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Purpose: This tutorial summarizes current practices using visual–acoustic biofeedback (VAB) treatment to improve speech outcomes for individuals with speech sound difficulties. Clinical strategies will focus on residual distortions of /ɹ/. Method: Summary evidence related to the characteristics of VAB and the populations that may benefit from this treatment are reviewed. Guidelines are provided for clinicians on how to use VAB with clients to identify and modify their productions to match an acoustic representation. The clinical application of a linear predictive coding spectrum is emphasized. Results: Successful use of VAB requires several key factors including clinician and client comprehension of the acoustic representation, appropriate acoustic target and template selection, as well as appropriate selection of articulatory strategies, practice schedules, and feedback models to scaffold acquisition of new speech sounds. Conclusion: Integrating a VAB component in clinical practice offers additional intervention options for individuals with speech sound difficulties and often facilitates improved speech sound acquisition and generalization outcomes. Supplemental Material: https://doi.org/10.23641/asha.21817722

Purpose To assess the concurrent validity of two tasks used to inform diagnosis of childhood apraxia of speech (CAS), this study evaluated the agreement between the Syllable Repetition Task (SRT) and the Maximum Repetition Rate of Trisyllables (MRR-Tri). Method A retrospective analysis was conducted with 80 children 7–16 years of age who were referred for treatment studies. All children had a speech sound disorder, and all completed both the SRT and the MRR-Tri. On each task, children were classified as meeting or not meeting the tool's threshold for CAS based on the sound sequencing errors demonstrated. Results The two tasks were in agreement for 47 participants (59% of the sample); both tasks classified 13 children as meeting the threshold for CAS and 34 children as not meeting the threshold for CAS. However, the two tasks disagreed on CAS classification for 33 children (41% of the sample). Overall, the MRR-Tri identified more children as having sound sequencing errors indicative of CAS ( n = 39) than did the SRT ( n = 20). Conclusions These two tasks of sound sequencing differ in the children they identify with CAS, possibly due to aspects of the underlying task requirements (e.g., time pressure). The SRT and the MRR-Tri should not be used in isolation to identify CAS but may be useful as part of a balanced CAS assessment battery that includes additional tasks that inform the nature of the impairment and that aid treatment planning. Supplemental Material https://doi.org/10.23641/asha.14110280

Purpose Prior studies report conflicting descriptions of the relationships between phonological awareness (PA), vocabulary, and speech perception in preschoolers with speech disorders. This study sought to determine the nature of these relationships in a sample of school-aged children with residual speech sound errors affecting /ɹ/. Method Participants included 110 children aged 7;0–17;4 (years;months) with residual errors impacting /ɹ/. Data on perceptual acuity and perceptual bias in an /ɹ/ identification task, receptive vocabulary, and PA were obtained. A theoretically and empirically motivated path model was constructed with vocabulary mediating the relationship between two measures of speech perception and PA. Model parameters were determined through maximum likelihood estimation with standard errors that were robust to nonnormality. Monte Carlo simulation was used to examine achieved power at the current sample size. Results The saturated path model explained 19% of the variance in PA. The direct path between age-adjusted perceptual acuity and PA was significant, as was the direct path between vocabulary and PA. Contrary to our hypothesis, there was no evidence in the current sample that vocabulary skill mediated the relationship between speech perception and PA. Each individual path was adequately powered at the current sample size. Conclusions The overall model provided evidence for a continued relationship between speech perception, measured by perceptual acuity of the sound in error, and PA in school-aged children with residual speech errors. Thus, measures of speech perception remain relevant to the assessment of school-aged children and adolescents in this population. Supplemental Material https://doi.org/10.23641/asha.13641275

The extent to which treatment of speech errors that are phonetic in nature (i.e., distortions) produces generalization to untrained sounds is not well understood. This case study reports a child referred for treatment of a velarized distortion of American English /ɹ/, who also demonstrated an inconsistent velarized distortion of /l/. Acoustic analysis revealed evidence of a covert contrast between /ɹ/ and /l/ prior to treatment. Ultrasound biofeedback treatment and perceptual training targeted /ɹ/ only, but progress was tracked for both /ɹ/ and /l/. Substantial improvements in perceptually rated accuracy and significant changes in acoustic features were observed for both sounds, indicating generalization. These results highlight that generalization from trained to untrained sounds is possible for children with residual speech errors characterized by phonetic distortions.

PurposeThis tutorial summarizes current best practices in treating American English /r/ distortions in children with residual speech errors.MethodTo 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.ResultsAlthough 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.ConclusionTreatment 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 Materialhttps://doi.org/10.23641/asha.12771329

Purpose Operationalized treatments for school-age children with speech sound disorders may result in more replicable and evidence-based interventions. This tutorial describes Speech Motor Chaining (SMC) procedures, which are designed to build complex speech around core movements by incorporating several principles of motor learning. The procedures systematically manipulate factors such as feedback type and frequency, practice variability, and stimulus complexity based on the child's performance. Method The rationale and procedures for SMC are described. Examples are presented of how to design stimuli, deliver feedback, and adapt the approach. Free resources are provided to guide clinicians through implementation of the procedure. Data on fidelity of implementation and dose per session are presented. Clinical and research evidence is provided to illustrate likely outcomes with the procedure. Results SMC is a method that can result in successful acquisition of target speech patterns and generalization to untrained words. Most clinicians can implement the procedure with over 90% fidelity, and most children can achieve over 200 trials per session. Conclusion Clinicians and researchers can use or adapt the operationally defined SMC procedures to incorporate several principles of motor learning into treatment for school-age children with speech sound disorders. Supplemental Material https://osf.io/5jmf9/

Purpose This study evaluated whether outcomes from treatment, which includes ultrasound visual feedback (UVF), would be more or less effective when combined with auditory perception training for children with residual /ɹ/ errors. Method Children ages 8–16 years with /ɹ/ distortions participated in speech therapy that included real-time UVF of the tongue. Thirty-eight participants were randomized to speech therapy conditions that included a primary focus on articulation using UVF or a condition that included auditory perceptual training plus UVF (incorporating category goodness judgments and self-monitoring). Generalization of /ɹ/ production accuracy to untrained words was assessed before and after 14 hr of therapy. Additionally, the role of auditory perceptual acuity was explored using a synthetic /ɹ/–/w/ continuum. Results There was no difference between the treatment groups in rate of improvement of /ɹ/ accuracy (increase of 34% for each group; p = .95, η p 2 = .00). However, pretreatment auditory acuity was associated with treatment progress in both groups, with finer perceptual acuity corresponding to greater progress ( p = .015, η p 2 = .182). Conclusion Similar gains in speech sound accuracy can be made with treatment that includes UVF with or without auditory perceptual training. Fine-grained perceptual acuity may be a prognostic indicator with treatment. Supplemental Material https://doi.org/10.23641/asha.11886219

Purpose Ultrasound visual feedback of the tongue is increasingly used as a component of speech therapy in clinical research and practice. The purpose is to offer a preliminary summary of the nature of participant-reported undesired effects related to ultrasound visual feedback. Method Sixty-two participants across 3 sites (mean age = 11.9 years) and 38 parents responded to a 2-item verbal questionnaire following 14–16 hr of treatment regarding any aspects of the treatment they did not like. Responses were thematically categorized. Results The 62 participants provided 65 distinct responses, which were categorized as follows: 31% no concerns, 40% gel-related (e.g., cold, sticky), 21% positioning of the probe (e.g., uncomfortable, annoying), 3% chin hurting (qualified as being minor in nature), and 5% other (i.e., unrelated to the use of the ultrasound). Responses from all parents suggested no concerns about the use of ultrasound; however, 8% expressed concerns unrelated to ultrasound use (e.g., fatigue). Conclusion These data inform clinicians and researchers about participant's experience and highlight the type of comments most likely to be encountered with ultrasound in speech therapy. Although the reported adverse effects can be considered minor, they should be weighed against the potential benefits of visual feedback in treatment.

Background There is a need to develop effective interventions and to compare the efficacy of different interventions for children with residual speech-sound errors (RSSEs). Rhotics (the r-family of sounds) are frequently in error American English-speaking children with RSSEs and are commonly targeted in treatment. One treatment approach involves the use of ultrasound visual feedback of the tongue. Aims Although prior studies have shown that children with RSSEs acquire rhotics and generalize to untrained words with ultrasound visual feedback treatment, predictions from schema-based motor learning theory suggest that visual feedback might impede generalization. Therefore, the primary aim was to compare the generalization of rhotics treated with and without ultrasound in children with RSSEs. Methods & Procedures Twelve children aged 10–16 years with RSSEs affecting rhotics participated in a multiple-baseline single-case design with two treatment phases. For each participant, rhotics in one syllable position were treated for 7 h-long sessions with ultrasound visual feedback and rhotics in a different syllable position were treated without ultrasound in a second treatment phase. The order of treatment conditions was counterbalanced across participants. A treatment framework incorporating the principles of motor learning through chaining procedures was implemented across both treatment phases; thus the primary distinction between conditions was the use of ultrasound visual feedback. Outcomes & Results On average, both treatments resulted in an approximately 30% increase in accuracy of untreated words in seven sessions. However, variability in response suggested some children showed a preferential response to one treatment over another, some responded well to both interventions, and some responded minimally to both interventions. Conclusions & Implications Motor-based treatment with and without ultrasound visual feedback of the tongue may aid in speech-sound acquisition for children with RSSEs. Both approaches may be viable options for some children. Future research is necessary to determine which children are the best candidates for interventions with and without ultrasound visual feedback.

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

Purpose The purpose of this study was to evaluate the role of practice variability, through prosodic variation during speech sound training, in biofeedback treatment for children with childhood apraxia of speech. It was hypothesized that variable practice would facilitate speech sound learning. Method Six children ages 8–16 years with persisting speech sound errors due to childhood apraxia of speech participated in a single-subject experimental design. For each participant, 2 speech sound targets were treated with ultrasound visual feedback training: one with prosodic variation (i.e., practicing sound targets in words and phrases spoken fast, slow, loud, as a question, command, and declarative), and one without prosodic variation. Each target was treated for half of the 1-hr session for 14 treatment sessions. Results As measured by standardized effect sizes, all participants showed greater change on generalization probes for sound targets treated under the prosodic variation condition with mean effect sizes ( d 2 ) of 14.5 for targets treated with prosodic variation and 8.3 for targets treated without prosodic variation. The average increase in generalization scores was 38% in the prosodic variation condition compared to 31% without. Conclusions Ultrasound visual feedback may facilitate speech sound learning and learning may be enhanced by treating speech sounds with explicit prosodic variation. Supplemental Materials https://doi.org/10.23641/asha.5150119

Ultrasound imaging is an adjunct to traditional speech therapy that has shown to be beneficial in the remediation of speech sound errors. Ultrasound biofeedback can be utilized during therapy to provide clients additional knowledge about their tongue shapes when attempting to produce sounds that are in error. The additional feedback may assist children with childhood apraxia of speech in stabilizing motor patterns, thereby facilitating more consistent and accurate productions of sounds and syllables. However, due to its specialized nature, ultrasound visual feedback is a technology that is not widely available to clients. Short-term intensive treatment programs are one option that can be utilized to expand access to ultrasound biofeedback. Schema-based motor learning theory suggests that short-term intensive treatment programs (massed practice) may assist children in acquiring more accurate motor patterns. In this case series, three participants ages 10-14 diagnosed with childhood apraxia of speech attended 16 hours of speech therapy over a two-week period to address residual speech sound errors. Two participants had distortions on rhotic sounds, while the third participant demonstrated lateralization of sibilant sounds. During therapy, cues were provided to assist participants in obtaining a tongue shape that facilitated a correct production of the erred sound. Additional practice without ultrasound was also included. Results suggested that all participants showed signs of acquisition of sounds in error. Generalization and retention results were mixed. One participant showed generalization and retention of sounds that were treated; one showed generalization but limited retention; and the third showed no evidence of generalization or retention. Individual characteristics that may facilitate generalization are discussed. Short-term intensive treatment programs using ultrasound biofeedback may result in the acquisition of more accurate motor patterns and improved articulation of sounds previously in error, with varying levels of generalization and retention.

The purpose was to provide a preliminary within-participant comparison of speech therapy with and without exposure to ultrasound visual feedback for postvocalic rhotics (/r/- colored vowels). Effects of the two treatments on acquisition, retention, and generalization were explored. It was hypothesized that treatment with ultrasound would facilitate acquisition but hinder retention and generalization.A single subject randomized block design was replicated across four American English-speaking participants ages 7-9 years. Each participant was trained on postvocalic /r/. Each week for seven weeks, one session with ultrasound visual feedback and one session with no ultrasound were randomly ordered. A Training Probe and Generalization Probe were used to measure acquisition within each session as well as retention and generalization between two consecutive sessions. Graphical displays of the data, effect size calculation, and statistical results from a randomization test were used to analyze the results.Two participants showed essentially no evidence of acquisition, retention or generalization of rhotics (5%). Of the two who showed evidence of acquisition, one participant showed a significant advantage and large effect size for ultrasound sessions over no ultrasound sessions in acquisition of rhotics. However, no participants showed differences between treatment conditions in generalization or retention of rhotics.For some children, acquisition may be facilitated by ultrasound visual feedback. Ultrasound visual feedback neither inhibited nor facilitated retention or generalization of rhotics. As a whole, the 14 treatment sessions (7 with ultrasound and 7 without) were effective for 2 of the 4 participants when comparing pre/post generalization scores. Future studies should evaluate the effectiveness of ultrasound visual feedback given a larger dose and differing age groups.

There is a need to develop effective interventions and to compare the efficacy of different interventions for children with residual speech-sound errors (RSSEs). Rhotics (the r-family of sounds) are frequently in error American English-speaking children with RSSEs and are commonly targeted in treatment. One treatment approach involves the use of ultrasound visual feedback of the tongue.Although prior studies have shown that children with RSSEs acquire rhotics and generalize to untrained words with ultrasound visual feedback treatment, predictions from schema-based motor learning theory suggest that visual feedback might impede generalization. Therefore, the primary aim was to compare the generalization of rhotics treated with and without ultrasound in children with RSSEs.Twelve children aged 10-16 years with RSSEs affecting rhotics participated in a multiple-baseline single-case design with two treatment phases. For each participant, rhotics in one syllable position were treated for 7 h-long sessions with ultrasound visual feedback and rhotics in a different syllable position were treated without ultrasound in a second treatment phase. The order of treatment conditions was counterbalanced across participants. A treatment framework incorporating the principles of motor learning through chaining procedures was implemented across both treatment phases; thus the primary distinction between conditions was the use of ultrasound visual feedback.On average, both treatments resulted in an approximately 30% increase in accuracy of untreated words in seven sessions. However, variability in response suggested some children showed a preferential response to one treatment over another, some responded well to both interventions, and some responded minimally to both interventions.Motor-based treatment with and without ultrasound visual feedback of the tongue may aid in speech-sound acquisition for children with RSSEs. Both approaches may be viable options for some children. Future research is necessary to determine which children are the best candidates for interventions with and without ultrasound visual feedback.

Ultrasound visual feedback of the tongue is one treatment option for individuals with persisting speech sound errors. This study evaluated children’s performance during acquisition and generalisation of American English rhotics using ultrasound feedback. Three children aged 10–13 with persisting speech sound errors associated with childhood apraxia of speech (CAS) were treated for 14 one-hour sessions. Two of the participants increased the accuracy of their rhotic production during practise trials within treatment sessions, but none demonstrated generalisation to untreated words. Lack of generalisation may be due to a failure to acquire the target with sufficient accuracy during treatment, or to co-existing linguistic weaknesses that are not addressed in a motor-based treatment. Results suggest a need to refine the intervention procedures for CAS and/or a need to identify appropriate candidates for intervention to optimise learning.