Visual feedback in speech habilitation: focus on treating r with ultrasound

1
Visual feedback in speech habilitation focus on
treating r with ultrasound

• P. Bacsfalvi, PhD, CCC-SLP(C)
• Registered Speech Language Pathologist and
  Consultant for Deaf and Hard of Hearing
• Washington Speech Language Hearing Association
  Convention,
• October 11, 2008 Spokane, WA

2
My clinical background

• Work history
• Types of clients to date (pilot work and
  clinical)
• cleft palate, Down syndrome, deaf, persistent
  speech disorders, oral motor, ESL
• Current work place UBC
• PRP-AO and ultrasound

3
Why visual feedback?
4
My research background

• Began research 2001
• Pilot study with the collaboration of the Burnaby
  School District and UBC
• Provincial Oral Prog.- housed at Burnaby South
  Secondary
• All students were on my caseload and oral deaf
  with severe-to-profound hearing loss
• Presented our pilot data at Canadian Hard of
  Hearing Association Annual Conference in 2001
  (CHHA BC)
• Student spoke to an audience of over 100

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So why do we care about visual feedback.?

• Cost effective
• Motivating
• Preferred method?

6
Motivating for students with persistent speech
disorders
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Motivating for students with severe hearing loss
8
Clinical research at UBC

• Main researchers at SASS
• Dr. Penelope Bacsfalvi, SLP (my doctoral
  research)
• Dr. B. May Bernhardt, SLP, School of Audiology
  and Speech Sciences, UBC (my doctoral supervisor)
• Masters students Marcy Adler-Bock, Geeta Modha,
  Benjamin Perry, Bosko Radanov (all working SLPs
  in B.C.)
• Community collaborators Susan Fawcett, SLP from
  Down Syndrome Research Foundation

9
Visual feedback therapy projects to date

• Pilot projects studies have included
• people who are deaf or hard of hearing
• cochlear implant users
• ESL learners
• Cleft palate
• Persistent speech disorders
• Clinical model consultative model
• People with Down Syndrome
• Both adults and children

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A brief history of visual feedback in speech
pathology therapy
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A brief history

• Effective for establishing new phones
• Visual information useful
• Technologies have been used successfully
• Acoustic displays, electropalatography,
  glossometry
• Dagenais Ertmer Fletcher Gibbon, Hardcastle
  Maki, Ruscello, Rvachew Shuster, Ruscello, Toth,
  Smith

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History of visual feedback as an intervention tool

• OUTLINE
• Visual feedback has been around a long time
• Abbreviated history to be presented
• Focus on visual feedback used with persons with
  hearing loss

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The pitch meter

• Boone (1966)advocated for the use of a pitch
  meter
• Pitch meter could help the child explore vocal
  range
• Simple, but effective

14
Voiscope

• The Voiscope was studied by Wirz et al. (1979)
• suprasegmental aspects of speech of children with
  profound hearing impairments.
• displayed pitch patterns (fundamental
  frequencies)
• compare and copy the teachers productions
• helpful in the modification of air-stream
  control, pitch control, pitch movement and rhythm
  within an utterance (Wirz et al. 1979).

15
First ultrasound investigation for speech (that
we know of)

• Shawker Sonies(1985)used ultrasound biofeedback
  in a case study
• Do not know if 1-D or 2-D ultrasound was used.
• Success /r/ in single words and in open-ended
  sentences with 88 accuracy.
• This case study was the beginning to signal
  further exploration

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Electropalatography(EPG)

• Another case study targeted a lateral /s/
• Often resistant to traditional speech therapy
  treatments
• (Gibbon Hardcastle, 1987).
• A programme of four-one hour weekly sessions
• Great success
• a 12-year-old hearing child boy
• mastered /s/ in four weeks after years of
  traditional therapy that had not been successful.

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Exploratory study with ultrasound

• Klajman et al. (1988) investigated the
  articulatory setting of vowels
• majority able to improve their tongue shapes
• Sixteen out of the 21 children partially or
  completely matched the teachers target vowels in
  one session.
• The researchers commented that it was very
  important for the instructor to have specific
  knowledge of phonetics, and the ability to give
  precise help based on this knowledge.

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EPG children with profound hearing impairment

• Fletcher et al. (1991) used EPG to teach
  consonants
• Following the brief 3-4 week period of daily
  therapy, these participants all produced many
  more consonants
• The authors reported that their training
  principles followed some traditional procedures

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US exploratory study of adults tongue movements
with dysarthria

• Keller (1987) used ultrasound to investigate
  vertical tongue dorsum movements in several cases
  of motor disturbance
• identify the control and impairment variables.
• Useful in collecting quantitative information for
  speech motor disturbances.
• important findings included
• variability in movement amplitude and duration
• insufficient coordination in his participants

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EPG adult with unrepaired palatal cleft

• Fletcher (1985) explored the uses of
  electropalatography (EPG) for speech production
• explored the articulator roles in stops and
  fricatives
• his findings revealed the speakers compensatory
  strategies
• gave insight into lingua-palatal contacts of
  speech.

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Glossometry Palatometry

• Dagenais(1992) used both glossometry and
  palatometry as an adjunct to traditional speech
  training
• His past studies with visual biofeedback had
  resulted in a lack of generalization to
  spontaneous speech.
• The participants improved on all targeted speech
  sounds
• The results revealed that visually based speech
  training was a viable adjunct to traditional
  auditorily based training.

22
EPG CleftNet, Scotland

• Gibbon, Stewart, Hardcastle, Crampin(1999)
  initiated an EPG network
• Four clinic centres across Scotland were set up
  with EPG systems and each centre was provided
  with a number of portable training units (PTU)
  that could be loaned out to clinicians.
• At the hub was an EPG specialist, and the PTUs
  could be loaned out to the communities where they
  were most needed.
• The role of the specialists declined
• Extremely successful for children with cleft
  palate across the U.K.-see website for more info.
  

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Visual feedback by the late 1990s

• many speech and language specialists had found
  visual biofeedback devices to be useful adjuncts
  in speech habilitation
• outcomes of investigations were all positive
• most small centres, or centres without a research
  institute usually did not have access to these
  technologies or therapeutic techniques
• goal in the current decade to increase access to
  speech technologies in habilitation settings.

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Speech production outcomes case study for a child
with a CI

• One child, long term CI user
• Speech difficult to understand
• Worked with SLP for habilitation on EPG
• Worked primarily on fricatives
• Improvement seen
• Bernhardt, B, Loyst, D., Pichora-Fuller, K.
  Williams, R. (2000)

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BALDI

• newer software such as Baldi (Massaro Light,
  2004)
• based on info. incorporated from various visual
  biofeedback devices
• Baldi offers all the acoustic information
  available in programmes like Speech Viewer,
  Dr. Speech and The Rosetta Stone as well as
  additional articulatory information from
  ultrasound, electropalatography or other such
  high-tech instrumentation
• allows observation of dynamic articulatory
  movements.

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Effectiveness of Baldi

• seven students ages 8 to 13.
• aided hearing threshold levels were all within
  the mild-to-moderate range.
• Their programme consisted of a computer-animated
  talking head (Baldi)
• students can view what is happening on the inside
  of the mouth and neck.
• range of information

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Effectiveness of Baldi 2

• Training was over 21 weeks at twice a week for 45
  minutes.
• The students worked mostly on their own with
  Baldi as their trainer
• gains from 23 to 76 accuracy.
• weakness of programme- inability of students to
  see what they were doing in comparison to the
  model

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Phonological disorders and intervention
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Speech assessment and intervention

• Differences in phonology (speech perception,
  representation and production)
• The impact of phonological differences (Delay,
  Impairment) on life activity and participation
• Signs and sources
• Comparison with typically developing norms

30
Phonological disorders

• What is it?
• Articulation/speech that is developmentally
  different or delayed
• Anything else?

31
Stats on the impaired comprehension of the sound
system of language

• For 80 of children with phonological disorders,
  the disorders are sufficiently severe to require
  clinical treatment.
• Relationship b/t early phonological disorders and
  subsequent reading, writing, spelling and
  mathematical abilities
• In 2006, 90 of SLPs in schools indicated that
  they served individuals with phonolgical/articualt
  ion disorders.
• From ASHA website, 2008

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Definition of Phonological disorder

• World Health Organization Intl. Classification of
  Function
• Body Structure anatomical parts of body
• Function- physiological functions of body systems
• Activity- execution of a task by an individual
• Participation in life involvement in life
  situation

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Limitations-

• Structure or function limitations in
• Representation of phonetic, handshape form
• Processing of phonetic, handshape form
• Actual articulation of phonetic, handshape form

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Apparent everyday.

• Demonstrated by
• Phonological awareness, literacy delays
  (activity)
• Speech or sign thats difficult to understand for
  age
• Withdrawal, difficulty in peer interaction
  (participation)

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Age and frequency in hearing population

• 50 of caseloads in health system, schools
• Children with speech impairment- one of the
  largest groups with communication difficulty
  (Harasty Reed, 1994)
• Not just children
• Residual differences can persist into adulthood
• Sibilants, /l/, /r/, flaps, multisyllabic words
  (case)
• Difficulties as preschoolers may impact
  subsequent educational, occupational and social
  opportunities throughout life for many people.
• Learning new multisyllabic words is challenging
  for everyone!

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Frequency of hearing loss

• In the U.S. 31.5 million USers had hearing loss
  in 2004 (ASHA)
• Of the 1,200,000 hearing impaired individuals in
  Canada, 40,000 are profoundly deaf. (BCASLPA)

37
Speech issues in children who are DHH

• Many of these children have speech issues
• Most have speech issues due to hearing loss
• Some have concomitant phonological disorders
• Production errors include vowels as well as
  consonants

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Treatment for disordered speech

• What do we do about it?
• Behavioural intervention
• Complex, multicomponential process
• Intervention by trained professionals
• Training
• Phonetics
• Phonology
• Neuroanatomy Physiology
• Disordered speech
• Voice Therapy

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ICF incorporates both impairment and social
factors.

• when working with children with speech impairment
• Goals set for these children and their families
  must consider life-long communication and
  literacy needs

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ICF meta theory

• Assists us in considering all the possibilities
  of speech intervention
• Correct production of speech sounds
• Intelligible conversational speech
• Enhance childs participation in social
  interaction
• Increase self-esteem
• Decrease negative societal attitudes

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Persons with structural or functional limitations
in phonology

• Often show signs of difficulty at all
  componential levels to some degree!

42
Frequently correlated factors?

• Auditory perception issues
• sensorineural loss, (otitis media)
• Oral motor skills for speech movements
• General language deficits, particularly
  production
• Psychosocial issues chicken or egg

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More severe limitations signs

• Language, oral-motor, hearing, social factors 
• Impoverished syllable and word structure
• Chronological mismatch CV, but has /l/ or /r/
• Greater within-word variability than is typical
• More uncommon substitutions or defaults
• nasal snort, dorsal default, continuant WI
  default (st), lateral emission, glottal stop
  default, ungrooved sibilants beyond second
  dentition, clicks for sibilants
• Prosody aberrations speech breathing, rate,
  rhythm, stress
• Limitations in vowel system
• Lack of imitative skills (or for toddlers,
  babbling)

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More factors.

• Environmental input
• Word familiarity
• Preference/interests
• Physiological and motor development
• Complexity of sound productions
• Perception

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Case Example Its not that easy to tell.

• Problem or not?
• Therapy or not?
• Parent/Assistant intervention or SLP
  intervention?
• Challenging goals or less challenging goals?
• In the end efficacy or maturation.

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Red flags for impairment?

• Processes at later stages
• Need to know what is typical to know what is
  impaired
• Need to know hearing loss profile
• Unusual processes

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And on a related note.Societal attitudes
towards children with speech impairments

• One study noted that a child with a mild speech
  impairment (a child who uses /w/ for /r/ was
  considered to be
• Less talkative
• Can hear less well
• Dysfluent
• Unpleasant to listen to
• Soft
• Boring
• Dull
• More tense
• Nervous
• Afraid
• Handicapped
• Isolated
• Uncomfortable

48
Studies from SASS ISRL, University of
British Columbia, Canada
School of Audiology Speech ScienceInterdiscipl
inary Speech Research Lab
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Pilot study Everyday listener study

• In everyday life
• speakers need to communicate with unfamiliar
  listeners who have no phonetic training.
• through the ears of everyday listeners who were
  familiar neither with the speakers nor with
  speech disorders.

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Pilot study Background

• Mostly acoustic displays
• Somewhat successful
• Have to infer articulatory and movement patterns
  from the display

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Evaluation

• How do we evaluate success/change?
• Severely disordered speech takes more time to
  change.
• One way is through listener studies

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Method

• 4 high school students (grades 10-12)
• Ages 16-18
• Have had years of speech therapy and training
  from TDHH and SLPs
• Bilateral severe-to-profound sloping
  sensorineural hearing loss
• All oral deaf

53
Speech profile summary

• Typical of those with significant sensorineural
  hearing loss
• All had mild hypernasality
• Difficulty with loudness regulation
• 2 had difficulty regulating pitch and
  coordinating breath support for speech
• Sibilants and liquids were least established
• Tense-lax distinction for vowels was not well
  established
• Obstruents showed devoicing, particularly word
  finally
• Often deaspirated initial stops
• Fricatives sometimes produced as stops and vice
  versa
• Difficulty with sibilants in terms of placement
  and air flow
• Diphthongs reduced to monophthongs
• And moretypical of speakers with congenital
  hearing impairment

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Treatment

• 4 weeks with no technology
• 15 weeks with visual feedback tech.
• Part with EPG and part with U/S
• All student received treatment with both
  technologies
• Intervention twice a week
• Once with technology
• Once without technology

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Goals included

• Sibilant place contrast
• Liquid place contrast
• Tense-lax vowel contrast with high vowels

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Results Pamela

• Sibilants
• S- improvement word I
• SH- improvement word I/F
• Liquids
• L- improvement word F (had I)
• R- improvement word I/F
• Vowels
• Improvement on two vowels

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Results Purdy

• Sibilants
• S- improvement word I/F
• SH- had alrady
• Liquids
• L- improvement word F (had I)
• R- improvement word I/F
• Vowels
• Improvement on 3/4 vowels

58
Results Palmer

• Sibilants
• S- improvement word I/F
• SH- improvement word I/F
• Liquids
• L- improvement word F (had I)
• R- improvement word I/F
• Vowels
• Improvement on 4/4 vowels

59
Results Peran

• Sibilants
• S- improvement word I/F
• SH- improvement word I/F
• Liquids
• L- improvement word I/F
• R- improvement word I/F
• Vowels
• Improvement on 1/4 vowels

60
Overall

• All demonstrated significant improvement
• Very short term as each goal was worked on for a
  few weeks
• Need for further studies
• This leads us to.

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My doctoral research

• Focus on visual feedback technologies
• Focus on speech science
• (SLPs you need all your physiology and speech
  science training!)
• Acoustic correlates of vowels and consonants
• Formant data as corresponds to speech sounds
• Tongue palate contact analysis
• Tongue shape patterns
• Dynamic tongue movement patterns
• Gestural components of speech sounds
• Focus on quality of life issues
• Focus on experiences during and after intervention

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Study 1 Vowel remediation for adolescents with
hearing impairment

• Background
• 8 month olds with HI produce fewer vowel
  distinctions than age-matched hearing babies
• Dagenais and Critz-Crosby (1992)
• tongue movements and positions for vowels
  differed significantly
• Less studies on vowel intervention

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Method

• Three 18 year olds
• Oral programme
• Severe-to-profound sensorineural hearing loss
  before the age of 26
• Pre-post intervention pilot study
• 6 weeks of treatment

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Treatment

• Twice a week for 6 weeks
• Treatment conducted by 2 SLPs
• One session with ultrasound
• One session without
• Required weekly practice schedule
• Treatment was with both EPG and Ultrasound

65
Analysis

• How do objectively measure change?
• Acoustic analysis
• EPG contact target analysis
• Phonetic transcription (fine, not broad)

66
Results

• Overall reduced variability for productions in
  all three participants
• Variability is a hallmark of speech of people who
  are DHH
• 8 of the 15 vowels showed gains
• All of these students had high frequency loss so
  improvement for /i/ for all three is noteworthy
• Results revealed that contact pattern changes do
  not necessarily imply a change in the acoustic
  signal.

67
Study 2 Attaining the lingual components of /r/
for three adolescents with cochlear implants

• Background
• Many older children who are recipients of CIs
  continue to require speech habilitation
• Even years after receiving CIs difficulties with
  speech production continues
• /r/ is a very challenging speech sound to learn
  for hearing and hearing impaired speakers

68
Method

• 3 participants
• Severe-to-profound sensorineural hearing loss
• Early onset of hearing loss
• Use of unilateral CI for more than 3 months
• Desire and motivation to improve speech
  production
• Educational environment with emphasis on oral
  approach
• Access to speech therapy

69
Research design

• Non-concurrent multiple baseline across
  participants
• Single subject design with
• (a) baseline,
• (b) intervention,
• (c) follow-up
• Componential approach to therapy

70
Intervention process

• All students attended weekly 45-60 minute
  treatment sessions
• All students also received Auditory training to
  develop listening skills with a trained SLP or
  AUD
• Parts of /r/ were trained

71
Results

• All three students were able to learn the
  gestural components of /r/
• Component level vs. Word level
• more rhotic quality by the end of this study

72
Study 3 Long-term outcomes of speech therapy
for seven adolescents with visual feedback
technologies

• Background
• Short term outcomes have been successful
• Need for longer term outcomes
• Evidence based practice is needed to maximize
  treatment effectiveness
• Need for clinical intervention studies

73
Method

• 7 young men and women who had participated in
  past studies
• All have severe-to-profound sensorineural hearing
  loss
• Follow-up was 2 to 4 years post intervention

74
Study design

• Within subject evaluation
• 7 expert listeners evaluated the speech of one
  speaker
• Listener evaluation study
• Three sets of data evaluated
• 1. before treatment with visual feedback
• 2. immediately post treatment
• 3. long term follow up post

75
Results

• Overall, listeners rated six out of seven
  speakers maintained or improved
• Goal maintenance or improvement since last
  therapy session

76
Study 4 A qualitative follow-up of long term
outcomes

• Background
• Long term negative impacts of unintelligible
  speech in the life of people with hearing loss
  (Takala and Seppala, 1994 Skelton and Valentine,
  2003 Blackorby and Wagner, 2007).
• Negative effects on
• Interpersonal relationships with family and
  friends
• Performance in school
• Ability to get jobs
• Ability to participate in society in general

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Beneficial change from treatment

• WHO requirement
• Beneficial change from treatment
• One ultimate goal
• Enhanced social participation
• Increased self esteem

78
Understanding the impact of speech therapy

• Past focused only on quantitative results
• Less know about lived experiences
• Qualitative analysis able to illustrate benefits
  unavailable from quantitative analysis alone

79
Method

• 5 past participants
• 4 stake holders in their lives
• Semi-structured interviews
• Interviews were between 1 and 2 hours
• All interviews conducted in auditory-oral
  modality
• Questions designed to generate candid
  descriptions of experiences

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Analysis method

• Interviews collected over 6 months
• Transcribed verbatim
• Each transcript read several times
• Data were open coded and recoded
• Data were placed into categories and themes
• Constant comparison and contrasting of codes

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Findings

• Most prominent themes
• Good experience
• Therapy method
• New information
• Benefits
• Outcomes Generalization

82
Quotes good experience

• I like itit help to talk clearand it helps me
  to practice with that (the US).
• Another participant explained how unfamiliar
  listeners could understand him now.and added-
  now I can know how to talk.

83
Findings Therapy Method

• A few participants indicated now it had been hard
  work, but worth it.
• Yes, it was hard before, in the beginning, it
  was hard (work)and then it got better and
  better, and now it is easy- I like it.
• A couple of students also indicated that they
  felt this method was more informative than
  traditional methods.

84
Quotes New Information

• It was helpful to see what happen(s), whats
  happeningto show how to do it the right way.

85
Findings Benefits

• at the university, that was really important
  for me- because this way I could talk with
  peoplemake people understand me, like most of
  the time- otherwise people dont have time to
  (have you) repeat, and try to understand what you
  sayagain, againthey get tired. So thats why it
  was very important for me, for my life too.

86
Quote from a stakeholder

• And now , now he knows it- hes learned it. So,
  I think its been really effective, and Im
  positive that if you hadnt had this visual
  stimulus there for him to see, he would have
  given up long before he would have never got
  where he got.

87
Stakeholder perspective on practice

• Well, I think if it was in, especially at his
  school, for an oral deaf person, who is really
  working on speech and who really is, you know,
  youre really trying to use (speech).I mean,its
  not just schooling, its part of their life.

88
Parker Age 16 Sensorineural hearing loss,
cochlear implant user

• Severe-to-profound sensorineural hearing loss
  since birth. CHARGE syndrome. Attending signing
  programme, grade 10.
• Slight language delay School SLP, Hearing
  Resource Teacher
• Participant in ultrasound therapy studies over
  the past year
• CI 1.5 years ago Understands all conversations
  in Aud. only
• Difficulty discriminating /r/ - /w/
• Since CI Listening therapy (AVT) and ultrasound
• Current speech status intelligible speech to
  naïve listeners
• This term /r/ with ultrasound, pitch control,
  coordinating voice and speech onset (acoustic
  software). Excellent results.
• Continued work in pitch control generalization is
  needed.

89
Speech Therapy process for work with people with
hearing loss

• Most SLPs on the team are offering a combination
  speech and listening therapy while using auditory
  verbal techniques.
• Must be constantly aware of frequency and formant
  information
• Remember vowels are louder than consonants and
  only two consonants approach the mean peak power
  of a vowel- r and l, and these sounds develop
  later in speech production (Pollack, 1997).

90
Other studies on r completed by our lab.
91
Study 5 Rural ultrasound project

• Background
• Rural clients have limited access to technology
• Could a consultative model work?

92
Rural project

• Thirteen 7 to 15 year olds
• All needed /r/
• All had previous SLP therapy
• Three phases
• No U/S
• 1-3 sessions
• No U/S
• Training of local SLPs on new knowledge

93
Results of study

• The group that received 2-3 hours of U/S in
  therapy over 3-4 sessions over 2 days improved
  more than the group who received 1 tx. with U/S
  in a half day session

94
Quotes from community SLPs

• Some students had years of unsuccessful therapy
  for /r/. Some of these students got a good /r/ in
  15 minutes with the ultrasound and an experienced
  therapist SLP consultant.
• The children in this study really improved- they
  are not great at monitoring their speech but Im
  very pleased with their ability to make good /r/
  sounds when they are focued (good placement).

95
Study 6 pilot revealed success for people with
Down Syndrome

• Background
• Most people with D.S. experience some degree of
  reduced speech intelligibility
• Few speech studies in people with D.S.
• Research has shown learning through the visual
  modality is a strength
• Effective tool for people in general
• EPG has been shown to be effective for people
  with D.S.

96
Study design

• Three adult participants
• Teach components of /r/
• Single subject repeated withdrawals design
• Withdrawal of ultrasound
• Revealed rapid loss of newly acquired skills

97
Results of study

• Success
• All participants could produce /r/ at the word
  level post intervention

98
Perspectives to Date

• VF technology Useful adjunct
• New targets established
• A bargain over time
• Easy to interpret
• New phonetics knowledge used now in regular
  therapy

99
General Discussion

• Visual feedback cannot take the place of
  instruction based on knowledge of phonology,
  phonetics, voice, anatomy and physiology, etc.
  (SLP training)- but it is a tool that will
  greatly change the way we practice

100
Challenges and questions

• Acoustic or other visual feedback equally useful?
• Need regular therapy for continued generalization
• Cost in the short-term
• Accessibility?
• Need knowledge and equipment!
• Need bigger studies for conclusive evidence based
  practice

101
Home practice- invaluable

• An important part of therapy- a collaborative
  team approach and/or involvement of the family.
• A parent, grandparent or older sibling can be
  involved.
• We have found home practice of achievable targets
  without ultrasound invaluable to making progress.
  For example one gestural component, such as
  tongue root retraction, can be practiced at home.
  Practice needs to happen at least every other
  day.

102
School based practice- invaluable

• What about those families that just cannot seem
  to practice?
• We found success with the school based team-
• CDAs, OIs, EAs, TDHH, CT
• Team pulled together in the school
• Great success for the student

103
Valuable practice in school

• The school team can also be very valuable
• practice with the EA at the school for even 15
  minutes a day is a great help.
• We have trained teachers, oral interpreters and
  education assistants to help with the carry-over
  practice sessions
• without ultrasound

104
Reading the ultrasound

• How to read the ultrasound image
• Is it safe?

105
Reading the ultrasound image

• Ultrasound transducer (probe) placed under the
  chin
• Two perspectives
• Sagittal- tongue root to tip
• Coronal- height of sides or raising in midline
• Two dimensional ultrasound reveal 2-D perspective
• Ultrasound waves collide with the air in the
  mouth above the tongues surface and reflect back
  to the probe- these digital image are translated
  onto the screen

106
How safe is ultrasound?

• Quite safe

107
About r
108
What happens in the process-an example with /r/

• Knowledge change
• Clients learn to describe the components of the
  target segment.
• Acoustics e.g. Lowering of third formant in /r/.
  (Another useful tool is Praat).
• Tongue shape change (max target) as displayed on
  ultrasound
• Tongue tip raising
• Tongue body lowering
• Root retraction
• Groove

109
A volunteer please.

• Demonstration of ultrasound for therapy

110
Additional techniques

• Clay models
• Drawing the tongue shapes
• Facilitation by use of known target
• Velars
• High back vowel

111
Therapy Procedure with sample /r/

• Single gt combined movements
• Tip Retroflexed gt bunched Sagittal view
• Tongue root retraction into pharynx
• Sagittal view
• Lateral tongue margins/molar contact
• for bracing, groove Coronal view
• Inhibition of non-target movement
• Excessive labialization Mirror
• Tongue back raising (from w) Sagittal
• Relative advancement of tongue Sagittal

112
Clinical cases Lower Mainland School Board
clinical pilots
113
MartinCase 1

• Hearing within normal limit
• Above average student in academics
• Now in grade 7
• Artic. Therapy in grade 3 and group therapy in
  grades 4 5
• Gave up in grade 6

114
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115
Martin Tx. with U/S as adjunct

• -One group tx. session
• -5 individual tx. sessions
• -3.5 months to complete generalisation
• -needed bunched r
• -practiced at home regularly with dad

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RubyCase 2

• Hearing within normal limits
• O.T. ax. inconclusive, mild fine motor delay
• In grade 3 and 4 mild delays in literacy and
  phonological awareness
• Had received SLP intervention
• Now in grade 6, functioning WNL

117
Ruby Tx. with U/S as adjunct

• One group therapy session
• 14 individual sessions
• Timeline
• 2 months to achieve r at word level
• Using r in connected speech after 5 months
• 2 months to achieve k in connected speech

118
References P. 1

• BCASLPA (2008). Statistics from Website
  www.bcaslpa.ca
• ASHA. (2006). 2006 Schools Survey report
  Caseload characteristics. Rockville, MD Author.
• Bacsfalvi, P. Bernhardt, B.M. Phonology and
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  2008 AUDI 451 School of Audiology and Speech
  Science, UBC, Canada
• Bacsfalvi, P. Bernhardt, B.M. (2001). The new
  speech therapy for people with a hearing loss.
  Presentation at CHHA-BC, Richmond, BC.
• Bacsfalvi, P., Bernhardt, B.M. and Gick, B.
  (2007). Electropalatography and ultrasound in
  vowel remediation for adolescents with hearing
  impairment. Advances in Speech Language
  Pathology, 9(1), 36-45.
• Bernhardt, B.M., Bacsfalvi, P, Adler-Bock, M.,
  Shimizu, R. Cheney, A., Giesbrecht, N.,
  OConnell, M., Sirianni, J., Radanov, B.
  (2008). Ultrasound as a visual feedback in speech
  habilitation Exploring consultative use in rural
  British Columbia, Canada

119
References P.2

• Bernhardt, B., Fuller, K., Loyst, D., Williams,
  R. (2000). Speech production outcomes before and
  after palatometry for a child with a cochlear
  implant. Journal of the Association of
  Rehabilitative Audiology, 23, 11-37.
• Blackorby, J. Wagner, M. (2007). Longitudinal
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  Findings from the national longitudinal
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• Fawcett, S., Bacsfalvi, P. Bernhardt, B.M.
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  Therapy for /r/ with Adults with Down Syndrome.
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• Gick, B., Bacsfalvi, P., Bernhardt, B.M., Oh, S.,
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  English /r/ variants in normal and disordered
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• Gierut, J.A. (1998). Treatment efficacy
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  childrens speech and voice physiology after
  cochlear implantation. Ear and Hearing, 24(1),
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References P.3

• Skelton, T. Valentine, G. (2003). It feels
  like being deaf is normal An exploration into
  the complexities of defining D/Deafness and young
  D/Deaf peoples identities. The Canadian
  Geographer, 47, 451-466.
• Stoel-Gammon, C. Otomo, K. (1986). Babbling
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  hearing subjects. Journal of Speech and Hearing
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• Takala, M. Seppala, U. (1994). My life as a
  deaf person in Finnish society Stories about
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