1. Speech Sound Disorders: the use of biofeedback in treating residual errors in school aged children. Paediatric Speech Group Presented by Vani Gupta, Rachel Furniss & Thizbe Wenger

2. Speech EBP Group 2014 Outline of presentation  Overview  Definitions  Results  What’s next Image from Wall Street Journal (October 2014) Paediatric Speech EBP Group, 2014

3. Overview  In 2014 the group has covered papers relating to Principles of Motor Learning, Child Apraxia of Speech and Multiple Oppositions  The primary focus for the latter half of 2014 has been on the use of biofeedback in treating residual speech sound disorders Paediatric Speech EBP Group, 2014

4. CAT In school age children with residual speech errors do interventions including PML and/or biofeedback lead to improvements in speech accuracy? Image from CASL Research Centre at Queen Margaret University (accessed November 2014)

5. What we know  There is an increasing body of research to support the successful use of visual feedback to remediate clients with speech sound difficulties in a time and cost effective manner.  Current research includes studies targeting populations including those with CAS, hearing impairment, cochlear implants, speech sound disorders such as lateral and interdental lisps. Paediatric Speech EBP Group, 2014

6. Definitions  What is biofeedback?  What types of biofeedback are supported by research? Image from Science Direct (October 2014) Image from CASL Research Centre at Queen Margaret University (accessed November 2014)

7. Summary of research and CAPs 6 articles identified and reviewed in 2014.  Bacsfalvi, P. & Bernhardt, B. M. (2011). Long-term outcomes of speech therapy for seven adolescents with visual feedback technologies: ultrasound and electropalatography. Clinical Linguistics and Phonology, 25(11-12), p 1034-1043.  Bacsfalvi, P., Bernhardt, B. M. and Gick, B. (2007). Electropalatography and ultrasound in remediation for adolescents with hearing impairment. Advances in Speech-Language Pathology, 9 (1), 36-45  Bernhardt, B, Gick, B., Bacsfalvi, P. & Ashdown, J. (2003) Speech habilitation of hard of hearing adolescents using electropalatography and ultrasound as evaluated by trained listeners. Clinical linguistics & phonetics, 17, 3, 199-216  Lipetz, H.M. & Bernhardt, B.M. (2013) A multi-modal approach to intervention for adolescent’s frontal lisp. Clinical Linguistics and Phonetics, 27(1), 1-17.  McAuliffe, M.J. & Cornwell, P.L. (2008). Research Report: Intervention for lateral /s/ using electropalatography (EPG) biofeedback and an intensive motor learning approach: a case report. Int. J. Lang. Comm. Dis., March-April, V. 43, No. 2, 219-229.  Preston, J., Brick, N., & Landi, N. (2013). Ultrasound biofeedback treatment for persisting childhood apraxia of speech. American Journal of Speech-Language Pathology, 22, 627-643. Paediatric Speech EBP Group, 2014

8. Summary of research and CAPs  All studies had small sample sizes, ranging from 1- 7 participants.  The participants were predominantly male.  Many participants were adolescents who had received various interventions as children and had residual speech sound errors.  The types of errors varied across participants. Paediatric Speech EBP Group, 2014

9. Summary of research and CAPs  Most of the studies outlined weekly or bi-weekly therapy sessions, over a period of several weeks or months, with or without breaks, with or without “homework modules”. Some studies had individual therapy sessions, whilst one had group and individual sessions.  The treatment targets and treatment approach, e.g. type of biofeedback and type of “traditional articulation therapy” also varied from study to study. … i.e. lots of variability! Paediatric Speech EBP Group, 2014

10. Results of research and CAPs  Multimodal approaches to intervention including ultrasound, education about articulatory setting, traditional articulation therapy and online visual-acoustic feedback have potential for remediating residual speech errors, specifically frontal lisp. (Lipetz & Bernhardt, 2013)  No improvements after isolated teaching about articulation setting without production practice. (Lipetz & Bernhardt, 2013)  Ultrasound biofeedback, used in conjunction with more traditional speech sound training drills, may be effective for school-aged children with CAS. (Preston, Brick & Landi 2013)  Adolescents with severe to profound hearing loss treated with ultrasound and electropalatography (EPG) to increase accuracy of speech production, maintained or increased their accuracy 2-4 years post treatment. (Bacsfalvi & Bernhardt, 2011)  Visual feedback in the form of EPG and ultrasound can be useful in treating vowel errors in adolescents with hearing impairment. (Bacsfalvi et al., 2007)  Use of EPG and ultrasounds can improve specific speech sound targets for adolescents with moderate to severe sensorineural hearing loss. (Bernhardt et al., 2003) Image from CASL Research Centre at Queen Margaret University (accessed November 2014) Paediatric Speech EBP Group, 2014

11. In summary...  There is an increasing body of research to support the use of biofeedback to remediate residual speech sound errors, particularly for school age children.  Although sample sizes are small, research supports maintenance of treatment effects post- intervention. Paediatric Speech EBP Group, 2014

12. In summary….  Biofeedback can be effectively ‘faded out’ following establishment of skills.  The Paediatric Speech Group trialled the use of ultrasound in September this year and found the equipment easy to use and interpret! (thanks Tricia McCabe) Paediatric Speech EBP Group, 2014

13. What we think is really, really useful about biofeedback!  It’s quick to set up and easy to use  Ability to engage and achieve success with clients, especially those who have attended LOTS of intervention  Ultrasound has the ability to provide “intra-oral snapshots” to other treating speech pathologists will improve the accuracy and documentation clinical handover (National Standard 6)  Intrinsically promotes self-awareness and self- correction – a step towards generalisation  It’s fun! Paediatric Speech EBP Group, 2014

14. So why aren’t we using biofeedback?  Access to equipment  Confidence in using new technology  Lack of evidence to support use in commonly presenting caseloads  Slow transition from research to the clinic – but watch this space! Paediatric Speech EBP Group, 2014

15. What’s next?  Further evidence on the use of biofeedback in different age groups and diagnostic populations is required.  Look out for further research (Tricia McCabe) Paediatric Speech EBP Group, 2014

16. 2015…. Focus on bilingualism and SSD, with questions at present: ‘In children with SSD whose primary language is not English, does treatment in the child’s primary language directed by a speech pathologist who does not share the same primary language, result in improved speech intelligibility compared to no treatment?’ ‘In children with SSD who are bi/multilingual, does treatment in one language lead to improvements in speech intelligibility in other languages, compared to treatment in both languages or no treatment?’ Paediatric Speech EBP Group, 2014

17. References  Bacsfalvi, P., Bernhardt, B. M. and Gick, B. (2007). Electropalatography and ultrasound in remediation for adolescents with hearing impairment. Advances in Speech- Language Pathology, 9 (1), 36-45  Bacsfalvi, P., & Bernhardt, B.M., (2011) Long-term outcomes of speech therapy for seven adolescents with visual feedback technologies: ultrasound and electropalatography. Clinical Linguistics & Phonetics, 25 (11-12): 1034-1043  Bernhardt, B, Gick, B., Bacsfalvi, P. & Ashdown, J. (2003) Speech habilitation of hard of hearing adolescents using electropalatography and ultrasound as evaluated by trained listeners. Clinical linguistics & phonetics, 17, 3, 199-216  Lipetz, H.M., Bernhardt, B.M. (2013) A multi-modal approach to intervention for adolescent’s frontal lisp. Clinical Linguistics and Phonetics, 27(1), 1-17  McAuliffe, M.J. & Cornwell, P.L. (2008). Research Report: Intervention for lateral /s/ using electropalatography (EPG) biofeedback and an intensive motor learning approach: a case report. Int. J. Lang. Comm. Dis., March-April, V. 43, No. 2, 219-229.  Preston, J., Brick, N., & Landi, N. (2013). Ultrasound biofeedback treatment for persisting childhood apraxia of speech. American Journal of Speech-Language Pathology, 22, 627-643. Paediatric Speech EBP Group, 2014

18. Thank you! Thanks to Elise Baker & Bronwyn Carrigg for their leadership of the Paediatric Speech EBP group and to everyone in the group for their time and commitment to evidence based practice! Paediatric Speech EBP Group, 2014