Effect of Rapid Syllable Transition Treatment (ReST) vs

Ultrasound Biofeedback on School Aged Children with

Childhood Apraxia of Speech

Background

The majority of speech is generated through an airflow originating in the lungs and

propelled upward through the trachea (commonly known as the windpipe) and the oral and

nasal passages. As this airflow progresses, it undergoes alterations from the various speech

organs, each of which imparts distinct acoustic characteristics used to distinguish sounds. The

production of a speech sound can be

dissected into four distinct yet

interconnected processes: the

initiation of the airflow, typically in

the lungs; its phonation in the larynx

involving the operation of the vocal

folds; its direction by the velum, guiding it into either the oral cavity or the nasal cavity (known

as the oronasal process); and finally, its articulation, primarily accomplished by the tongue but

includes lips, teeth, alveolar ridge, and palate of the mouth within the oral cavity (Giegerich,

1992).

For speech to take place, communication signals originating in the brain must be

transmitted to the muscles responsible for sound production in the mouth. These signals

instruct the muscles on the precise movements and timing required to create sounds. When a

child is affected by childhood apraxia of speech (CAS), these communication signals do not
transmit accurately.

Consequently, the child may

struggle to coordinate the

movements of their lips or

tongue correctly, even if their

muscles are not weak. In some

cases, this difficulty can result in limited verbal output. A child with CAS possesses the ideas and

intentions necessary for speech. The issue lies not in the child's cognitive process but in how

the brain conveys instructions to the muscles in the mouth (ASHA, 2007).

Speech production is a highly intricate motor process involving the coordination of

respiratory, laryngeal, and supraglottal articulators. Even simple speech gestures require

coordination of various articulators. The underlying speech motor control system integrates

auditory, somatosensory, and motor information from different brain regions, aiming to

produce fluent and intelligible speech. The etiology and neurophysiology of CAS remains

unknown (Webb, 2017). Speech motor control relies on a network of brain regions in the

frontal lobes, including primary, premotor, supplementary motor areas, inferior frontal gyrus,

and other regions like the insula, somatosensory and auditory cortices, subcortical, and

cerebellar regions (Landin-Romero et al., 2021).

Childhood Apraxia of Speech (CAS) is “a motor-based speech sound disorder involving

impairments in speech sound accuracy along with disrupted transitions between sounds and

syllables, prosodic disturbances, and token-to-token inconsistency” (American Speech-

Language- Hearing Association (ASHA, 2007). It is a disorder of motor planning and

programming that often results in imprecise, inconsistent, and unintelligible speech that affects

0.1% of the population and is typically occurring with other complex neurodevelopmental

disorders. The condition is believed to stem from an impairment in motor programming or

planning. In this context, it implies that children have a clear idea of what they want to express

but encounter challenges in organizing and executing the precise and rapid movements

necessary for accurate speech production. Synonyms such as verbal dyspraxia and

developmental apraxia of speech have been used. The most commonly used terms today are

CAS and developmental verbal dyspraxia (DVD).

A lack of motor programming or planning is believed to be the underlying cause of

Childhood Apraxia of Speech (CAS). In CAS, children have a clear idea of what they want to say,

but they struggle with organizing and executing the necessary movements for producing speech

accurately. SLPs widely agree on three key diagnostic characteristics of CAS: (1) inconsistent

error production on both consonants and vowels across repeated productions of syllables or

words; (2) lengthened and impaired coarticulatory transitions between sounds and syllables;

and (3) inappropriate prosody (ASHA 2007)."

Acquired apraxia of speech results from brain damage affecting the regions responsible

for speech sound production like the left insula or Broca's area. This damage can stem from

factors like brain injuries, strokes, tumors, or other illnesses. On the other hand, childhood

apraxia of speech is congenital. CAS is not a condition that children naturally outgrow. A child

with CAS will not develop speech sounds in the typical order and will not make progress

without suitable intervention.

 Rapid Syllable Transition Treatment (ReST) is aimed at treating suspected core speech-

motor planning disorder in CAS and pushes children to utilize their speech motor planning skills.

It uses pseudo-words with varying lexical stress, effectively improves articulation, prosody, and

coarticulatory transitions in children with CAS. It helps them learn to imitate these pseudo-

words and apply their skills to untreated pseudo-words as well as real words. Using pseudo

words enables the children to practice motor planning and programming on word-like forms

without interference from previously incorrectly learned plans.

Ultrasound biofeedback involves training articulatory patterns using real-time visual

displays of the tongue. Biofeedback gives information about how well a movement matches the

intended one. This knowledge of performance is helpful for learning new motor skills, especially

in the early stages. It's different from

knowledge of results, which tells if the

movement was correct and is more useful for

applying what was learned. This is a relatively

new type of technology-aided speech-

language therapy and has displayed potential

in effectively treating speech sound disorders.

Aims:

Compare the efficacy of ReST and Ultrasound Biofeedback in improving speech production in

children with CAS.

Key terms:

Childhood Apraxia of Speech (CAS)

Rapid Syllable Transition Treatment (ReST)
Ultrasound feedback
intervention
School age

Methodology

Design

This study will use a randomized controlled trial (RCT) design to investigate the

comparative efficacy of Rapid Syllable Transition Treatment (ReST) and Ultrasound Biofeedback

in improving speech production skills in school-aged children diagnosed with Childhood Apraxia

of Speech (CAS).

Participants

Participants will be school aged children, ages 8-10, diagnosed with CAS by a certified

speech-language pathologist This study will employ a randomized controlled trial (RCT) design

to investigate the comparative efficacy of Rapid Syllable Transition Treatment (ReST) and

Ultrasound Biofeedback in improving speech production skills in school-aged children

diagnosed with Childhood Apraxia of Speech (CAS) with pervious history of intervention making

limited progress and no comorbidities. A total of 30 participants will be recruited with 15

participants randomly assigned to each intervention type. Participants in the first group will

receive ReST, a well-established CAS intervention. ReST sessions will be conducted two times a
week, for one-hour sessions, for six weeks. Participants in the second group will receive training

sessions using ultrasound biofeedback technology, with a focus on improving speech sound

accuracy. The sessions will follow the same frequency and duration as the ReST group.

Procedures

Before starting treatment, a baseline assessment will be completed for each participant

using the Hodson Assessment of Phonological Patters Multisyllabic Word Screening (HAPP-3).

Both groups will meet for one-hour sessions, twice a week, for six weeks. The ReST group will

be given 100 nonsense words per session with varied stress and sounds so children learn the

instructions to say these words, but also to use these as a template to learn other words and fix

existing real word productions. ReST is designed to be used with children who can produce a

reasonable number of sounds and use CV structured syllables. The minimum repertoire is 4

consonants and 4 vowels. If the participant can produce at least five different three syllable

words (do not have to be 100% accurate) start with three syllable words, if they cannot, start

with two syllable words. The nonsense word sets focus on 4 consonants, 3 long vowels and

schwa. The list below is a shortened example of a three-syllable word set that focuses on the

consonants /f, b, d, k/.

 fardekee fedooki bedeeka barkefi

fekeeba foodabee koofedi koodefi

deekeba befardi deekefa farbekee

koofeba fekardi febarki debeefa

feedika deboofee kefeeda kedeefa

Each week there is a training phase and a practice phase. The training phase is when the

clinician explains that the participant needs to exactly match the way the clinician says the

word and they need to make 5 correct productions (does not have to be spontaneous or

consecutive). This phase should only last 20 minutes the first three sessions and then reduced

to 10 for the rest of them. The second phase is the practice phase and is the most important.

Practice occurs in 20 trial drill segments, interspersed with 2-minute intervals of non-

therapeutic games designed to offer the child a brief break from the intensive practice and to

serve as a rewarding activity. These games can encompass a variety of enjoyable options, but

they should not revolve around speech, language, or literacy objectives. While the participants

are producing the nonsense words, they will be audio recorded and then scored by three blind

listeners, other certified SLPs. For the word to be correct, they need to get the sounds, beats,

and smoothness. Any words they had excessive difficulty with can be reviewed the following

session during the training phase.

For the Ultrasound Biofeedback group, the ultrasound transducer is positioned beneath

the chin, and the resulting ultrasound images are used to instruct children on altering the

positions of their tongues to create specific speech movements. This data can assist speech-
language pathologists in offering the child guidance regarding their tongue placement. The

participants will be given three targets per session. The very first session, the participants are

oriented to the ultrasound image and show understanding of the image they are looking at. An

example session could look something like 10 minutes biofeedback on /kl/ like close, closet,

clank, clear, client, clapper and then 10 minute active rest, activities in which more traditional

approaches were used to target the same sequences like card games, then 10 minutes

biofeedback on /st/ like street, stop, steeple, stain, stranded, sticker, and then 10 more minutes

of active rest, onto 10 minutes of biofeedback on another target and ending with the last 10

minutes of active rest. Sessions will be audio recorded and will be scored by three blind

listeners, other certified SLPs. They do not have to say the word in its entirety correctly, as long

as they get the target they are working on, it is correct.

One week after the final session is completed, each participant will be assessed using

the HAPP-3 to get a read on how effective it has been in the short term and then two months

later they will get assessed again with the same assessment, the HAPP-3, to see how it has

affected them long-term.

Predicted Outcomes

While both intervention strategies have been proven to be effective, I predict that the

ReST intervention method will show more improvement in speech production with children

with CAS than Ultrasound Biofeedback treatment. There are many reasons in which I believe

this to be the case. First of all, Ultrasound Biofeedback is a little complex and can be difficult to

understand what you are looking at and what you want your tongue to look like versus what it
does look like. I think an older population might benefit more from this intervention than

children. On the other hand, the ReST intervention can be worked on at home and it does not

have to be face-to-face like the Ultrasound Biofeedback does. ReST can be done online and has

been shown to be just as effective (Thomas et al., 2016).

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