participation.

METHOD

Four speakers with chronic AOS and aphasia were each administered SPT and MPT in a replicated crossover design (ABACA/ACABA) with nonconcurrent multiple baselines across participants and behaviors. Treatment outcomes were compared with respect to whole word correctness (WWC) for treated and untreated multisyllabic word targets. Speech intelligibility was assessed using the Chapel Hill Multilingual Intelligibility Test, and communicative participation was measured using the Communicative Participation Item Bank at baseline, washout, and follow-up phases.

RESULTS

Three of the four participants experienced statistically significant improvements in WWC with SPT, and three of the four participants with MPT. Based on a priori criteria, three participants demonstrated relatively greater benefit from SPT and one participant demonstrated relatively greater benefit from MPT. There were measurable improvements in intelligibility following SPT for three of the four participants. Only one participant in this investigation reported a significant change in communicative participation, and only following MPT.

CONCLUSIONS

This study demonstrated that individuals in the chronic stages of AOS can benefit from both SPT and MPT, corroborating prior research on articulatory kinematic and rate and/or rhythm control treatment approaches. It contributes a comparison of two protocols for AOS with respect to whole word targets, intelligibility, and individual self-report of communicative participation changes. More participants showed a relative advantage of SPT over MPT. One individual reported communicative participation improvement after MPT.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.23971929.

Articulatory and segmental performance in children with and without speech disorder: A multiple case pilot study

This multiple case pilot study explored how nonword imitation influences articulatory and segmental performance in children with and without speech disorder. Eight children, ages 4- to 8-years-old, participated, including two children with childhood apraxia of speech (CAS), four children with phonological disorder (PD), and two children with typical development (TD). Tokens included two complexity types and were presented in random order. Minimal feedback was provided and nonwords were never associated with a referent. Kinematic and transcription data were analysed to examine articulatory variability, segmental accuracy, and segmental variability in session 1 and session 5. Descriptive statistics, percent change, effect sizes, and Pearson correlations are reported. In session 1, the two participants with CAS showed high articulatory variability, low segmental accuracy, and high segmental variability compared to the participants with PD and TD. By session 5, both participants with CAS, two with PD, and one with TD showed increased articulatory variability in the lowest complexity nonword. Segmental accuracy remained low and variability remained high for the two participants with CAS in session 5, whereas several participants with PD and TD showed improved segmental performance. Articulatory and segmental variability were not significantly correlated. The results of this study suggest that motor practice with minimal feedback and no assignment of a lexical referent can instantiate positive changes to segmental performance for children without apraxia. Positive changes to segmental performance are not necessarily related to increased articulatory control; these two processing levels can show distinct and disparate learning trajectories.

The role of lag effect in distributed practice on learning novel vocabulary

PURPOSE

The purpose of the current study was to investigate the lag effects in two different versions of distributed practice on learning novel language vocabulary.

METHOD

Forty-four healthy monolingual English-speaking participants were randomly assigned to two versions of distributed practice. The two versions of distributed practice were created by altering the temporal lag between the practice sessions. Participants in both groups completed a similar practice regimen wherein they practiced 30 French occupations five times each for a total of 150 times. The pre/post-design employed in this experiment involved participants completing baseline, immediate, and delayed retention tests. The outcome measures included a comprehensive multiple-choice test and a written expression task.

RESULTS

The findings from the comprehensive and expressive tasks indicated that the learning performance of participants across both groups was better during the immediate retention test compared to the delayed retention test. With regard to the group, participants assigned to the condensed version of distributed practice demonstrated superior learning of the novel vocabulary over participants assigned to the extended version of distributed practice.

CONCLUSION

The findings indicate that an increased temporal lag between the practice sessions results in a "non-monotonic function," wherein the learning continues to improve until an optimal lag, after which the learning declines as the lag continues to increase. This line of research will have a substantive impact on service-delivery models in speech-language pathology.

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.

Speech and Music Therapy in the Treatment of Childhood Apraxia of Speech: An Introduction and a Case Study

PURPOSE

Speech-Music Therapy for Aphasia (SMTA), a method that combines speech therapy and music therapy, is introduced as a treatment method for childhood apraxia of speech (CAS). SMTA will be evaluated in a proof-of-principle study. The first case study is presented herein.

METHOD

SMTA was evaluated in a study with a single-subject experimental design comparing 10 weeks of treatment with 2 months of no treatment. The research protocol included a pretest, baseline phase, treatment phase, posttest, no-treatment phase, and follow-up test. The participant was a boy with CAS aged 5;8 (years;months). Outcome measures were selected to reflect both intelligibility in daily communication as well as features of CAS and speech motor planning and programming.

RESULTS

Results on the Intelligibility in Context Scale-Dutch (ICS-Dutch) and in the analysis of a spontaneous speech sample suggest generalization of treatment effects. Improvements were found in measures that reflect complex speech motor skills, that is, the production of consonant clusters and consistency.

CONCLUSIONS

This case study showed that speech production of the participant improved after treatment with SMTA. Although intelligibility as measured with the ICS-Dutch improved over the study period, objectifying changes at the level of intelligibility in daily communication proved to be difficult. Additional measures may be necessary to gain more insight into treatment effects at this level. Overall, the results of this first case study provide sufficient support and important leads for further evaluation of SMTA in the treatment of CAS in a proof-of-principle study.

A Randomized Controlled Trial of Treatment Distribution and Biofeedback Effects on Speech Production in School-Age Children With Apraxia of Speech

PURPOSE

This study examines how ultrasound biofeedback and intensive treatment distribution affect speech sound generalization during an evidence-based treatment, Speech Motor Chaining, for children with persisting speech errors associated with childhood apraxia of speech (CAS).

METHOD

In a 2 × 2 factorial randomized controlled trial, children ages 9-17 years meeting CAS criteria were randomized to receive (a) a distributed treatment (20 sessions twice weekly over 10 weeks) or intensive treatment (20 hr in 5 weeks, with 10 hr in Week 1) and (b) treatment with or without biofeedback. Due to the COVID pandemic, some participants were randomized to distributed/intensive telepractice treatment only. The primary outcome was percent target sounds correct on untreated phrases (i.e., generalization) at the 10-week time point. More than 50,000 narrow phonetic transcriptions were analyzed.

RESULTS

Forty-eight participants completed treatment. Intensive treatment significantly increased generalization at all time points. The effect of biofeedback was significant at 5 weeks from the start of treatment but not significant at the primary 10-week time point. However, when comparing each group immediately after their 20 hr of treatment finished, generalization was significantly greater in intensive over distributed treatment and greater in ultrasound over no-ultrasound treatment (with a significant interaction favoring intensive treatment with ultrasound). Only the advantage of intensive treatment remained significant 5 weeks after groups finished treatment. There was no significant difference between face-to-face and telepractice modalities.

CONCLUSIONS

When the number of treatment hours is fixed, an intensive schedule of Speech Motor Chaining facilitated greater improvement than a distributed schedule. Ultrasound biofeedback initially accelerated learning, but the benefits may dissipate as treatment continues or after it ends.

The Multilevel Word Accuracy Composite Scale: A Novel Measure of Speech Production in Childhood Apraxia of Speech

PURPOSE

The Multilevel word Accuracy Composite Scale (MACS) is a novel whole-word measure of speech production accuracy designed to evaluate behaviors commonly targeted in motor-based intervention for childhood apraxia of speech (CAS). The MACS yields a composite score generated through ratings of segmental accuracy, word structure maintenance, prosody, and movement transition. This study examined the validity of the MACS through comparison to established measures of speech accuracy. Reliability was also examined within and between practicing speech-language pathologists (SLPs).

METHOD

The MACS was used to rate 117 tokens produced by children with severe CAS. Ratings were performed in the laboratory setting by two expert raters and by practicing SLPs (N = 19). Concurrent validity was estimated through comparison of expert MACS ratings (i.e., MACS score and each component rating) to measures of speech accuracy (percent phoneme correct and the 3-point scale) using correlational analyses. Reliability was examined between expert raters and across SLP raters using the intraclass correlation coefficient to examine interrater reliability of expert ratings, in addition to inter- and intrarater reliability of SLP ratings.

RESULTS

Correlation analyses between MACS ratings (i.e., MACS score and component ratings) and existing measures of speech accuracy revealed small to large positive correlations between measures. Reliability analyses revealed moderate to excellent reliability for MACS ratings performed by expert raters and between (interrater) and within (intrarater) SLP raters.

CONCLUSIONS

Analyses of concurrent validity indicate that the MACS aligns with established measures, yet contributes novel elements for rating speech accuracy. Results further support the MACS as a reliable measure for rating speech accuracy in children with severe speech impairment for ratings performed by expert raters and practicing clinicians.

Weekly Treatment for Childhood Apraxia of Speech With Rapid Syllable Transition Treatment: A Single-Case Experimental Design Study

PURPOSE

The aim of this study was to pilot the efficacy of rapid syllable transition (ReST) treatment when provided once per week for a 50-min treatment session for 12 weeks with five children with childhood apraxia of speech. Of central importance was the children's retention and generalization of gains from treatment as indicators of speech motor learning.

METHOD

A multiple-baseline across-participant design was employed to investigate (a) treatment effect on the 20 treated pseudowords, (b) generalization to 40 untreated real words and 10 untreated polysyllabic word sentences, and (c) maintenance of any treatment and generalization goals to up to 4 months posttreatment. To investigate any difference between in-session performance and retention, a comparison was made between data collected during treatment and probe sessions.

RESULTS

Treatment data collected during therapy showed all children improving across their 12 treatment sessions. Three of the five children showed a treatment effect on treated pseudowords in the probe sessions, but only one child showed generalization to untreated real words, and no children showed generalization to sentences.

CONCLUSIONS

ReST treatment delivered at a dose frequency of once per week was efficacious for only one of the five children. In-session treatment data were not a reliable indicator of children's learning. One session per week of ReST therapy is therefore not recommended.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.23751018.

Naive Listener Ratings of Speech Intelligibility Over the Course of Motor-Based Intervention in Children With Childhood Apraxia of Speech

PURPOSE

The aim of this study was to describe changes in speech intelligibility and interrater and intrarater reliability of naive listeners' ratings of words produced by young children diagnosed with childhood apraxia of speech (CAS) over a period of motor-based intervention (dynamic temporal and tactile cueing [DTTC]).

METHOD

A total of 120 naive listeners (i.e., listeners without experience listening to children with speech and/or language impairments; age range: 18-45 years) orthographically transcribed single-word productions by five children (age range: 2;6-3;11 [years;months]) across three time points over an intervention period (baseline, post-treatment, maintenance). Changes in intelligibility and interrater and intrarater reliability were examined within and across time points.

RESULTS

Speech intelligibility significantly increased in children with CAS over the course of treatment, and these gains were also maintained at 6 weeks posttreatment. There was poor-to-fair consistency between listeners (interrater reliability) and excellent consistency within listeners (intrarater reliability) in ratings of speech intelligibility within and across time points.

CONCLUSIONS

Motor-based intervention increases speech intelligibility following a period of DTTC treatment. Variability among naive listeners of speech intelligibility was also present, with intrarater reliability (within listeners) yielding greater consistency than interrater reliability (between listeners). The implications for including naive listeners as raters of speech intelligibility for research and clinical purposes are discussed.

Update on Identification and Treatment of Infants and Toddlers With Suspected Childhood Apraxia of Speech

PURPOSE

The purpose of this tutorial is to (a) provide an updated review of the literature pertaining to proposed early features of childhood apraxia of speech (CAS), (b) discuss the findings of recent treatment studies of infants and toddlers with suspected CAS (sCAS), and (c) present evidence-based strategies and tools that can be used for the identification of and intervention for infants and toddlers with sCAS or at high risk for the disorder.

METHOD

Since Davis and Velleman's (2000) seminal work on assessment and intervention in infants and toddlers with sCAS, limited research has guided clinicians in the complex task of identifying and treating early speech motor difficulties prior to a definitive diagnosis of CAS. Following the structure of Davis and Velleman, we explore the proposed early characteristics of CAS with reference to contemporary research. Next, we describe the limited treatment studies that have investigated intervention for infants and toddlers at risk of or suspected of having CAS. Finally, we present practical suggestions for integrating this knowledge into clinical practice.

CONCLUSIONS

Many of the originally proposed correlates of CAS in infants and toddlers now have research supporting their presence. However, questions remain about the developmental trajectory of the disorder. Although limited in number and restricted by lack of experimental control, emerging treatment studies can help guide clinicians in providing appropriate intervention to infants and toddlers with sCAS who need not wait for a definitive diagnosis to initiate intervention.

The Effectiveness of Rapid Syllable Transition Treatment in Improving Communication in Children with Cerebral Palsy: A Randomized Controlled Trial

Cerebral palsy (CP) is a movement disorder and majority of children with CP have communication impairments which impact participation with this population. Rapid Syllable Transition Treatment (ReST) is a motor speech intervention primarily for children with Childhood Apraxia of Speech (CAS). A recent pilot study in which ReST was trialed with children with CP showed improved speech performance. Therefore, a single blind randomized controlled trial to compare ReST to usual care with 14 children with moderate-to-severe CP and dysarthria was conducted. ReST was provided on telehealth. ANCOVA with 95% confidence intervals indicated significant group differences in favor of ReST in speech accuracy (F = 5.1, p = .001), intelligibility (F = 2.8, p = .02) and communicative participation on both the FOCUS (F = 2, p = .02) and Intelligibility in Context Scale (F = 2.4, p = .04). ReST was found to be more effective than usual care.

Dynamic Temporal and Tactile Cueing: Quantifying Speech Motor Changes and Individual Factors That Contribute to Treatment Gains in Childhood Apraxia of Speech

PURPOSE

Speech motor skill is refined over the course of practice, which is commonly reflected by increased accuracy and consistency. This research examined the relationship between auditory-perceptual ratings of word accuracy and measures of speech motor timing and variability at pre- and posttreatment in children with childhood apraxia of speech (CAS). Furthermore, the degree to which individual patterns of baseline probe word accuracy, receptive language, and cognition predicted response to treatment was explored.

METHOD

Probe data were collected from seven children with CAS (aged 2;5-5;0 [years;months]) who received 6 weeks of Dynamic Temporal and Tactile Cueing (DTTC) treatment. Using a multidimensional approach to measuring speech performance, auditory-perceptual (whole-word accuracy), acoustic (whole-word duration), and kinematic (jaw movement variability) analyses were conducted on probe words produced pre- and posttreatment. Standardized tests of receptive language and cognition were administered pretreatment.

RESULTS

There was a negative relationship between auditory-perceptual measures of word accuracy and movement variability. Higher word accuracy was associated with lower jaw movement variability following intervention. There was a strong relationship between word accuracy and word duration at baseline, which became less robust posttreatment. Furthermore, baseline word accuracy was the only child-specific factor to predict response to DTTC treatment.

CONCLUSIONS

Following a period of motor-based intervention, children with CAS appeared to refine speech motor control in conjunction with improvements in word accuracy. Those who demonstrated the poorest performance at treatment onset displayed the greatest degree of gains. Taken together, these results reflect a system-wide change following motor-based intervention.

A randomized crossover single-case series comparing blocked versus random treatment for anomia

The motor learning literature has demonstrated that blocked practice facilitates better acquisition of motor skills, whereas random practice facilitates retention and transfer. The verbal learning and memory literature offers similar evidence. The purpose of this study was to investigate effects of blocked versus random practice in treatment for anomia. The study used a single site, randomized crossover design, with two replicated experimental phases (two blocked and two random) for each of 10 individuals with anomia. Each phase consisted of a cued picture-naming treatment. Individual treatment and maintenance effects, as well as weighted averages and group effects, were calculated using Tau-U based on the proportion of correctly named probes. Nine of 10 participants demonstrated treatment effects during each of the four phases. Acquisition was comparable for blocked and random practice. Maintenance effects were observed following seven blocked phases of treatment and 12 random phases of treatment across participants. For four of 10 participants the random schedule resulted in better maintenance of trained items. Although further research is needed, the present data suggest that for word retrieval treatment with multiple repetitions of the same items, a random presentation may benefit maintenance of treatment gains.

Dose frequency randomized controlled trial for Dynamic Temporal and Tactile Cueing (DTTC) treatment for childhood apraxia of speech: protocol paper

BACKGROUND

Childhood apraxia of speech (CAS) is a pediatric motor-based speech sound disorder that requires a specialized approach to intervention. The extant literature on the treatment of CAS commonly recommends intensive treatment using a motor-based approach, with some of the best evidence supporting the use of Dynamic Temporal and Tactile Cueing (DTTC). To date, a rigorous and systematic comparison of high and low dose frequency (i.e., frequency of therapy sessions) has not been undertaken for DTTC, resulting in a lack of evidence to guide decisions about the optimal treatment schedule for this intervention. The current study aims to fill this gap in knowledge by comparing treatment outcomes when dose frequency is varied.

METHODS

A randomized controlled trial will be conducted to examine the efficacy of low versus high dose frequency on DTTC treatment outcomes in children with CAS. A target of 60 children, 2;6-7;11 years of age, will be recruited to participate in this study. Treatment will be provided in the community setting by speech-language pathologists who have completed specialized training administering DTTC in a research reliable manner. True randomization with concealed allocation will be used to assign children to either the low or high dose frequency group. Treatment will be administered in 1-h sessions either 4 times per week over a 6-week period (high dose) or 2 times per week over a 12-week period (low dose). To measure treatment gains, probe data will be collected before treatment, during treatment, and 1 day, 1 week, 4 weeks, and 12 weeks post-treatment. Probe data will consist of customized treated words and a standard set of untreated words to assess generalization of treatment gains. The primary outcome variable will be whole word accuracy, encompassing segmental, phonotactic, and suprasegmental accuracy.

DISCUSSION

This will be the first randomized controlled trial to evaluate dose frequency for DTTC treatment in children with CAS.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT05675306, January 6, 2023.

Changes in variability during intervention for childhood apraxia of speech: implications for therapy

Typically developing children are variable in their speech production with decreasing variability indicating mastery of speech. Excessive variability which does not change over time may be an indication of unstable motor plans as often seen in children with childhood apraxia of speech (CAS). Dynamic Systems Theory (DST) provides a framework for understanding the role of variability in speech development and disorder. There are few studies that explore the impact of therapy on speech variability. This work explores the impact of therapy on perceptual speech production variability. It is a post-hoc analysis of data collected in two intervention studies of a motor-based treatment approach with children with CAS and explores DST variability effects in speech skill acquisition based on the case data from those studies. There were six participants in total across the two studies. Findings were mixed showing some non-linear changes in variability with larger changes in variability observed in participants who engaged in more extensive therapy. However, the pattern of variability change was not consistent across the participants. These findings suggest that targeting variability in therapy may be an effective way to improve the speech of children with CAS. A model for utilising variability in therapy is presented.

Motor Speech Interventions for Children With Cerebral Palsy: A Systematic Review

PURPOSE

Dysarthria is common among children with cerebral palsy (CP) and results in poor speech intelligibility and subsequently low communicative participation. Neuroplasticity evidence suggests that adherence to principles of motor learning (PML) improves motor speech intervention outcomes. Motor speech interventions aim to improve speech intelligibility and ultimately facilitate participation, but the effectiveness of these interventions and their inclusion of PML are not clear. Aims are as follows: (a) evaluate the effectiveness motor speech interventions in improving speech intelligibility; (b) summarize the aims, outcome measures, and outcomes relating to the International Classification of Functioning and Disability Child and Youth; and (c) summarize the principles of motor learning used in the intervention.

METHOD

Eight databases were searched, complemented by a hand search. Studies of any level of evidence were included if they used a motor speech intervention and measured speech in children with CP aged 0-18 years. Studies before 2000 or not in English were excluded. The review was conducted and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study quality was rated using the Single Case Experimental Design Scale and Physiotherapy Evidence Database-P rating scales. The strength of evidence was evaluated with Grading of Recommendations, Assessment, Development and Evaluation.

RESULTS

Of 1,036 initial articles, 21 were included. Eight interventions were identified including 131 participants aged 3-18 years. All studies aimed to improve speech intelligibility or articulation and reported improvement at sound, word, or sentence level. One study reported improvements in communicative participation. The strength of evidence ranged from very low to moderate for one intervention. Adherence to PML was inconsistent.

CONCLUSIONS

The quality of evidence is very low to moderate. More research on motor speech interventions that adhere to PML is required.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21817959.

Speech Intervention for Children With Cleft Palate Using Principles of Motor Learning

PURPOSE

This is a pilot study to apply an articulatory kinematic speech intervention that uses the principles of motor learning (PML) to improve speech and resonance outcomes for children with cleft palate. It is hypothesized that (a) treatment that applies select PML during practice will improve production of treated phonemes, representing both active and inconsistent passive errors, at word level in children with cleft palate; (b) effects of practice on phonemes with active or inconsistent passive errors will generalize to untreated exemplars of treated phonemes; and (c) learning will be retained for at least 1-month posttreatment.

METHOD

A multiple-baseline design across participants combined with a crossover single-case experimental model was used. Participants attended two 8-week blocks of twice-weekly face-to-face speech therapy (40-50 min/treatment) to treat active and inconsistent passive cleft speech errors using articulatory kinematic speech intervention that applied PML. The participants were four children with cleft-type speech errors. The primary dependent variable measured was percentage of words correct across treatment items, generalization items, and control items. Perceptual accuracy of target words was scored. Effect sizes were calculated to quantify the magnitude of treatment effect.

RESULTS

For three children with active and inconsistent passive cleft speech errors and one child with active cleft speech errors and developmental phonological speech errors, this approach resulted in improvements to their treated items and generalization to their untreated items. Inconsistent passive cleft speech errors were particularly responsive to the treatment in the three children who presented with these errors.

CONCLUSION

This Phase I study has shown that articulatory kinematic speech intervention that applies the PML is effective in improving the speech outcomes for children with cleft palate and that there is validity in pursuing further research into this approach.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21644831.

Respiratory Responses to Two Voice Interventions for Parkinson's Disease

PURPOSE

The purpose of this study was to examine the respiratory strategies used by persons with Parkinson's disease (PD) to support louder speech in response to two voice interventions. Contrasting interventions were selected to investigate the role of internal and external cue strategies on treatment outcomes. LSVT LOUD, which uses an internal cueing framework, and the SpeechVive prosthesis, which employs an external noise cue to elicit louder speech, were studied.

METHOD

Thirty-four persons with hypophonia secondary to idiopathic PD were assigned to one of three groups: LSVT LOUD (n = 12), SpeechVive (n = 12), or a nontreatment clinical control (n = 10). The LSVT LOUD and SpeechVive participants received 8 weeks of voice intervention. Acoustic and respiratory kinematic data were simultaneously collected at pre-, mid- and posttreatment during a monologue speech sample. Intervention outcomes included sound pressure level (SPL), utterance length, lung volume initiation, lung volume termination, and lung volume excursion.

RESULTS

As compared to controls, the LSVT LOUD and SpeechVive participants significantly increased SPL at mid- and posttreatment, thus confirming a positive intervention effect. Treatment-related changes in speech breathing were further identified, including significantly longer utterance lengths (syllables per breath group) at mid- and posttreatment, as compared to pretreatment. The respiratory strategies used to support louder speech varied by group. The LSVT LOUD participants terminated lung volume at significantly lower levels at mid- and posttreatment, as compared to pretreatment. This finding suggests the use of greater expiratory muscle effort by the LSVT LOUD participants to support louder speech. Participants in the SpeechVive group did not significantly alter their respiratory strategies across the intervention period. Single-subject effect sizes highlight the variability in respiratory strategies used across speakers to support louder speech.

CONCLUSIONS

This study provides emerging evidence to suggest that the LSVT LOUD and SpeechVive therapies elicit different respiratory adjustments in persons with PD. The study highlights the need to consider respiratory function when addressing voice targets in persons with PD.

An Investigation of Developmental Coordination Disorder Characteristics in Children With Childhood Apraxia of Speech

PURPOSE

Children with childhood apraxia of speech (CAS) evidence a high rate of co-occurring fine and gross motor deficits. This clinical focus article reports a preliminary investigation of characteristics of developmental coordination disorder (DCD), a neurodevelopmental disorder categorized by poor motor proficiency and functional limitations, in this population.

METHOD

Children with CAS underwent a comprehensive motor evaluation using the Movement Assessment Battery for Children-Second Edition, the Developmental Coordination Disorder Questionnaire, and a developmental history questionnaire to determine if they met criteria for a DCD diagnosis as specified in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

RESULTS

Six out of seven participants met DCD criteria based on the DSM-5 criteria. Four of these children had a co-occurring diagnosis of developmental language disorder, and all met criteria for DCD.

CONCLUSIONS

Consistent with previous research, the majority of participants demonstrated motor deficits and 85% met criteria for DCD. Despite this high rate of motor deficits, only 57% had previously undergone a physical/occupational therapy evaluation and intervention and only one had a previous diagnosis of DCD. These findings suggest that formal movement assessments are essential for children with a CAS diagnosis.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.20540193.

Graduate Student Clinicians' Perceptions of Child Speech Sound Errors

Purpose

Speech-language pathologists (SLPs) rely on auditory perception to form judgments on child speech. This can be challenging for graduate student clinicians with limited clinical experience as they often need to judge children's speech errors using their auditory perception. This study examined how consistently graduate student clinicians used a 3-point perceptual rating scale to judge child speech.

Method

Twenty-four graduate student clinicians rated single words produced by children with typically developing speech and language skills and children with speech sound disorders. All participants rated the productions using a 3-point scale, where "2" was an accurate production, "1" was a close approximation, and "0" was an inaccurate production. Ratings were solely based on the auditory signal. These ratings were compared to a consensus rating formed by two experienced SLPs.

Results

Graduate student clinicians reached substantial agreement with the expert SLP rating. They reached the highest percentage agreement when rating accurate productions, and the lowest agreement when rating inaccurate productions.

Conclusions

Graduate student clinicians reached substantial agreement with expert SLP rating in judging child speech using a 3-point scale when provided with detailed descriptions of each rating category. These results are consistent with previous findings on the role that clinical experience plays in speech error perception tasks and highlight the need for additional listening training in speech-language pathology graduate programs.

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.

Predicting Treatment Outcomes in Rapid Syllable Transition Treatment: An Individual Participant Data Meta-Analysis

PURPOSE

The purpose of this study is to identify predictors of treatment outcomes in Rapid Syllable Transition Treatment (ReST) for childhood apraxia of speech through an individual participant data meta-analysis.

METHOD

A systematic literature search identified nine ReST studies for inclusion. Individual participant data were obtained, and studies were coded for methodological design, baseline participant characteristics, service delivery factors, and treatment outcomes. Bivariate analyses were conducted to identify potential predictor variables. Multiple linear regressions were then performed to identify predictors of treatment outcomes.

RESULTS

Data for 36 participants from seven studies were included in the statistical analyses. In multivariate modeling, better performance on treated pseudowords posttreatment was predicted by higher baseline expressive language and Goldman-Fristoe Test of Articulation scores, lower speech inconsistency and percentage of vowels correct, and higher pretreatment accuracy on pseudoword targets. Better performance on untreated real words posttreatment was predicted by higher pretreatment accuracy on real words. Gains in performance and retention of gains were not significantly predicted by any individual variable or combination of variables.

CONCLUSIONS

Baseline speech and expressive language skills and accuracy on pseudowords and real words were significant predictors of absolute posttreatment performance. Regardless of baseline characteristics, all children were statistically as likely to achieve gains during ReST and retain these gains for up to 4 weeks posttreatment. Large-scale prospective research is required to further examine the effects of dose frequency and co-occurring language impairments on treatment outcomes and the complex co-effects of percentage of vowels correct with other potential predictors.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19611714.

Telepractice Treatment of Residual Rhotic Errors Using App-Based Biofeedback: A Pilot Study

PURPOSE

Although mobile apps are used extensively by speech-language pathologists, evidence for app-based treatments remains limited in quantity and quality. This study investigated the efficacy of app-based visual-acoustic biofeedback relative to nonbiofeedback treatment using a single-case randomization design. Because of COVID-19, all intervention was delivered via telepractice.

METHOD

Participants were four children aged 9-10 years with residual errors affecting American English /ɹ/. Using a randomization design, individual sessions were randomly assigned to feature practice with or without biofeedback, all delivered using the speech app Speech Therapist's App for /r/ Treatment. Progress was assessed using blinded listener ratings of word probes administered at baseline, posttreatment, and immediately before and after each treatment session.

RESULTS

All participants showed a clinically significant response to the overall treatment package, with effect sizes ranging from moderate to very large. One participant showed a significant advantage for biofeedback over nonbiofeedback treatment, although the order of treatment delivery poses a potential confound for interpretation in this case.

CONCLUSIONS

While larger scale studies are needed, these results suggest that app-based treatment for residual errors can be effective when delivered via telepractice. These results are compatible with previous findings in the motor learning literature regarding the importance of treatment dose and the timing of feedback conditions.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.18461576.

A survey of the clinical management of childhood apraxia of speech in the United States and Canada

PURPOSE

Limited information is available about the current practices of generalist speech-language pathologists (SLPs) in relation to their management of childhood apraxia of speech (CAS). This study was designed to investigate four primary questions separately for the US and Canada; 1. What treatment approaches are used by SLP clinicians to treat CAS? 2. What treatment format and intensity are used to deliver CAS treatment? 3. What are the attitudes and perspectives of SLPs to evidence-based practice (EBP) as it pertains to CAS treatment? and 4. What are the perceived barriers to the implementation of EBP in CAS treatment?

METHOD

An online questionnaire was used to investigate the four primary research questions. The questionnaire was distributed online through social media, some state-based associations and through forums affiliated with national speech-language-hearing associations.

RESULTS

Most survey respondents reported frequently using an eclectic approach to treat CAS (US 85%; Canada 89%). Although no intervention emerged as the most preferred primary treatment for CAS, US-based clinicians more commonly reported using the Kaufman Speech to Language Protocol (K-SLP) (33%) and Dynamic, Temporal and Tactile Cueing (DTTC) (28%); while clinicians in Canada used PROMPT ® (31%). SLPs demonstrated a positive attitude towards EBP however, they identified a range of perceived barriers that impacted their implementation of EBP.

CONCLUSION

SLPs in the US and Canada frequently used an eclectic approach to treat CAS which is consistent with previous findings both in the CAS literature and the wider speech disorders literature. The more commonly used primary interventions were the K-SLP and DTTC (US); and PROMPT ® (Canada), with one of the strongest factors that influenced clinicians' choice of intervention being familiarity with the treatment approach. Face to face therapy was preferred by clinicians across both countries, with clinicians in the US providing therapy between 2-5 times per week, while those in Canada delivered therapy up to once per week. Clinicians identified a number of barriers to implementing evidence-based practice, among which, being time poor was most commonly selected across clinicians in both the US and Canada.

Retrospective Case-Control Study of Communication and Motor Abilities in 143 Children With Suspected Childhood Apraxia of Speech: Effect of Concomitant Diagnosis

Purpose

This study sought to determine if children with childhood apraxia of speech (CAS) plus another major diagnosis (CAS+) are equivalent in communication and motor profiles to those with a primary diagnosis of CAS and no indication or report of any other diagnosis (CAS-Primary).

Method

This retrospective case-control study included a chart review of 143 children who were suspected of having CAS at Children's Hospital-Wisconsin between 1998 and 2004. Participants were between 30 and 127 months old and included 107 males. Participants were assigned to the suspected CAS-Primary group (n = 114) if they had characteristics of CAS but no other major diagnosis (e.g., galactosemia) and to the CAS+ group (n = 29) if a comorbid diagnosis was present. Groups were compared across demographic, communication, and motor characteristics.

Results

Children with CAS+ evidenced more severe motor profiles than those with CAS-Primary, χ² = (1, n = 122) = 4.952, p = .026, and a small-to-medium effect size (Φ = .201). On average, communication profiles also tended to be more severe among those with CAS+ wherein receptive language was poorer and phonemic inventories were smaller than those with CAS-Primary.

Conclusions

These retrospective data suggest that comorbid diagnosis may play an important role in communication and motor development in children with suspected CAS. These exploratory findings should motivate future prospective studies that consider the role of concomitant diagnoses in symptom profile and response to treatment in children with CAS.

Speech-Language Pathologists' Ratings of Speech Accuracy in Children With Speech Sound Disorders

PURPOSE

Forming accurate and consistent speech judgments can be challenging when working with children with speech sound disorders who produce a large number and varied types of error patterns. Rating scales offer a systematic approach to assessing the whole word rather than individual sounds. Thus, these scales can be an efficient way for speech-language pathologists (SLPs) to monitor treatment progress. This study evaluated the interrater reliability of an existing 3-point rating scale using a large group of SLPs as raters.

METHOD

Utilizing an online platform, 30 SLPs completed a brief training and then rated single words produced by children with typical speech patterns and children with speech sound disorders. Words were closely balanced across the three rating categories of the scale. The interrater reliability of the SLPs ratings to a consensus judgment was examined.

RESULTS

The majority of SLPs (87%) reached substantial interrater reliability to a consensus judgment using the 3-point rating scale. Correct productions had the highest interrater reliability. Productions with extensive errors had higher agreement than those with minor errors. Certain error types, such as vowel distortions, were especially challenging for SLPs to judge.

CONCLUSIONS

This study demonstrated substantial interrater reliability to a consensus judgment among a large majority of 30 SLPs using a 3-point rating. The clinical implications of the findings are discussed along with proposed modifications to the training procedure to guide future research.

Application of the Challenge Point Framework During Treatment of Speech Sound Disorders

Purpose The purpose of this article is to provide trial-by-trial practice performance data in relation to learning (outcome probe data) as collected from 18 treatment sessions provided to children with severe speech sound disorders. The data illustrate the practice-learning paradox: Specific, perfect practice performance is not required for speech production learning. Method We detailed how nine student speech-language pathologists (SSLPs) implemented and modified the motor learning practice conditions to reach a proposed challenge point during speech practice. Eleven participants diagnosed with a severe speech sound disorder received high-intensity speech therapy 3 times per week for 6 weeks. SSLPs implemented treatment procedures with the goal of achieving at least 100 practice trials while manipulating practice parameters to maintain practice at the challenge point. Specifically, child performance was monitored for accuracy in five-trial increments, and practice parameters were changed to increase functional task difficulty when the child's performance was high (four or five correct responses) or to decrease functional task difficulty when the child's performance was low (fewer than four correct responses). The practice stimulus, type and amount of feedback, structure of practice, or level of support might be changed to ensure practice at the challenge point. Results On average, the children achieved 102 practice trials per session at a level of 58% correct responses. Fast achievement of connected speech with the lowest amount of support was associated with high scores on generalization probes. Even with high levels of error during practice, the children improved percent consonants correct with maintenance of learning 3 months posttreatment. Conclusion The results of this study show that it may not be necessary to overpractice or maintain a high degree of performance accuracy during treatment sessions to achieve transfer and retention of speech production learning.

Comparing Biofeedback Types for Children With Residual /ɹ/ Errors in American English: A Single-Case Randomization Design

Purpose Research comparing different biofeedback types could lead to individualized treatments for those with residual speech errors. This study examines within-treatment response to ultrasound and visual-acoustic biofeedback, as well as generalization to untrained words, for errors affecting the American English rhotic /ɹ/. We investigated whether some children demonstrated greater improvement in /ɹ/ during ultrasound or visual-acoustic biofeedback. Each participant received both biofeedback types. Individual predictors of treatment response (i.e., age, auditory-perceptual skill, oral somatosensory skill, and growth mindset) were also explored. Method Seven children ages 9-16 years with residual rhotic errors participated in 10 treatment visits. Each visit consisted of two conditions: 45 min of ultrasound biofeedback and 45 min of visual-acoustic biofeedback. The order of biofeedback conditions was randomized within a single-case experimental design. Acquisition of /ɹ/ was evaluated through acoustic measurements (normalized F3-F2 difference) of selected nonbiofeedback productions during practice. Generalization of /ɹ/ was evaluated through acoustic measurements and perceptual ratings of pretreatment/posttreatment probes. Results Five participants demonstrated acquisition of practiced words during the combined treatment package. Three participants demonstrated a clinically significant degree of generalization to untreated words on posttreatment probes. Randomization tests indicated one participant demonstrated a significant advantage for visual-acoustic over ultrasound biofeedback. Participants' auditory-perceptual acuity on an /ɹ/-/w/ identification task was identified as a possible correlate of generalization following treatment. Conclusions Most participants did not demonstrate a statistically significant difference in acoustic productions between the ultrasound and visual-acoustic conditions, but one participant showed greater improvement in /ɹ/ during visual-acoustic biofeedback. Supplemental Material https://doi.org/10.23641/asha.14881101.

Autism-Centered Therapy for Childhood Apraxia of Speech (ACT4CAS): A Single-Case Experimental Design Study

Purpose A subset of children with autism spectrum disorder (ASD) has speech sound disorders, including childhood apraxia of speech (CAS). To date, virtually all speech treatment studies consider ASD an exclusionary criterion, resulting in little scientific evidence for treatment of CAS for children who also have ASD. This study proposes and tests a novel approach, Autism-Centered Therapy for Childhood Apraxia of Speech (ACT4CAS), as a theoretically and clinically informed speech treatment option for this population. Method Using a multiple-baseline design within and across participants, three children with co-occurring ASD and CAS received 11-18 treatment sessions. Treatment targets were individually designed and matched with untreated control words. Probes were administered at the start of each session to assess speech production accuracy perceptually. Changes in production accuracy were examined through visual inspection and quantified with effect sizes. Results Findings were mixed, with one child showing significant gains for half of the treated targets at follow-up and two children showing no clear improvement. Conclusions Preliminary evidence suggests potentially positive treatment effects for ACT4CAS when implemented as intended, although treatment intensity and disorder severity likely influence treatment outcome. Replication and comparison of ACT4CAS to other speech treatments is needed. Supplemental Material https://doi.org/10.23641/asha.14110445.

Procedural Learning, Grammar, and Motor Skills in Children With Childhood Apraxia of Speech, Speech Sound Disorder, and Typically Developing Speech

Purpose This case-control study sought to determine if (a) children with childhood apraxia of speech (CAS), other speech sound disorders (SSDs), and typical development would perform differently on a procedural learning assessment and (b) whether grammatical ability would impact group differences. Method Communication, motor, and procedural learning abilities were assessed in 48 children with CAS (n = 13), SSD (n = 20), and typical development (n = 15), between 43 and 97 months of age (M = 66 months, SD = 12 months). Results On average, children with CAS demonstrated grammatical and motor impairments and required an increased number of exposures to the visuospatial sequence to demonstrate procedural learning, compared to peers with SSD or typical development. A subset of children from each group demonstrated an unanticipated procedural learning pattern wherein they evidenced an uptick in reaction time during the second sequenced block. Children with CAS with this pattern still evidenced procedural learning gains by the fifth sequenced block. In contrast, children with SSD and typical development with this pattern showed poor procedural learning outcomes and were characterized by lower scores on language and motor assessments as well. Conclusions This research provides partial support for the procedural learning deficit hypothesis in children with CAS and for a subset of children with SSD as well. Future research should examine the role of a serial reaction time task in identifying children at risk of multisystem communication and motor deficits. Supplemental Material https://doi.org/10.23641/asha.14173532.

Development and Validation of a Probe Word List to Assess Speech Motor Skills in Children

Purpose The aim of the study was to develop and validate a probe word list and scoring system to assess speech motor skills in preschool and school-age children with motor speech disorders. Method This article describes the development of a probe word list and scoring system using a modified word complexity measure and principles based on the hierarchical development of speech motor control known as the Motor Speech Hierarchy (MSH). The probe word list development accounted for factors related to word (i.e., motoric) complexity, linguistic variables, and content familiarity. The probe word list and scoring system was administered to 48 preschool and school-age children with moderate-to-severe speech motor delay at clinical centers in Ontario, Canada, and then evaluated for reliability and validity. Results One-way analyses of variance revealed that the motor complexity of the probe words increased significantly for each MSH stage, while no significant differences in the linguistic complexity were found for neighborhood density, mean biphone frequency, or log word frequency. The probe word list and scoring system yielded high reliability on measures of internal consistency and intrarater reliability. Interrater reliability indicated moderate agreement across the MSH stages, with the exception of MSH Stage V, which yielded substantial agreement. The probe word list and scoring system demonstrated high content, construct (unidimensionality, convergent validity, and discriminant validity), and criterion-related (concurrent and predictive) validity. Conclusions The probe word list and scoring system described in the current study provide a standardized method that speech-language pathologists can use in the assessment of speech motor control. It can support clinicians in identifying speech motor difficulties in preschool and school-age children, set appropriate goals, and potentially measure changes in these goals across time and/or after intervention.

Sound Production Treatment for Acquired Apraxia of Speech: An Examination of Dosage in Relation to Probe Performance

Purpose This study was designed to examine the association of dosage and effects of Sound Production Treatment (SPT) for acquired apraxia of speech. Method Treatment logs and probe data from 20 speakers with apraxia of speech and aphasia were submitted to a retrospective analysis. The number of treatment sessions and teaching episodes was examined relative to (a) change in articulation accuracy above baseline performance, (b) mastery of production, and (c) maintenance. The impact of practice schedule (SPT-Blocked vs. SPT-Random) was also examined. Results The average number of treatment sessions conducted prior to change was 5.4 for SPT-Blocked and 3.9 for SPT-Random. The mean number of teaching episodes preceding change was 334 for SPT-Blocked and 179 for SPT-Random. Mastery occurred within an average of 13.7 sessions (1,252 teaching episodes) and 12.4 sessions (1,082 teaching episodes) for SPT-Blocked and SPT-Random, respectively. Comparisons of dosage metric values across practice schedules did not reveal substantial differences. Significant negative correlations were found between follow-up probe performance and the dosage metrics. Conclusions Only a few treatment sessions were needed to achieve initial positive changes in articulation, with mastery occurring within 12-14 sessions for the majority of participants. Earlier occurrence of change or mastery was associated with better follow-up performance. Supplemental Material https://doi.org/10.23641/asha.12592190.

Computer-assisted challenge point intervention for residual speech errors

Purpose

This preliminary case series investigated the effects of biofeedback intervention for residual rhotic errors delivered within a modified challenge point framework. In the challenge point framework, practice difficulty is adaptively adjusted with the goal of enhancing generalization learning. This study more specifically evaluated the feasibility of a computer-mediated implementation of challenge point treatment for rhotic errors using a custom open-source software, the Challenge Point Program (CPP).

Method

Participants were five native English speakers, ages 7;3-15;5, who had established but not generalized correct rhotic production in previous treatment; overall treatment duration was flexible. Treatment incorporated either electropalatographic or visual-acoustic biofeedback and was structured by challenge point principles implemented using the CPP software.

Results

Participants were highly variable in the magnitude of generalization gains attained. However, the median overall effect size was 4.24, suggesting that participants' response in treatment tended to exceed the minimum value considered clinically significant.

Conclusions

These findings provide preliminary evidence that computer-mediated implementation of the challenge point framework can be effective in producing generalization in some participants.

A Comparison of Intervention Intensity and Service Delivery Models With School-Age Children With Speech Sound Disorders in a School Setting

Purpose This study examined intervention intensity and service delivery with school-age children with mild or mild-moderate speech sound disorders. The commonly used business-as-usual (BAU) service delivery model and a shorter, more frequent, individual model (experimental [EXP]) were compared. Method A between-subjects group design was selected. In BAU, 11 children received group sessions, 2 times per week, 30 min per session for 6 weeks. In EXP, 11 children received individual session, 3 times per week, 5 min per session for 6 weeks. Group differences on measures of dose (i.e., therapeutic input and production trials) and cumulative treatment intensity were examined. The extent to which children, across both conditions, demonstrated gains in speech sound accuracy and the extent to which gains differed between BAU and EXP were examined. Results There was a significant group difference on dose. Children in BAU received more therapeutic input and production trials than children in EXP. Cumulative treatment intensity was not statistically different between groups when dose was calculated as therapeutic input or production trials. Results from both conditions indicated statistically significant differences on measures of speech sound accuracy with large effect sizes. No group differences on gains were noted. Conclusions Dose calculated as therapeutic input and production trials plays an important role in understanding the impact of cumulative intervention intensity. Children with mild or mild-moderate speech sound disorders may benefit more from a shorter, frequent, individual service delivery model than a BAU model.

Auditory-perceptual acuity in rhotic misarticulation: baseline characteristics and treatment response

The rhotic sound /r/ is one of the latest-emerging sounds in English, and many children receive treatment for residual errors affecting /r/ that persist past the age of 9. Auditory-perceptual abilities of children with residual speech errors are thought to be different from their typically developing peers. This study examined auditory-perceptual acuity in children with residual speech errors affecting /r/ and the relation of these skills to production accuracy, both before and after a period of treatment incorporating visual biofeedback. Identification of items along an /r/-/w/ continuum was assessed prior to treatment. Production accuracy for /r/ was acoustically measured from standard/r/stimulability probes elicited before and after treatment. Fifty-nine children aged 9-15 with residual speech errors (RSE) affecting /r/ completed treatment, and forty-eight age-matched controls who completed the same auditory-perceptual task served as a comparison group. It was hypothesized that children with RSE would show lower auditory-perceptual acuity than typically developing speakers and that higher auditory-perceptual acuity would be associated with more accurate production before treatment. It was also hypothesized that auditory-perceptual acuity would serve as a mediator of treatment response. Results indicated that typically developing children have more acute perception of the /r/-/w/ contrast than children with RSE. Contrary to hypothesis, baseline auditory-perceptual acuity for /r/ did not predict baseline production severity. For baseline auditory-perceptual acuity in relation to biofeedback efficacy, there was an interaction between auditory-perceptual acuity and gender, such that higher auditory-perceptual acuity was associated with greater treatment response in female, but not male, participants.

Effects of Practice Variability on Second-Language Speech Production Training

BACKGROUND

Mastering the phonetics of a second language (L2) involves a component of speech-motor skill, and it has been suggested that L2 learners aiming to achieve a more native-like pronunciation could benefit from practice structured in accordance with the principles of motor learning.

PARTICIPANTS AND METHODS

This study investigated the influence one such principle, high versus low variability in practice, has on speech-motor learning for Korean adults seeking to acquire native-like production of English rhotics. Practice incorporated a commercially available intraoral placement device ("R Buddy," Speech Buddies Inc.). In a single-subject across-behaviors design, 8 participants were pseudorandomly assigned to practice rhotic targets in a low-variability (single word) or high-variability (multiple words) practice condition.

RESULTS

The hypothesized advantage for high-variability over low-variability practice was observed in the short-term time frame. However, long-term learning was limited in nature for both conditions.

CONCLUSION

These results suggest that future research should incorporate high-variability practice while identifying additional manipulations to maximize the magnitude of long-term generalization learning.

The influence of type of feedback during tablet-based delivery of intensive treatment for childhood apraxia of speech

PURPOSE

One of the key principles of motor learning supports using knowledge of results feedback (KR, i.e., whether a response was correct / incorrect only) during high intensity motor practice, rather than knowledge of performance (KP, i.e., whether and how a response was correct/incorrect). In the future, mobile technology equipped with automatic speech recognition (ASR) could provide KR feedback, enabling this practice to move outside the clinic, supplementing speech pathology sessions and reducing burden on already stretched speech-language pathology resources. Here, we employ a randomized controlled trial design to test the impact of KR vs KP feedback on children's response to the Nuffield Dyspraxia Programme 3, delivered through an android tablet. At the time of testing, ASR was not feasible and so correctness of responses was decided by the treating clinician.

METHOD

Fourteen children with CAS, aged 4-10 years, participated in a parallel group design, matched for age and severity of CAS. Both groups attended a university clinic for 1-hr therapy sessions 4 days a week for 3 weeks. One group received high frequency feedback comprised of both KR and KP, in the style of traditional, face-to-face intensive intervention on all days. The other group received high frequency KR + KP feedback on 1 day per week and high frequency KR feedback on the other 3 days per week, simulating the service delivery model of one clinic session per week supported by tablet-based home practice.

RESULTS

Both groups had significantly improved speech outcomes at 4-months post-treatment. Post-hoc comparisons suggested that only the KP group showed a significant change from pre- to immediately post-treatment but the group difference had dissipated by 1-month post-treatment. Heterogeneity in response to intervention within the groups suggests that other factors, not measured here, may be having a substantive influence on response to intervention and feedback type.

CONCLUSION

Mobile technology has the potential to increase motivation and engagement with therapy and to mitigate barriers associated with distance and access to speech pathology services. Further research is needed to explore the influence of type and frequency of feedback on motor learning, optimal timing for transitioning from KP to KR feedback, and how these parameters interact with task, child and context-related factors.

How the Study of Speech Motor Control Can Inform Assessment and Intervention in Childhood Apraxia of Speech

Purpose

The study of speech motor control has led to great advancements in the current understanding of childhood apraxia of speech (CAS). There remains a significant need to bridge the gap between theory and practice to fully understand the clinical implications of past research.

Method

This review article reviews the speech motor control research in CAS and discusses how these works have offered key information about the underlying motor deficits (Grigos et al., 2015; Terband et al., 2019), the influence of structured practice on speech performance (Case & Grigos, 2016; Grigos & Case, 2018), and the role of task complexity (Case, 2019; Case & Grigos, 2016; Grigos & Case, 2018). We highlight salient points from this existing literature and clinical implications to the assessment and treatment of CAS.

Conclusion

The study of speech motor control has shed light on a number of key factors related to CAS. Even within perceptually accurate speech, children with CAS display differences in movement patterning and timing control. Assessment must aim to more directly tax speech motor skills to obtain a thorough and accurate illustration of production deficits. Intervention is challenged with the task of not only improving production accuracy but also facilitating more efficient motor planning and programming. Motor-based intervention that applies motor learning principles and introduces variability across motor, phonetic, and prosodic contexts is believed to achieve this goal, though research is needed to better understand changes in speech motor control with treatment.

Rapid Syllable Transition Treatment—A Treatment for Childhood Apraxia of Speech and Other Pediatric Motor Speech Disorders

Purpose

Childhood apraxia of speech (CAS) is a speech disorder that many generalist speech-language pathologists feel underqualified to treat. For children with CAS, this may result in ad hoc interventions resulting in slower progress. Research evidence for various CAS treatments is primarily limited to single-case experimental design studies; however, two treatments (Rapid Syllable Transition Treatment [ReST] and the Nuffield Dyspraxia Programme, Third Edition) have been compared in a single randomized controlled trial.

Conclusion

This tutorial describes one of those treatments: ReST which was designed to address the three consensus core features of CAS simultaneously: consistency and accuracy of sounds, sequencing, and prosody. The treatment uses nonwords to help children build and store accurate motor plans and programs using principles of motor learning. Treatment data are described, and commonly reported clinical issues are discussed. Recommendations for which children may be suitable for ReST and for evidence-based practice are described.

Dynamic Temporal and Tactile Cueing: A Treatment Strategy for Childhood Apraxia of Speech

Purpose The purpose of this article is to describe a treatment approach, Dynamic Temporal and Tactile Cueing (DTTC), and to provide clinicians and clinical researchers a clear understanding of the theory and principles that contributed to the design of the treatment as well as the clinical decisions that must be made when implementing it. While brief descriptions of DTTC have been provided in textbooks, a complete summary of the rationale, essential elements, method, and procedures has not yet been published. Such a summary is important so that clinicians can gain a better understanding of and more confidence in using the method for appropriate children. Furthermore, this article provides clinicians and clinical researchers essential information for measurement of fidelity. Method The important elements of the DTTC method with rationale for their inclusion are described. The temporal hierarchy of DTTC is depicted, and the dynamic procedure is described in detail, with suggestions for fidelity measurement. Finally, a discussion of important decisions clinicians must make when implementing DTTC is presented. Conclusions The goal of DTTC is to improve the efficiency of neural processing for the development and refinement of sensorimotor planning and programming. The rationale for DTTC in general, as well as the key elements important to its administration, are supported by models of speech production and theories of motor learning. Important clinical decisions regarding stimuli, organization of practice, and feedback are based on principles of motor learning in order to facilitate acquisition, retention, and continued improvement of motor speech skills.

Role of Massed Versus Distributed Practice in Learning Novel Foreign Language Utterances

The current study compared the role of massed versus distributed practice in learning novel foreign language utterances. Fifty healthy native English-speaking participants were randomly assigned to either massed or distributed practice groups. All participants practiced eight novel French utterances 25 times each for a total of 200 times, with the spacing of practice sessions differing between the two groups. Both the groups completed an immediate retention as well as a delayed retention test. Participants' learning was evaluated based on phonetic accuracy and naturalness of the French utterances. The findings revealed that participants involved in distributed practice demonstrated better learning over participants involved in massed practice. Future research should aim to extrapolate these findings in treating speech disorders.

A Survey of Clinicians With Specialization in Childhood Apraxia of Speech

Purpose Little is known about how clinicians develop expertise in childhood apraxia of speech (CAS), a rare speech disorder with heterogeneous presentation. The purpose of this survey study was to examine the beliefs and practices of clinicians specializing in CAS. Method Speech-language pathologists who self-identify as having expertise in CAS (n = 165) completed an online survey regarding influences on clinical practice and beliefs about CAS. Practice patterns and perspectives regarding CAS were analyzed for respondents who self-identify as having expertise in CAS, across 4 experience bands (1-5, 6-10, 11-15, and 15+ years). Results A majority of the respondents to this survey provide treatment to preschool-age children with CAS. Respondents report features used in differential diagnosis aligned with the American Speech-Language-Hearing Association's (2007) technical report, with inconsistency as a key feature. Results suggest that continuing education courses are highly influential in the perceived development of expertise and perspectives regarding CAS. Respondents expressed uncertainty about comorbidity of CAS with other communication disorders. Overall, beliefs and practices are relatively uniform across levels of clinical experience. Conclusions Practices and perspectives of clinicians who self-identify as having expertise with CAS are influenced by factors noted in previous literature. Results of this survey highlight the need for research on the development of expertise in the clinical management of CAS, updated consensus statements that reflect advances in current research, clarification regarding comorbidity of CAS with other communication disorders, and evaluation of continuing education opportunities. Supplemental Material https://doi.org/10.23641/asha.9755459.

Motor Performance in Children With Childhood Apraxia of Speech and Speech Sound Disorders

Purpose This study sought to determine if (a) children with childhood apraxia of speech (CAS), other speech sound disorders (SSDs), and typical development (TD) would perform differently on a standardized motor assessment and (b) whether comorbid language impairment would impact group differences. Method Speech, language, and motor abilities were assessed in children with CAS (n = 10), SSD (n = 16), and TD (n = 14) between the ages of 43 and 105 months. Motor skills were evaluated using the Movement Assessment Battery for Children-Second Edition (Henderson, Sugden, & Barnett, 2007), a behavioral assessment that is sensitive in identifying fine/gross motor impairments in children with a range of motor and learning abilities. Data were reanalyzed after reclassifying children by language ability. Results The CAS group performed below the normal limit on all components of the motor assessment and more poorly than the TD and SSD groups on Aiming and Catching and Balance. When children were reclassified by language ability, the comorbid CAS + language impairment group performed worse than the SSD-only and TD groups on Manual Dexterity and Balance and worse than the TD group on Aiming and Catching; all 7 children with CAS + language impairment evidenced performance in the disordered range compared to 1 of 3 children in the CAS-only group and 2 of 6 children in the SSD + language impairment group. Conclusions Children with CAS + language impairment appear to be at an increased risk for motor impairments, which may negatively impact social, academic, and vocational outcomes; referrals for motor screenings/assessments should be considered. Findings may suggest a higher order deficit that mediates cognitive-linguistic and motor impairments in this population.

Bang for Your Buck: A Single-Case Experimental Design Study of Practice Amount and Distribution in Treatment for Childhood Apraxia of Speech

Purpose The aim of this study was to examine 2 aspects of treatment intensity in treatment for childhood apraxia of speech (CAS): practice amount and practice distribution. Method Using an alternating-treatments single-subject design with multiple baselines, we compared high versus low amount of practice, and massed versus distributed practice, in 6 children with CAS. Conditions were manipulated in the context of integral stimulation treatment. Changes in perceptual accuracy, scored by blinded analysts, were quantified with effect sizes. Results Four children showed an advantage for high amount of practice, 1 showed an opposite effect, and 1 showed no condition difference. For distribution, 4 children showed a clear advantage for massed over distributed practice post treatment; 1 showed an opposite pattern, and 1 showed no clear difference. Follow-up revealed a similar pattern. All children demonstrated treatment effects (larger gains for treated than untreated items). Conclusions High practice amount and massed practice were associated with more robust speech motor learning in most children with CAS, compared to low amount and distributed practice, respectively. Variation in effects across children warrants further research to determine factors that predict optimal treatment conditions. Finally, this study adds to the evidence base supporting the efficacy of integral stimulation treatment for CAS. Supplemental Material https://doi.org/10.23641/asha.9630599.