Treatment intensity and childhood apraxia of speech

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.

Effectiveness of the Kaufman Speech to Language Protocol for Children With Childhood Apraxia of Speech and Comorbidities When Delivered in a Dyadic and Group Format

PURPOSE

The current study is a Phase I clinical study with the goal of determining feasibility and the effectiveness of the Kaufman Speech to Language Protocol (K-SLP) for children with childhood apraxia of speech (CAS) and comorbidities. We hypothesized that K-SLP intervention would result in improved outcomes and maintenance of treatment effect at 3-4 months postintervention.

METHOD

Single-subject experimental design with multiple baselines across behaviors was replicated across a group of six children. Five out of six participants completed the study. The K-SLP intervention was administered in dyads four times a week for three consecutive weeks. Outcomes included assessment of word/syllable shapes, articulation accuracy, speech intelligibility, and functional communication. Treatment progress was measured through: (a) the administration of custom probe word lists and (b) assessments carried out at pretreatment, immediately following intervention and approximately 3-4 months after the study period.

RESULTS

Four out of five participants demonstrated significant improvements to words targeted in treatment and three out of five generalized these to untreated words. Furthermore, three out of five participants showed immediate and clinically significant posttreatment improvements in speech intelligibility and functional outcomes, and this increased to four out of five participants at 3-4 months follow-up.

CONCLUSIONS

The study provides preliminary support for the effectiveness of the K-SLP program when delivered in dyads to children with CAS with comorbidities. The study replicates earlier findings and reaffirms the positive outcomes of K-SLP for children with CAS.

The Reliability of Expert Diagnosis of Childhood Apraxia of Speech

PURPOSE

The current standard for clinical diagnosis of childhood apraxia of speech (CAS) is expert clinician judgment. The psychometric properties of this standard are not well understood; however, they are important for improving clinical diagnosis. The purpose of this study is to determine the extent to which experts agree on the clinical diagnosis of CAS using two cohorts of children with mixed speech sound disorders (SSDs).

METHOD

Speech samples of children with SSDs were obtained from previous and ongoing research from video recordings of children aged 3-8 years (n = 36) and audio recordings of children aged 8-17 years (n = 56). A total of 23 expert, English-speaking clinicians were recruited internationally. Three of these experts rated each speech sample to provide a description of the observed features and a diagnosis. Intrarater reliability was acceptable at 85% agreement.

RESULTS

Interrater reliability on the presence or absence of CAS among experts was poor both as a categorical diagnosis (κ = .187, 95% confidence interval [CI] [0.089, 0.286]) and on a continuous "likelihood of CAS" scale (0-100; intraclass correlation = .183, 95% CI [.037, .347]). Reliability was similar across the video-recorded and audio-only samples. There was greater agreement on other diagnoses (such as articulation disorder) than on the diagnosis of CAS, although these too did not meet the predetermined standard. Likelihood of CAS was greater in children who presented with more American Speech-Language-Hearing Association CAS consensus features.

CONCLUSIONS

Different expert raters had different thresholds for applying the diagnosis of CAS. If expert clinician judgment is to be used for diagnosis of CAS or other SSDs, further standardization and calibration is needed to increase interrater reliability. Diagnosis may require operationalized checklists or reliable measures that operate along a diagnostic continuum.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.23949105.

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.

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.

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.

Research Priorities for Childhood Apraxia of Speech: A Long View

This article introduces the Journal of Speech, Language, and Hearing Research Special Issue: Selected Papers From the 2022 Apraxia Kids Research Symposium. The field of childhood apraxia of speech (CAS) has developed significantly in the past 15 years, with key improvements in understanding of basic biology including genetics, neuroscience, and computational modelling; development of diagnostic tools and methods; diversity of evidence-based interventions with increasingly rigorous experimental designs; and understanding of impacts beyond impairment-level measures. Papers in this special issue not only review and synthesize the some of the substantial progress to date but also present novel findings addressing critical research gaps and adding to the overall body of knowledge. A second aim of this prologue is to report the current research needs in CAS, which arose from symposium discussions involving researchers, clinicians, and Apraxia Kids community members (including parents of children with CAS). Four primary areas of need emerged from discussions at the symposium. These were: (a) What questions should we ask? (b) Who should be in the research? (c) How do we conduct the research? and (d) How do we move from research to practice? Across themes, symposium attendees emphasized the need for CAS research to better account for the diversity of people with CAS and improve the timeliness of implementation of high-level evidence-based practice across the lifespan. It is our goal that the articles and prologue discussion in this special issue provide an appreciation of advancements in CAS research and an updated view of the most pressing needs for future research.

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.

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.

Accuracy of Speech Sound Analysis: Comparison of an Automatic Artificial Intelligence Algorithm With Clinician Assessment

PURPOSE

Automatic speech analysis (ASA) and automatic speech recognition systems are increasingly being used in the treatment of speech sound disorders (SSDs). When utilized as a home practice tool or in the absence of the clinician, the ASA system has the potential to facilitate treatment gains. However, the feedback accuracy of such systems varies, a factor that may impact these gains. The current research analyzes the feedback accuracy of a novel ASA algorithm (Amplio Learning Technologies), in comparison to clinician judgments.

METHOD

A total of 3,584 consonant stimuli, produced by 395 American English-speaking children and adolescents with SSDs (age range: 4-18 years), were analyzed with respect to automatic classification of the ASA algorithm, clinician-ASA agreement, and interclinician agreement. Further analysis of results as related to phoneme acquisition categories (early-, middle-, and late-acquired phonemes) was conducted.

RESULTS

Agreement between clinicians and ASA classification for sounds produced accurately was above 80% for all phonemes, with some variation based on phoneme acquisition category (early, middle, late). This variation was also noted for ASA classification into "acceptable," "unacceptable," and "unknown" (which means no determination of phoneme accuracy) categories, as well as interclinician agreement. Clinician-ASA agreement was reduced for misarticulated sounds.

CONCLUSIONS

The initial findings of Amplio's novel algorithm are promising for its potential use within the context of home practice, as it demonstrates high feedback accuracy for correctly produced sounds. Furthermore, complexity of sound influences consistency of perception, both by clinicians and by automated platforms, indicating variable performance of the ASA algorithm across phonemes. Taken together, the ASA algorithm may be effective in facilitating speech sound practice for children with SSDs, even in the absence of the clinician.

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.

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.

Enhancing Speech Rehabilitation in a Young Adult with Trisomy 21: Integrating Transcranial Direct Current Stimulation (tDCS) with Rapid Syllable Transition Training for Apraxia of Speech

Apraxia of speech is a persistent speech motor disorder that affects speech intelligibility. Studies on speech motor disorders with transcranial Direct Current Stimulation (tDCS) have been mostly directed toward examining post-stroke aphasia. Only a few tDCS studies have focused on apraxia of speech or childhood apraxia of speech (CAS), and no study has investigated individuals with CAS and Trisomy 21 (T21, Down syndrome). This N-of-1 randomized trial examined the effects of tDCS combined with a motor learning task in developmental apraxia of speech co-existing with T21 (ReBEC RBR-5435x9). The accuracy of speech sound production of nonsense words (NSWs) during Rapid Syllable Transition Training (ReST) over 10 sessions of anodal tDCS (1.5 mA, 25 cm) over Broca's area with the cathode over the contralateral region was compared to 10 sessions of sham-tDCS and four control sessions in a 20-year-old male individual with T21 presenting moderate-severe childhood apraxia of speech (CAS). The accuracy for NSW production progressively improved (gain of 40%) under tDCS (sham-tDCS and control sessions showed < 20% gain). A decrease in speech severity from moderate-severe to mild-moderate indicated transfer effects in speech production. Speech accuracy under tDCS was correlated with Wernicke's area activation (P3 current source density), which in turn was correlated with the activation of the left supramarginal gyrus and the Sylvian parietal-temporal junction. Repetitive bihemispheric tDCS paired with ReST may have facilitated speech sound acquisition in a young adult with T21 and CAS, possibly through activating brain regions required for phonological working memory.

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.

Music and musical elements in the treatment of childhood speech sound disorders: A systematic review of the literature

PURPOSE

Music-based interventions are used in the treatment of childhood speech sound disorders (SSDs). Hypotheses on working mechanisms are being developed, focussing on shared neural processes. However, evidence of the effect of treatment with musical elements in SSDs in children is lacking. This study reviews the literature regarding the use of music-based interventions in the treatment of childhood SSDs.

METHOD

A systematic search in six databases was conducted, yielding 199 articles, eight of which met the inclusion criteria. Included articles were reviewed on study characteristics, patient characteristics, interventions, outcomes and methodological quality.

RESULT

This review included four case studies, three single-subject design studies and one cohort study. Seven studies reported positive outcomes on speech production, but outcome measures in the four studies with experimental design were not all aimed at the level of speech (motor) processes. Methodological quality was sufficient in one study.

CONCLUSION

Seven out of eight studies in this review report positive outcomes of music-based interventions in the treatment of SSDs. However, these outcomes are not sufficiently supported by evidence due to insufficient methodological quality. Suggestions for improving methodological quality in future research are presented.

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.

A Pilot Randomized Control Trial of Motor-Based Treatments for Childhood Apraxia of Speech: Rapid Syllable Transition Treatment and Ultrasound Biofeedback

PURPOSE

Both Rapid Syllable Transition Treatment (ReST) and ultrasound biofeedback are effective approaches to treating childhood apraxia of speech (CAS). The purpose of the study was to compare outcomes from these two motor-based treatment approaches for school-age children with CAS.

METHOD

In a single site, single blind randomized control trial, 14 children with CAS ages 6-13 years were randomly assigned to 12 sessions over 6 weeks of either of ultrasound biofeedback treatment (with a speech motor chaining practice structure) or ReST. Treatment was delivered at The University of Sydney by students trained and supervised by certified speech-language pathologists. Transcriptions from blinded assessors were used to compare the two groups on speech sound accuracy (percent phonemes correct) and prosodic severity (lexical stress errors and syllable segregation) in untreated words and sentences at three time points: pretreatment, immediately posttreatment, and 1-month posttreatment (i.e., retention).

RESULTS

Both groups showed significant improvement on treated items indicating a treatment effect. At no time was there a difference between groups. Both groups showed a significant improvement in speech sound accuracy on untreated words and sentences from pre to post and neither group showed an improvement in prosody pre-post. Changes to speech sound accuracy were retained by both groups at 1-month follow-up. Significant improvement in prosodic accuracy was reported at the 1-month follow-up.

CONCLUSIONS

ReST and ultrasound biofeedback were equally effective. Either ReST or ultrasound biofeedback may be viable treatment options for school-age children with CAS.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.22114661.

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.

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.

Implicit learning in children with Childhood Apraxia of Speech

BACKGROUND

Childhood Apraxia of Speech is a severe and persistent clinical subtype of Speech Sound Disorder. Given the difficulties in the acquisition, programming and control of the movements underlying speech and the slowdown in a wide range of non-linguistic skills, the difficulty in implicit learning of sequential information could play a role in the disorder, contributing to understand its etiopathological mechanisms and behavioral manifestations.

AIMS

The present study was aimed at investigating implicit learning in children with Childhood Apraxia of Speech.

METHODS AND PROCEDURES

Twenty-five children with Childhood Apraxia of Speech, aged between 4 and 12 years, were matched for IQ and age to a control group of 25 typically developing children. Implicit learning of participants was assessed by Serial Reaction Time Task.

OUTCOME AND RESULTS

Children with Childhood Apraxia of Speech did not show implicit learning, as documented by the absence of differences between reaction times in the sequenced block and the random block, usually considered as a measure of implicit learning effect.

CONCLUSION AND IMPLICATIONS

Our results underline an implicit learning deficit in children with Childhood Apraxia of Speech, supporting the concept of a disorder not only confined to the speech domain, but also involving non-linguistic skills, in a composite and complex picture.

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.

A Pilot Single-Case Experimental Design Study of Rapid Syllable Transition Treatment for Italian Children With Childhood Apraxia of Speech

Background The Rapid Syllable Transition (ReST) treatment is an effective intervention designed to address the planning and programming disorder found in childhood apraxia of speech. To date, no study has considered its use with children who speak languages other than English. Aim This pilot study aimed to examine the use of ReST treatment with Italian children. We hypothesized that the ReST approach would improve the overall accuracy of the targeted behaviors of lexical stress, smoothness, and phonemic accuracy, whereas phonemic and phonetic accuracy of untreated items would remain stable. Method Two monolingual Italian-speaking children with childhood apraxia of speech received therapy in 12 one-hour sessions, 2-3 times per week, using a single-case experimental design. The treatment procedures used in English were replicated in Italian with one change: In English, two stress patterns are treated. Italian commonly uses three stress patterns; therefore, the stimuli were modified accordingly. Accuracy of articulation, lexical stress, and smoothness were assessed at pretreatment and 1 day, 1 week, and 4 months posttreatment in treated and untreated pseudowords and in real words and sentences. Results Both children improved on treated pseudowords and real words with moderate effect sizes, but only one child generalized to untreated pseudowords. Maintenance of treatment results was observed in both participants. Articulation of control phonemes did not change. Conclusions ReST treatment in Italian is feasible, and a treatment effect was found, showing that its use may be valid in languages other than English. Further research is required. Supplemental Material https://doi.org/10.23641/asha.14348060.

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.

PROMPT intervention for children with severe speech motor delay: a randomized control trial

BACKGROUND

Currently, there is limited information on the intervention efficacy for children with speech motor delay (SMD). This randomized control trial (RCT) study examined the effectiveness of Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT) intervention to improve the outcomes in children with SMD. We hypothesized that children with SMD receiving PROMPT intervention would improve more in the measured outcomes than those waitlisted and receiving home training.

METHODS

Using a two-arm, parallel group, RCT, 49 children with SMD were allocated to either an intervention group (N = 24) that received 45 min of PROMPT intervention two times a week for 10 weeks or were waitlisted for the same duration and received only home training instructions (N = 25). Outcome measures for speech motor control, articulation, speech intelligibility (word and sentence levels), and functional communication were assessed at baseline and at a 10-week follow-up.

RESULTS

PROMPT intervention was associated with notable improvements in speech motor control, speech articulation, and word-level speech intelligibility. Intervention allocation yielded weak improvements in sentence-level speech intelligibility and functional communication.

CONCLUSIONS

PROMPT intervention is a clinically effective intervention approach for children with SMD.

IMPACT

Currently, there is limited information on the intervention efficacy for children with SMD. We report on the findings of a phase III intervention efficacy study on children with SMD using an RCT design. PROMPT intervention is a clinically effective intervention approach for children with SMD. Results of the study will be fundamental to the delivery of effective services for this population. These findings may facilitate the development of an evidence-based care pathway for children with severe speech sound disorders.

Assessing communicative participation in preschool children with the Focus on the Outcomes of Communication Under Six: a scoping review

AIM

To describe uses of the Focus on the Outcomes of Communication Under Six (FOCUS) in research with children with and without various communication disorders since its publication in 2010.

METHOD

Six databases were searched for the term 'Focus on the Outcomes of Communication Under Six'. With additional searches we ascertained 70 articles, of which 25 met inclusion criteria for full review and data extraction.

RESULTS

The FOCUS has been used in research across multiple countries, purposes, populations, contexts, and versions. Evaluative studies have described: the development of children's communicative participation skills and factors that impact the development of communicative participation; the impact of specific interventions on communicative participation; how FOCUS captures change relative to measures of impairment; and how FOCUS performs when used at different intervals. Adaptations have included: use of the FOCUS as a descriptive or discriminative tool; use with children outside the validated age range; use of select items; and use with typically developing children.

INTERPRETATION

The FOCUS is used worldwide in research and practice, and much has been learned about children's communicative participation. Future research is needed to explore the relationship between children's impairments and their communicative participation, develop a FOCUS App, and develop and validate a FOCUS for school-age children.

Métodos de avaliação da apraxia de fala na infância: revisão sistemática

RESUMO Objetivos Revisar sistematicamente os protocolos e/ou avaliações que contribuem para o diagnóstico de apraxia de fala na infância (AFI) e classificá-los de acordo com a dimensão clínica avaliada. Estratégia de pesquisa Estudo de revisão sistemática da literatura nas bases de dados MEDLINE (acessado via PubMed), LILACS, Scopus e SciELO, com os descritores Apraxias, Childhood apraxia of speech, Evaluation, Assessment, Validation Studies, Evaluation Studies, Language Therapy, Rehabilitation of Speech and Language Disorders, Child e Child, Preschool. Critérios de seleção A busca nas bases de dados foi conduzida por três pesquisadores independentes. Foram incluídos estudos que avaliavam, de forma clara, sujeitos com suspeita ou diagnóstico de AFI. Os revisores realizaram a coleta de dados no que diz respeito às características metodológicas, intervenções e desfechos dos estudos, por meio de planilhas previamente elaboradas especificamente para o presente estudo. O dado principal coletado foi referente aos procedimentos de avaliação da AFI para crianças. Resultados A maior parte dos estudos (14 dos 21 incluídos) realizou a associação entre a avaliação de habilidades motoras e/ou articulatórias e segmentais. Cinco realizaram avaliação de todos os aspectos elencados: motor e/ou articulatória, segmental e suprassegmental e dois realizaram apenas avaliação motora e/ou articulatória. A idade dos sujeitos variou de 3 a 12 anos. Conclusão A maioria das pesquisas considerou a associação entre habilidades motoras e/ou articulatórias e segmentais para avaliação da apraxia de fala na infância. Sugere-se a realização de mais estudos, a fim de buscar evidências de validade.

Tutorial: Motor-Based Treatment Strategies for /r/ Distortions

Purpose This tutorial summarizes current best practices in treating American English /r/ distortions in children with residual speech errors. Method To enhance the effectiveness of clinicians' cueing and feedback, the phonetics of /r/ production is reviewed. Principles of acquisition, which can inform how to practice /r/ in the early stages of therapy, are explained. Elements of therapy that lack scientific support are also mentioned. Results Although there is significant variability in /r/ production, the common articulatory requirements include an oral constriction, a pharyngeal constriction, tongue body lowering, lateral bracing, and slight lip rounding. Examples of phonetic cues and shaping strategies are provided to help clinicians elicit these movements to evoke correct /r/ productions. Principles of acquisition (e.g., blocked practice, frequent knowledge of performance feedback) are reviewed to help clinicians structure the earliest stages of treatment to establish /r/. Examples of approaches that currently lack scientific support include nonspeech oral motor exercises, tactile cues along the mylohyoid muscle, and heterogeneous groupings in group therapy. Conclusion Treatment strategies informed by phonetic science and motor learning theory can be implemented by all clinicians to enhance acquisition of /r/ for children with residual errors. Supplemental Material https://doi.org/10.23641/asha.12771329.

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.

Further Study of the Effects of Treatment Intensity on Outcomes of Sound Production Treatment for Acquired Apraxia of Speech: Does Dose Frequency Matter?

Purpose The aim of this study was to examine the effects of dose frequency, an aspect of treatment intensity, on articulation outcomes of sound production treatment (SPT). Method Twelve speakers with apraxia of speech and aphasia received SPT administered with an intense dose frequency and a nonintense/traditional dose frequency (SPT-T). Each participant received both treatment intensities in the context of multiple baseline designs across behaviors. SPT-Intense was provided for 3 hourly sessions per day/3 days per week; and SPT-T for 1 hour-long session per day/3 days per week. Twenty-seven treatment sessions were completed with each phase of treatment. Articulation accuracy was measured in probes of production of treated and untreated words. Results All participants achieved improved articulation of treated words with both intensities; there were no notable differences in magnitude of improvement associated with dose frequency. Positive response generalization to untrained words was found in 21 of 24 treatment applications; the cases of negligible response generalization occurred with SPT-T words. Conclusions Dose frequency (and corresponding total intervention duration) did not appear to impact treatment response for treated items. Disparate response generalization findings for 3 participants in the current study may relate to participant characteristics such as apraxia of speech severity and/or stimuli factors.

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.

An N-of-1 Randomized Controlled Trial of Interventions for Children With Inconsistent Speech Sound Errors

Purpose The aim of this study was to test the hypothesis that children with inconsistent speech errors would respond differentially to 1 of 3 specific interventions depending on their primary underlying impairment: Children with deficient motor planning were expected to respond best to an auditory-motor integration (AMI) intervention, and children with deficient phonological planning were expected to respond best to a phonological memory and planning (PMP) intervention. Method Twelve participants were diagnosed with a motor planning (n = 7) or phonological planning (n = 5) deficit based on a comprehensive assessment, which included the Syllable Repetition Task as an important source of diagnostic evidence. An N-of-1 randomized controlled trial was used. Each child experienced all 3 interventions: AMI, PMP, and control (CTL); however, these interventions were randomly allocated to sessions within weeks (3 sessions per week × 6 weeks for 18 sessions). The AMI intervention procedures targeted knowledge of the acoustic-phonetic target and integration of auditory and somatosensory feedback during speech practice. The PMP intervention procedures targeted segmenting and recompiling the phonological plan for each word. The CTL intervention was standard drill practice. The child was taught 5 pseudowords in a meaningful context in each intervention condition. Results Same-day (SD) probes assessed transfer from taught pseudowords to untaught real words, and next-day (ND) probes assessed retention of that learning. Nonparametric resampling tests with pooling of p values across children with the same diagnosis were used to assess the results. Pooled p values indicated a significant benefit of AMI over PMP for the group with a motor planning deficit (p = 2.01E-04 for SD probes and 2.97E-03 for ND probes) and a significant benefit of PMP over AMI for the group with a phonological planning deficit (p = 1.22E-02 for SD probes and 1.32E-02 for ND probes). Response to the CTL intervention was variable within groups. Conclusion In this study, the child's underlying psycholinguistic deficit helped to predict response to intervention.

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.

Assessment of Childhood Apraxia of Speech: A Review/Tutorial of Objective Measurement Techniques

Background With respect to the clinical criteria for diagnosing childhood apraxia of speech (commonly defined as a disorder of speech motor planning and/or programming), research has made important progress in recent years. Three segmental and suprasegmental speech characteristics-error inconsistency, lengthened and disrupted coarticulation, and inappropriate prosody-have gained wide acceptance in the literature for purposes of participant selection. However, little research has sought to empirically test the diagnostic validity of these features. One major obstacle to such empirical study is the fact that none of these features is stated in operationalized terms. Purpose This tutorial provides a structured overview of perceptual, acoustic, and articulatory measurement procedures that have been used or could be used to operationalize and assess these 3 core characteristics. Methodological details are reviewed for each procedure, along with a short overview of research results reported in the literature. Conclusion The 3 types of measurement procedures should be seen as complementary. Some characteristics are better suited to be described at the perceptual level (especially phonemic errors and prosody), others at the acoustic level (especially phonetic distortions, coarticulation, and prosody), and still others at the kinematic level (especially coarticulation, stability, and gestural coordination). The type of data collected determines, to a large extent, the interpretation that can be given regarding the underlying deficit. Comprehensive studies are needed that include more than 1 diagnostic feature and more than 1 type of measurement procedure.

Validity of a streamlined version of the Focus on the Outcomes of Communication Under Six: Process and outcome

BACKGROUND

The Focus on the Outcomes of Communication Under Six (FOCUS) is a 50-item outcome measure based on the framework and concepts of World Health Organization's International Classification of Functioning. The FOCUS has been shown to capture participation-level changes associated with speech and language therapy in children 18 to 72 months old and has established validity and reliability. However, there were reasons to try to reduce the measure without losing any of its proven value as a change-detecting instrument.

METHODS

Using data from 18,931 preschool children, we used item response models and a test of redundancy to reduce the original 50-item FOCUS to 34 items. We then assessed the correlations between FOCUS-50 and FOCUS-34 scores on these children.

RESULTS

Findings show that a shortened (34-item) version of FOCUS can be treated as equivalent to the full 50-item version.

CONCLUSION

The correlation between change scores on the two versions is .98. We suggest that in situations where only a total score is of interest, the FOCUS-34 can be used in place of the full FOCUS.

Investigating intervention dose frequency for children with speech sound disorders and motor speech involvement

BACKGROUND

Treatment outcome data for children with severe speech sound disorders with motor speech involvement (SSD-MSI) are derived from Phase I clinical research studies. These studies have demonstrated positive improvements in speech production. Currently there is no research examining the optimal treatment dose frequency for this population. The results of this study, which is the first of its kind, will inform the delivery of effective services for this population.

AIMS

To investigate optimal treatment dose frequency for the Motor Speech Treatment Protocol (MSTP) for children with SSD-MSI.

METHODS & PROCEDURES

A total of 48 children (aged 43-47 months) with SSD-MSI participated in the study. Participants received 45-min MSTP intervention sessions either once per week (lower dose frequency) or twice per week (higher dose frequency) for a 10-week period. Blinded outcome assessments were carried out at pre- and post-intervention.

OUTCOMES & RESULTS

Treatment-related change was assessed at body structures, functions and activities participation level as per the World Health Organization's International Classification of Functioning framework: Children and Youth Version (ICF-CY) framework WHO (2007). These measures are related to articulation, functional communication and speech intelligibility. One-way analysis of variance (ANOVA) revealed that for all variables the baseline scores were not statistically different (p > 0.05) between the two dose-frequency groups. Overall, there was a significant main effect of Time (pre-post) across all variables (p < 0.01). However, repeated-measures ANOVA did not result in any statistical interactions (Time × Dose frequency) for any of the variables tested (p > 0.05). Only marginal clinical advantages (< 4% change in intelligibility) were noted with the 10 extra sessions.

CONCLUSIONS & IMPLICATIONS

Overall, the MSTP intervention approach in conjunction with home practice led to significant positive changes for all measures in children with SSD-MSI. No statistical differences between high- and low-dose-frequency groups were observed for any of the variables. Clinical effects were examined using effect sizes, as well as changes in articulation, speech intelligibility and functional communication; these differed marginally between the two dose frequencies. This suggests limited benefits of 10 additional sessions per block. Thus, it is recommended that caregivers, speech-language therapists and policy-makers perform a cost-benefit analysis before determining the dose frequency, when considering additional sessions per block.

Examining factors affecting parental satisfaction with speech therapy in children with Phelan-McDermid Syndrome

Objectives: This paper explores the relationship between speech therapy intensity and parent satisfaction with speech therapy (ST) in children with Phelan-McDermid Syndrome (P-MS), a rare genetic disorder. Methods: ST intensity (ST Dose [minutes per session]) × (ST Dose Frequency) × (ST Length [years]) and parent satisfaction (modified PSQ-18) with ST were measured by online questionnaire. Non-parametric correlation, partial correlation, and linear regression calculations were performed. Results: Significant correlations between ST Dose and parent satisfaction were observed in the subscales of Time Spent with ST (r = .36, p < .05) and Accessibility and Convenience (r = .40, p < .05) in children with P-MS controlling for child age. ST Dose was also a significant independent predictor of parent satisfaction with ST in specific subscales. Conclusion: Significant positive correlation and linear regression results indicate increases in ST Dose (minutes per session) represent a mechanism for increasing parent satisfaction with ST in children with P-MS.

Parent experiences of variations in service delivery of Rapid Syllable Transition (ReST) treatment for childhood apraxia of speech

PURPOSE

To understand parents' perceptions of Rapid Syllable Transition (ReST) treatment and their experience of either telehealth or combined parent-clinician delivery of speech-language pathology.

METHOD

Thematic analyses of semi-structured interviews were conducted with 10 parents (5 telehealth, 5 parent-clinician) after their child completed 12 sessions of ReST treatment.

RESULTS

Three themes were unique to telehealth: "telehealth was a million times easier," "technical problems weren't deal breakers," and "telehealth therapy has different boundaries." Three themes were unique to parent-clinician delivery: "therapy is something to get over and done with," "I wasn't very good at doing therapy," and "my child doesn't like me as his therapist." Both groups had themes related to the significance of childhood apraxia of speech, the importance of specialist treatment, and ReST being a "different way forward."

CONCLUSIONS

Speech-language pathologists should carefully consider the suitability of caregiver-provided ReST treatment, and increase telehealth delivery of ReST treatment.

Effects of Treatment Intensity on Outcomes in Acquired Apraxia of Speech

PURPOSE

This investigation was designed to examine the effects of treatment intensity (i.e., dose frequency) on the outcomes of Sound Production Treatment (SPT) for acquired apraxia of speech.

METHOD

Five men with chronic apraxia of speech and aphasia received both intense SPT (3 hr per day/3 days per week) and nonintense/traditional SPT (SPT-T; 1 hr per day/3 days per week) in the context of single-case experimental designs. Each treatment was applied separately to a designated set of experimental words with 1 treatment applied at a time. Twenty-seven treatment sessions were conducted with each phase of treatment. Accuracy of articulation of target sounds within treated and untreated experimental words was measured during the course of the investigation.

RESULTS

All participants demonstrated improved articulation with both treatment intensities. Better maintenance of gains for treated items was found with SPT-T for 2 participants as measured at an 8-week posttreatment retention probe. Superior maintenance of increased accuracy of production of untreated items was also observed with SPT-T for all participants.

CONCLUSION

A less intense (distributed) application of SPT facilitated better maintenance of improved articulatory accuracy for untreated items, and in some cases treated items, than intense SPT.

SUPPLEMENTAL MATERIALS

https://doi.org/10.23641/asha.5734053.

Intensive Treatment for Persisting Rhotic Distortions: A Case Series

PURPOSE

The study explored changes in accuracy of American English rhotics as a result of an intensive 1-week therapy program for adolescents and young adults with residual speech sound errors that had not resolved with previous therapy.

METHOD

Four case reports are presented of individuals aged 13, 17, 21, and 22 years with residual /ɹ/ distortions. Each participant attended a 1-week intensive program consisting of pretreatment assessments, 14 hr of therapy, and posttreatment assessment. Treatment sessions included structured motor-based practice, ultrasound visual feedback of the tongue, and auditory speech perception training. To assess generalization, untreated words and sentences with rhotics were recorded before and after therapy; these were rated by listeners who were blind to when the recordings were taken.

RESULTS

All participants showed measurable and statistically significant improvement in speech sound accuracy. Averaged across the 4 participants, rhotic accuracy at the word level improved from 35% to 83%. At the sentence level, rhotic accuracy increased from 11% pretreatment to 66% posttreatment in 1 week.

CONCLUSION

The promise of an intensive treatment program that includes motor-based practice, biofeedback, and auditory perception training is illustrated by the case presentations in which substantial improvements in speech sound accuracy were observed.

SUPPLEMENTAL MATERIALS

https://doi.org/10.23641/asha.5561254.

Role of Constant, Random and Blocked Practice in an Electromyography-Based Oral Motor Learning Task

PURPOSE

The role of principles of motor learning (PMLs) in speech has received much attention in the past decade. Oral motor learning, however, has not received similar consideration. This study evaluated the role of three practice conditions in an oral motor tracking task.

METHOD

Forty-five healthy adult participants were randomly and equally assigned to one of three practice conditions (constant, blocked, and random) and participated in an electromyography-based task. The study consisted of four sessions, at one session a day for four consecutive days. The first three days sessions included a practice phase, with immediate visual feedback, and an immediate retention phase, without visual feedback. The fourth session did not include practice, but only delayed retention testing, lasting 10-15 minutes, without visual feedback.

RESULTS

Random group participants performed better than participants in constant and blocked practice conditions on all the four days. Constant group participants demonstrated superior learning over blocked group participants only on day 4.

CONCLUSION

Findings indicate that random practice facilitates oral motor learning, which is in line with limb/speech motor learning literature. Future research should systematically investigate the outcomes of random practice as a function of different oral and speech-based tasks.

The paired t test and beyond: Recommendations for testing the central tendencies of two paired samples in research on speech, language and hearing pathology

PURPOSE

In this tutorial we review current practice in the analysis of data obtained in designs involving two dependent samples and evaluate two conventional statistics: the t test for paired samples and its non-parametric alternative, the Wilcoxon Signed Ranks test (WSR). It is a sequel to our tutorial on the analysis of designs with two independent samples on the basis of non-count data (Rietveld & van Hout, 2015). The frequency with which these statistics are used is assessed on the basis of publications on disordered communication in Clinical Linguistics & Phonetics, Journal of Communication Disorders and Journal of Speech, Language and Hearing Research for the time interval 2006-2015. We conclude with a number of recommendations for the analysis and presentation of data.

CONCLUSIONS

Researchers should more consistently present the relevant characteristics of their data (means, medians, SD, skewness, tailedness, outliers etc.) and explicitly consider the assumptions that apply to their statistical methods, such as correlations between data obtained on two occasions, interactions between participants and treatment, and the symmetry of difference scores, many of which are hardly ever reported or even tested. Two recommendations are particularly relevant. First, the WSR is not a proper test for central tendencies as a replacement of the conventional t test for paired samples whenever assumptions about the dependent variable are in doubt. Second, researchers should choose statistical procedures on the basis of the null hypothesis (H0) to be tested and not primarily on the basis of the type of data (ordinal or interval). Two relevant H0's in the field of speech-language pathology are: (1) μ₁=μ₂ (the mean obtained in condition 1 is equal to the mean in condition 2) and (2) p=0.5, which says: the probability to obtain (for instance) higher scores in condition 2 than in condition 1 is 0.5. We recommend the permuted t test for paired samples to test the first H0 and the permuted Brunner-Munzel rank test to test the second.

Efficacious Treatment of Children With Childhood Apraxia of Speech According to the International Classification of Functioning, Disability and Health

There is increasing evidence for treatment approaches designed for children with childhood apraxia of speech (CAS). Despite this, no treatment has conclusive evidence to date. The CAS population is heterogeneous, with children presenting with varying symptom profiles, severity levels, and comorbidities. Consequently, treatment planning for children with CAS represents a clinical challenge. To assist clinicians in providing optimal care, this paper uses the International Classification of Functioning, Disability and Health (ICF) as a framework for identifying the body structures and functions, activities, and personal/environmental factors that should be considered when working with children with CAS. Evidence-based interventions are described and resources outlined to help guide the treatment planning process.

Parent-child interaction in motor speech therapy

PURPOSE

This study measures the reliability and sensitivity of a modified Parent-Child Interaction Observation scale (PCIOs) used to monitor the quality of parent-child interaction. The scale is part of a home-training program employed with direct motor speech intervention for children with speech sound disorders.

METHOD

Eighty-four preschool age children with speech sound disorders were provided either high- (2×/week/10 weeks) or low-intensity (1×/week/10 weeks) motor speech intervention. Clinicians completed the PCIOs at the beginning, middle, and end of treatment. Inter-rater reliability (Kappa scores) was determined by an independent speech-language pathologist who assessed videotaped sessions at the midpoint of the treatment block. Intervention sensitivity of the scale was evaluated using a Friedman test for each item and then followed up with Wilcoxon pairwise comparisons where appropriate.

RESULTS

We obtained fair-to-good inter-rater reliability (Kappa = 0.33-0.64) for the PCIOs using only video-based scoring. Child-related items were more strongly influenced by differences in treatment intensity than parent-related items, where a greater number of sessions positively influenced parent learning of treatment skills and child behaviors.

CONCLUSION

The adapted PCIOs is reliable and sensitive to monitor the quality of parent-child interactions in a 10-week block of motor speech intervention with adjunct home therapy. Implications for rehabilitation Parent-centered therapy is considered a cost effective method of speech and language service delivery. However, parent-centered models may be difficult to implement for treatments such as developmental motor speech interventions that require a high degree of skill and training. For children with speech sound disorders and motor speech difficulties, a translated and adapted version of the parent-child observation scale was found to be sufficiently reliable and sensitive to assess changes in the quality of the parent-child interactions during intervention. In developmental motor speech interventions, high-intensity treatment (2×/week/10 weeks) facilitates greater changes in the parent-child interactions than low intensity treatment (1×/week/10 weeks). On one hand, parents may need to attend more than five sessions with the clinician to learn how to observe and address their child's speech difficulties. On the other hand, children with speech sound disorders may need more than 10 sessions to adapt to structured play settings even when activities and therapy materials are age-appropriate.

A systematic review of treatment intensity in speech disorders

PURPOSE

Treatment intensity (sometimes referred to as "practice amount") has been well-investigated in learning non-speech tasks, but its role in treating speech disorders has not been largely analysed. This study reviewed the literature regarding treatment intensity in speech disorders.

METHOD

A systematic search was conducted in four databases using appropriate search terms. Seven articles from a total of 580 met the inclusion criteria. The speech disorders investigated included speech sound disorders, dysarthria, acquired apraxia of speech and childhood apraxia of speech. All seven studies were evaluated for their methodological quality, research phase and evidence level.

RESULT

Evidence level of reviewed studies ranged from moderate to strong. With regard to the research phase, only one study was considered to be phase III research, which corresponds to the controlled trial phase. The remaining studies were considered to be phase II research, which corresponds to the phase where magnitude of therapeutic effect is assessed. Results suggested that higher treatment intensity was favourable over lower treatment intensity of specific treatment technique(s) for treating childhood apraxia of speech and speech sound (phonological) disorders.

CONCLUSION

Future research should incorporate randomised-controlled designs to establish optimal treatment intensity that is specific to each of the speech disorders.

Telehealth delivery of Rapid Syllable Transitions (ReST) treatment for childhood apraxia of speech

BACKGROUND

Rapid Syllable Transitions (ReST) treatment uses pseudo-word targets with varying lexical stress to target simultaneously articulation, prosodic accuracy and coarticulatory transitions in childhood apraxia of speech (CAS). The treatment is efficacious for the acquisition of imitated pseudo-words, and generalization of skill to untreated pseudo-words and real words. Despite the growing popularity of telehealth as a method of service delivery, there is no research into the efficacy of telehealth treatments for CAS. Telehealth service delivery is associated with compromised audio and visual signal transmission that may affect the efficacy of treatment.

AIMS

To conduct a phase 1 efficacy study of telehealth delivery of ReST treatment for CAS, and to discuss the efficacy with reference to face-to-face ReST treatment.

METHODS & PROCEDURES

Using a multiple baseline across participants design, five children aged 5-11 years with CAS received ReST treatment four times a week for 3 weeks via video conferencing with Adobe Connect. The children's ability to imitate new pseudo-words, generalize the skills to untreated pseudo-words and real word items, and maintain the skills following treatment were assessed. Both visual and statistical analyses were utilized.

OUTCOMES & RESULTS

All five children significantly improved with their production of the imitated treated pseudo-word items and significantly generalized to similar untreated pseudo-words and real words. Additionally, two of the children showed significant generalization to imitated phrases with the treatment items. Four of the children maintained their treatment gains up to 4 months post-treatment. Telehealth delivery produced similar acquisition of pseudo-words and generalization to untreated behaviours as face-to-face delivery; however, in the 4 months following treatment, the children showed stable rather than improving speech skills. The intra- and inter-judge reliability was similar in telehealth delivery for face-to-face delivery. Caregivers and clinicians were satisfied with the telehealth treatment.

CONCLUSIONS & IMPLICATIONS

This phase 1 study provides promising indications of the efficacy of ReST treatment when delivered four times per week via telehealth, and warrants further large-scale investigation.