Contributions to Gain in Speech Sound Production Accuracy for Children With Speech Sound Disorders: Exploring Child and Therapy Factors

Group Size: An Active Ingredient of School-Based Language Therapy

PURPOSE

This study explored the relation between therapy group size and language outcomes for children receiving school-based language therapy through an implementation science lens.

METHOD

Data for the current study were gathered as part of the Speech-Language Therapy Experiences in Public Schools study. Participants included 273 English-speaking kindergarten through second-grade children with language impairment receiving business-as-usual therapy on the caseloads of 75 speech-language pathologists. Data were collected over an academic year, including weekly therapy logs, speech-language pathology questionnaires, and pre- and post-language measures.

RESULTS

Descriptive analysis revealed that children primarily experienced small-group therapy sessions (two to four children); however, there was considerable variability in group size. Hierarchical general linear modeling indicated that caseload size did not explain group size variability. However, the number of student cancellations was positively associated with receipt of large-group sessions. Notably, a significant negative association was found between receipt of large-group sessions (i.e., five to 10 children) and language outcomes. Children who received more than the average number of sessions in large groups (i.e., more than 5% of total sessions) experienced 0.18 SD less language gain over the academic year compared to the mean (0.54 SD). No other group size configurations (i.e., individual, small group, and extra large) yielded significant associations with language outcomes.

CONCLUSIONS

The findings suggest that young children receiving language-based therapy in large groups make substantially fewer language gains over an academic year. These results have considerable implications for educational policy and clinical practice, which are discussed through an implementation science frame.

Dimensionality of Speech-Language Pathologists' Child-Directed Talk During School-Based Therapy With Primary-Grade Students

PURPOSE

The purpose of this study was to examine the measurement structure of the linguistic features of speech-language pathologists' (SLPs) talk during business-as-usual therapy sessions in the public schools and to test the longitudinal stability of a theorized dimensional structure consisting of quantity, grammatical complexity, and lexical complexity.

METHOD

Seventy-five SLPs' talk during therapy sessions with primary-grade students was automatically transcribed and coded for linguistic features from a corpus of 579 videotaped therapy session videos collected at the beginning, middle, and end of one school year with an approximately 12-week interval. We explored video characteristics and conducted descriptive statistics on eight linguistic indices of SLP talk to examine the variability in SLP talk between therapy sessions. Confirmatory factor analyses were used to explore the dimensional structure of SLP talk at each time point separately for the theorized three dimensions, and we conducted longitudinal measurement invariance analyses to test the stability of the three-factor structural model across the academic year.

RESULTS

There were considerable variabilities among SLPs in the characteristics of SLP talk during therapy sessions. The proposed three-factor structure of SLP talk consisting of quantity, grammatical complexity, and lexical complexity had good model fit at all three time points. The linguistic measurement properties representing the three factors were invariant over time.

CONCLUSIONS

Results provided robust evidence of between-SLP variability in their child-directed talk, established a three-dimensional structure of the linguistic features in SLP talk, and identified that the linguistic features in SLP talk stably measured the same constructs across one school year, based on measurement invariance. The dimensions of SLP talk during therapy with students may represent important, malleable features of therapy that influence child language gains.

Predictors of Functional Communication Outcomes in Children With Idiopathic Motor Speech Disorders

PURPOSE

The purpose of the study was to investigate child- and intervention-level factors that predict improvements in functional communication outcomes in children with motor-based speech sound disorders.

METHOD

Eighty-five preschool-age children with childhood apraxia of speech (n = 37) and speech motor delay (n = 48) participated. Multivariable logistic regression models estimated odds ratios and 95% confidence intervals for the association between minimal clinically important difference in the Focus on the Outcomes of Communication Under Six scores and multiple child-level (e.g., age, sex, speech intelligibility, Kaufman Speech Praxis Test diagnostic rating scale) and intervention-level predictors (dose frequency and home practice duration).

RESULTS

Overall, 65% of participants demonstrated minimal clinically important difference changes in the functional communication outcomes. Kaufman Speech Praxis Test rating scale was significantly associated with higher odds of noticeable change in functional communication outcomes in children. There is some evidence that delivering the intervention for 2 times per week for 10 weeks provides benefit.

CONCLUSION

A rating scale based on task complexity has the potential for serving as a screening tool to triage children for intervention from waitlist and/or determining service delivery for this population.

Word-final complexity in speech sound intervention: two case studies

In speech sound intervention, consonant clusters promote generalisation (i.e. improvement in untreated sounds and words), ostensibly due to their relative complexity compared to other phonological targets. However, our understanding of clusters as intervention targets is largely restricted to those in word-initial position (e.g. [fl-], flip). The present study extends available work to consider the effects of word-final consonant cluster targets (e.g. [-ks]). Phonologically complex word-final clusters may be morphologically simple (e.g. mix) or morphologically complex (e.g. packs, inflected with third-person singular) - yet this cross-domain complexity remains an understudied phenomenon. Presently, two case studies provide an initial investigation of word-final cluster intervention targets for children with phonologically based speech sound disorders. Intervention targets for both Anna (3;7 [years;months]) and David (4;1) featured the phonologically complex word-final cluster [-ks], with Anna's target being morphologically simple and David's being morphologically complex. Intervention was provided in 45-minute, individual sessions three times per week for a maximum of 18 sessions. Both children demonstrated high target accuracy by intervention's end. Following intervention, both children demonstrated progress in intelligibility and ability to produce word-final consonant clusters; David further demonstrated generalisation across multiple measures. Results are interpreted with consideration of individual differences and existing research on complexity in phonological intervention. Overall, present findings motivate continued research, as manipulation of word-final complexity allows for emphasis on a context that is relevant for children with speech sound disorders, for peers with difficulties in morphology (including word-final grammatical morphemes) and for the substantial proportion of children demonstrating weaknesses in both domains.

Core components of a rehabilitation program in pediatric cardiac disease

There is increasing effort in both the inpatient and outpatient setting to improve care, function, and quality of life for children with congenital heart disease, and to decrease complications. As the mortality rates of surgical procedures for congenital heart disease decrease, improvement in perioperative morbidity and quality of life have become key metrics of quality of care. Quality of life and function in patients with congenital heart disease can be affected by multiple factors: the underlying heart condition, cardiac surgery, complications, and medical treatment. Some of the functional areas affected are motor abilities, exercise capacity, feeding, speech, cognition, and psychosocial adjustment. Rehabilitation interventions aim to enhance and restore functional ability and quality of life for those with physical impairments or disabilities. Interventions such as exercise training have been extensively evaluated in adults with acquired heart disease, and rehabilitation interventions for pediatric patients with congenital heart disease have similar potential to improve perioperative morbidity and quality of life. However, literature regarding the pediatric population is limited. We have gathered a multidisciplinary team of experts from major institutions to create evidence- and practice-based guidelines for pediatric cardiac rehabilitation programs in both inpatient and outpatient settings. To improve the quality of life of pediatric patients with congenital heart disease, we propose the use of individualized multidisciplinary rehabilitation programs that include: medical management; neuropsychology; nursing care; rehabilitation equipment; physical, occupational, speech, and feeding therapies; and exercise training.

Working memory span and receptive vocabulary assessment in Urdu speaking children with speech sound disorder

Emerging evidence suggests that impaired speech may be related to reduced working memory (WM). The current study aimed to validate and compare the influence of articulation, short-term memory (STM), WM, and receptive vocabulary abilities of Pakistani children with speech sound disorder (SSD; N = 50) versus typically developing (TD; N = 30) children aged 7-13 years. Assessments included the Test for Assessment of Articulation and Phonology in Urdu (TAAPU), Peabody Picture Vocabulary Test-4, translated to Urdu (U-PPVT-4), and Digit Memory Test (DMT) used to determine speech articulation, receptive vocabulary, and memory abilities respectively. The percentage correct consonants (PCC) score was used to divide the SSD group further into SSD severity groups. The TD and SSD groups significantly differed in performance on all tasks (p < 0.05). Moreover, the SSD severity groups showed significant differences (p < 0.0001) in performance on different components of TAAPU (total errors and substitution errors) and DMT tasks. However, the SSD severity groups did not show significant differences in performance on the U-PPVT-4. Correlational analyses indicate statistically significant correlations of PCC with STM, WM, and receptive vocabulary. Regression analyses suggested that both WM and STM contribute to speech intelligibility in children with SSD. Our findings in Urdu-speaking children support previous results in English-speaking children suggesting the articulation skills, receptive vocabulary, STM, and WM were less developed in children with SSD than in TD children.

Clinicians' Perspectives of Treatment for Lateralization Errors: A Quantitative and Qualitative Study

PURPOSE

This mixed-methods study aimed to obtain information regarding speech-language pathologists' (SLPs) perspectives about treatment of lateralization errors (LEs), challenges to implementing evidence-based LE treatment practice, and the sources SLPs' use to find evidence to treat LEs. This information can assist our understanding of ways to facilitate the uptake of evidence-based practice into the everyday treatment of clients with this disorder.

METHOD

A convergent parallel mixed-methods design was used to collect data from SLPs (N = 214) using 24 questions from an online survey distributed through electronic mailing lists and Speech and Hearing State Associations. Quantitative data were analyzed using frequencies and averages; themes and subthemes of qualitative data were analyzed using a content analysis approach with no a priori codes. Quantitative and qualitative results were compared and integrated.

RESULTS

Participants believed that LEs required individualized treatment before the age of 5 years, were largely caused by structural and neuromuscular factors, and required an understanding of orofacial and dental structure and function. Challenges to implementing LE treatment included a lack of skills and knowledge specific to LEs, competing demands on clinicians' time and resources, and a research-practice gap. Sources of evidence frequently used to obtain information about LE treatment were colleagues, trainings, workshops, and American Speech-Language-Hearing Association journals.

CONCLUSIONS

Clinicians believe that LE treatment is challenging and requires skill training. Future research in LEs will need to consider the real-world decisions clinicians must make when treating this disorder as well as clinicians' everyday constraints and challenges.

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.

Optimizing Outcomes for Children With Phonological Impairment: A Systematic Search and Review of Outcome and Experience Measures Reported in Intervention Research

PURPOSE

Reporting of outcome and experience measures is critical to our understanding of the effect of intervention for speech sound disorders (SSD) in children. There is currently no agreed-upon set of measures for reporting intervention outcomes and experiences. In this article, we introduce the Speech Outcome Reporting Taxonomy (SORT), a tool designed to assist with the classification of outcome and experience measures. In a systematic search and review using the SORT, we explore the type and frequency of these measures reported in intervention research addressing phonological impairment in children. Given the integral relationship between intervention fidelity and intervention outcomes, reporting of fidelity is also examined.

METHOD

Five literature databases were searched to identify articles written or translated into English published between 1975 and 2020. Using the SORT, outcome and experience measures were extracted and categorized. The number of intervention studies reporting fidelity was determined.

RESULTS

A total of 220 articles met inclusion criteria. The most frequently reported outcome domain was broad generalization measures (n = 142, 64.5%), followed by specific measures of generalization of an intervention target (n = 133, 60.5%). Eleven (5.0%) articles reported measures of the impact of the phonological impairment on children's activity, participation, quality of life, or others. Twenty articles (9.1%) reported on parent, child, or clinician experience or child engagement. Fidelity data were reported for 13.4% of studies of interventions.

CONCLUSIONS

The measurement of intervention outcomes is challenging yet important. No single type of measure was reported across all articles. Through using tailored measures closely related to intervention targets in combination with a universal set of measures of intelligibility, the impact of phonological impairment on children's lives, and the experience of receiving and providing intervention, researchers and clinicians could work together to progress insights and innovations in science and practice for children with SSD.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19497803.

Using the Experience Sampling Method to Examine the Details of Dosage in School-Based Speech Sound Therapy

PURPOSE

The purpose of this project was to collect practice-based evidence regarding dosage in speech sound therapy sessions in school-based settings. Dosage is the number of trials within a therapy session for any one particular child. School-based speech-language pathologists (SLPs) face a variety of obstacles to service delivery, often making the implementation of evidence-based practices difficult. To that end, we were interested in exploring how therapy parameters, such as group size and session frequency were associated with dosage.

METHOD

Using the experience sampling method, we queried school-based SLPs (n = 90) across the United States. SLPs participated via a phone application, which randomly alerted them to participate 3 times per day for 5 days. SLPs also completed a demographic questionnaire that included information regarding caseload size and job satisfaction.

RESULTS

We report results from 670 therapy sessions. Results revealed that the therapy parameter of group size was negatively related to dosage. The SLP parameter of caseload size was positively related to dosage, but this was a small association. The child parameter of comorbidity was negatively related to dosage.

CONCLUSIONS

Our results support that as group size increases, children receive smaller doses of speech sound practice. Similarly, children who have a reported comorbidity received smaller doses compared to children who have an isolated speech sound disorder. We discuss implications for school-based practitioners and researchers.

Comparing the Informativeness of Single-Word Samples and Connected Speech Samples in Assessing Speech Sound Disorders

Purpose Speech-language pathologists (SLPs) are faced with the challenge of quickly and accurately identifying children who present with speech sound disorders (SSD) compared to typically developing (TD) children. The goal of this study was to compare the clinical relevance of two speech sampling methods (single-word vs. connected speech samples) in how sensitive they are in detecting atypical speech sound development in children, and to know whether the information obtained from single-word samples is representative enough of children's overall speech sound performance. Method We compared the speech sound performance of 37 preschool children with SSD (M _age = 4;11 years) and 37 age-sex-matched typically developing children (M _age = 5;0 years) by eliciting their speech in two ways: (a) a picture-naming task to elicit single words, and (b) a story-retelling task to elicit connected speech. Four speech measures were compared across sample type (single words vs. connected speech) and across groups (SSD vs. TD): intelligibility, speech accuracy, phonemic inventory, and phonological patterns. Results Interaction effects were found between sample type and group on several speech sound performance measures. Single-word speech samples were found to differentiate the SSD group from the TD group, and were more sensitive than connected speech samples across various measures. The effect size of single-word samples was consistently higher than connected speech samples for three measures: intelligibility, speech accuracy, and phonemic inventory. The gap in sample type informativeness may be attributed to salience and avoidance effects, given that children tend to avoid producing unfamiliar phonemes in connected speech. The number of phonological patterns produced was the only measure that revealed no gap between two sampling types for both groups. Conclusions On measures of intelligibility, speech accuracy, and phonemic inventory, obtaining a single-word sample proved to be a more informative method of differentiating children with SSD from TD children than connected speech samples. This finding may guide SLPs in their choice of sampling type when they are under time pressure. We discuss how children's performance on the connected speech sample may be biased by salience and avoidance effects and/or task design, and may, therefore, not necessarily reveal a poorer performance than single-word samples, particularly in intelligibility, speech accuracy, and the number of phonological patterns, if these task limitations are circumvented. Our findings show that the performance gap, typically observed between the two sampling types, largely depends on which performance measures are evaluated with the speech sample. Our study is the first to address sampling type differences in SSD versus TD children and has significant clinical implications for SLPs looking for sampling types and measures that reliably identify SSD in preschool-aged children.

Is High-Intensity Speech Intervention Better? A Comparison of High-Intensity Intervention Versus Low-Intensity Intervention in Children With a Cleft Palate

Purpose The purpose of this study was to compare the effect of speech intervention provided with a low intensity with speech intervention provided with a high intensity on the speech and health-related quality of life (HRQoL) in Dutch-speaking children with a cleft palate with or without a cleft lip (CP ± L) between 4 and 12 years. Method A longitudinal, prospective, randomized controlled trial with a multiple baseline design was used. Twelve children with a CP ± L (M _age = 8.0 years, SD = 1.54) were divided into two groups using block randomization stratified by age and gender: One group received low-intensity speech intervention (LISI; n = 6) and one group received high-intensity speech intervention (HISI; n = 6). Children in the LISI group received intervention with a session duration of 1 hr, a dose frequency of 1 session per week, and a total intervention duration of 10 weeks. Children in the HISI group received intervention with a session duration of 1 hr, a dose frequency of 5 sessions per week, and a total intervention duration of 2 weeks. The cumulative intervention intensity was kept constant. Both groups received identical therapy programs provided by the same experienced speech therapist. Perceptual speech assessments were performed on baseline and posttreatment data points. Changes in HRQoL were assessed using the Velopharyngeal Insufficiency Effects on Life Outcomes (VELO) questionnaire. Both groups were compared over time using (generalized) linear mixed models. Results No significant Time × Group interactions were observed for the percentage of correctly produced consonants at the word and sentence levels, indicating no differences in evolution over time among the two groups. The variables speech understandability, speech acceptability, and the total VELO scores significantly improved following HISI, but not following LISI. Conclusions Children in the HISI group made equal and, for some variables, even superior progress in only 2 weeks of therapy compared to children in the LISI group who received 10 weeks of therapy. HISI is a promising strategy to improve speech outcomes and HRQoL in a shorter time period.

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.

A Comprehensive Treatment Approach to Address Speech Production and Literacy Skills in School-Age Children with Speech Sound Disorders

Children with speech sound disorders (SSDs) represent a large proportion of clients served by school-based speech-language pathologists (SLPs). While considerable evidence is available regarding the identification of SSD in school-age children, there is a paucity of information regarding service delivery aspects of school-based speech therapy, such as frequency of sessions, number of trials, distribution of sessions over time, and format (individual or group intervention) that impacts the ability of SLPs to effectively treat SSD in the schools. School-age children with SSD are at risk for later literacy deficits, and strategically addressing their language and emerging literacy needs in addition to speech production accuracy may lead to increased intelligibility and better educational outcomes. In this article, we discuss the heterogeneity of school-age children with SSD with regard to weaknesses in phonological processing skills and language skills. We summarize the information currently available regarding the aspects of service delivery that contribute to gains in speech production accuracy. We conclude by sharing an example of how school-based SLPs could target speech production, phonological awareness, and morphological awareness in the same session with a child with SSD to maximize gains in speech and literacy skills.

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.

Reading Risk in Children With Speech Sound Disorder: Prevalence, Persistence, and Predictors

Purpose The purpose of this study was to determine the extent to which school-age children with speech sound disorder (SSD) exhibit concomitant reading difficulties and examine the extent to which phonological processing and speech production abilities are associated with increased likelihood of reading risks. Method Data were obtained from 120 kindergarten, first-grade, and second-grade children who were in receipt of school-based speech therapy services. Children were categorized as being "at risk" for reading difficulties if standardized scores on a word decoding measure were 1 SD or more from the mean. The selected predictors of reading risk included children's rapid automatized naming ability, phonological awareness (PA), and accuracy of speech sound production. Results Descriptive results indicated that just over 25% of children receiving school-based speech therapy for an SSD exhibited concomitant deficits in word decoding and that those exhibiting risk at the beginning of the school year were likely to continue to be at risk at the end of the school year. Results from a hierarchical logistic regression suggested that, after accounting for children's age, general language abilities, and socioeconomic status, both PA and speech sound production abilities were significantly associated with the likelihood of being classified as at risk. Conclusions School-age children with SSD are at increased risk for reading difficulties that are likely to persist throughout an academic year. The severity of phonological deficits, reflected by PA and speech output, may be important indicators of subsequent reading problems.

How to Recruit, Support, and Retain Speech-Language Pathologists in Public Schools

Over the past two decades, there has been a persistent shortage of qualified speech-language pathologists (SLPs) across the United States. This shortage is predicted to continue, as data reported by the American Speech Language Hearing Association (ASHA) from the US Bureau of Labor Statistics indicates that there will be a 27% increase in job openings through the year 2028. In some states, the shortage has led to service provision from individuals without a background in speech-language pathology and/or without speech-language pathology certification and licensure. Speech and language services that are delivered by unqualified personnel may lead to inadequate time devoted to therapy—either too much, or too little—which is ultimately unethical, illegal, and expensive. However, there is a real issue at hand for school leadership—and that is: How to recruit, support, and retain highly qualified SLPs? In the current tutorial, we will provide evidence-based action steps for how and why to recruit, support, and retain certified and licensed SLPs. Specifically, we discuss the qualifications of the SLP, roles and responsibilities of school-based SLPs, caseload versus workload considerations, various service delivery models, and a review of SLP job satisfaction research. Throughout the tutorial, we will provide concrete and evidence-based ideas for school leadership to consider when recruiting, supporting, and retaining SLPs.