A multi-modal approach to intervention for one ...

Clinical Linguistics & Phonetics, January 2013; 27(1): 1–17 © 2013 Informa UK Ltd ISSN: 0269-9206 print / ISSN 1464-5076 online DOI: 10.3109/02699206.2012.734366

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A multi-modal approach to intervention for one adolescent’s frontal lisp

HEIDI MASSEL LIPETZ & B. MAY BERNHARDT School of Audiology and Speech Sciences, University of British Columbia, Vancouver, BC, Canada V6T 1Z3 (Received 24 July 2012; revised 23 September 2012; accepted 24 September 2012)

Abstract An adolescent with a persistent frontal lisp participated in a two-part 11-session intervention case study. The first phase used ultrasound imagery and acoustic, phonetic and voice education to provide information about articulatory setting (AS) and general awareness of the speech production process. The second phase used traditional articulation therapy, online visual–acoustic biofeedback and fluency strategies to target the frontal lisp directly (specifically /s/, /z/, /ʃ/ and /ʧ/). Trained listener evaluations of pre-intervention, post-phase 1 and postphase 2 assessments showed no improvement after phase 1, but notable improvement in all treatment targets immediately after phase 2. These improvements were substantially maintained at assessment 4 months post-intervention. The outcomes suggest that direct training was more effective than the AS approach; however, the client’s ability to self-monitor in phase 2, rapid acquisition of the targets and maintenance at 4 months post-intervention possibly reflected the knowledge gained in phase 1 about AS.

Keywords: frontal lisp, alveolar fricatives, residual error, articulatory setting, phonological awareness, spectrographic visual feedback, self-monitoring, traditional articulatory therapy, ultrasound, adolescent

Introduction Recent evidence has demonstrated that in spite of early intervention, a sizable proportion of children who have protracted phonological development as preschoolers and elementary school-aged children continue to have articulatory issues in adolescence and adulthood (Johnson et al., 2001; Ruscello, 2003; Veríssimo, Van Borsel, & de Britto Pereira, 2012). Speech sound errors that continue beyond the age of normalization (circa 9 years) are referred to as “residual” or “persistent errors” in the literature (Preston & Edwards, 2009). Studies have shown that only 20–50% of children who received earlier phonological intervention show long-term normalization (Bernhardt & Major, 2005; Preston & Edwards, 2009; Shriberg, Kwiatkowski, & Gruber, 1994). A study that examined the rates of phonological errors in 69 children aged 5–13 diagnosed with either high-functioning autism spectrum disorder or Asperger syndrome concluded that 41% of the group produced some type of speech sound errors (Cleland, Gibbon, Peppe, O’hare, & Rutherford, 2010). Cleland

Correspondence: Dr B. May Bernhardt, School of Audiology and Speech Sciences, University of British Columbia, 2177 Wesbrook Mall, Vancouver, BC, Canada V6T 1Z3. Tel: 1 604 822 2319. Fax: 1 604 822 6569. E-mail: [email protected]; advanlanglit@ gmail.com


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H. M. Lipetz & B. M. Bernhardt

et al. concluded: “Whether or not speech disorders are related specifically to autism, their presence adds an additional communication and social barrier and should be diagnosed and treated as early as possible in individual children” (2010, p. 75). The current intervention case study report describes the process and outcomes for remediation of a frontal lisp in an adolescent. The multi-modal treatment approach was conducted in two phases, and incorporated a general awareness of articulatory setting (AS). The following sections provide background for the study, outlining first the impact of residual errors on speaker intelligibility and self-esteem, and then the two major approaches to phonological intervention utilized in the study: direct speech sound training versus a focus on AS and awareness. While a lisp rarely interferes with intelligibility, adolescents and adults who have a lisp are often perceived negatively by typical speakers, at least initially (Ruscello, 2003; Van Borsel, Van Rentergem, & Verhaeghe, 2007; Veríssimo et al., 2012). Veríssimo et al. (2012) surveyed 80 adults with residual /s, r/, /s/ or /r/ mismatches. In their study, 38.9% of the participants reported that they felt insecure in speech situations and that the speech sound disorder interfered with their work or social life. Although this proportion was less than half of their sample, it was far above chance, suggesting that persistent speech difficulty can have notable social impacts for some people. The “traditional” approach to remediation of specific segmental (individual consonant or vowel) difficulties focuses primarily on the motor aspects of articulation. Traditional therapy uses demonstration by the therapist followed by imitation by the client of the target or idealized model. The therapist may shape approximations by increasing the demand for “perfect” forms of the target segment until accurate articulatory positions are achieved. Segments are typically targeted in isolation, then in syllables and/or single words and finally in carrier phrases and sentences, with the goal of generalization to spontaneous speech (Powell, Elbert, Miccio, Strike-Roussos, & Brasseur, 1998). These techniques were introduced prior to the 1970s and continue to be used in conjunction with other methods (Baker, 2010). Traditional articulation therapy has been found to be effective for some, but not all, speakers over the long term (Preston & Edwards, 2009; Shriberg et al., 1994; Shuster, Ruscello, & Toth, 1995). While approaches such as direct imitation and drill-based articulation continue to have their place in treatment programs for speakers who respond to them (Hesketh, Adams, Nightingale, & Hall, 2000), other approaches may result in more effective, efficient and stable remediation for speakers with persistent errors. More recently, alternative methods have been developed and investigated for remediating residual errors. Visual feedback technologies have been effective for some speakers: for example, electropalatography (Dagenais, Critz-Crosby, & Adams, 1994; Gibbon & Wood, 2010); spectrograms (Shuster et al., 1995); and ultrasound (Bernhardt, Gick, Bacsfalvi, & Adler-Bock, 2005). In addition, awareness-building approaches have provided information about speech production and increased speakers’ monitoring of their own and others’ productions (Dean, Howell, Waters, & Reid, 1995; Hesketh, Adams, Nightingale, & Hall, 2000). These approaches are elaborated below. Awareness-building and AS Dean et al. (1995) suggested that “… to be maximally effective, therapy should not be an inexplicable, adult-led activity but should motivate the child to take an active and informed role in therapy” (p. 1). For some children with articulatory difficulties, building “… conscious awareness and reflection …” of metalinguistic/metaphonological skills seems to be critical to developing a new, “subconscious” processing system (Dean et al., 1995, p. 3). The notion of building awareness where little exists is the basis of phonological awareness therapy. The evidence comparing phonological awareness and traditional therapy is mixed. Hesketh et al. (2000) found no significant difference between phonological awareness therapy and articulation training in a study of 61 preschool-aged children with phonological delay. In contrast, Powell


Multimodal approach to lisp remediation

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et al. (1998) found that, compared with conceptual treatment, motoric therapy was more effective overall in treating /s/ in children. However, for those children who already had /s/ in their phonetic inventory prior to the study, conceptual therapy resulted in better generalization. This link between conceptual or awareness treatments and generalization is important for speakers with residual errors because many of them would have already had years of unsuccessful or partially successful traditional treatment, with occasional accurate productions. One aspect of metalinguistic awareness training that has only rarely been explored as an intervention strategy involves a focus on “AS” (Ball, Manuel, & Müller, 2004). AS is defined as an individual’s habitual oral postures (Laver, 1980) that have a general impact on the articulation of segments. Wilson (2006) evaluated AS instrumentally. He used ultrasound images and Optotrak to document inter-speech postures (the resting position between individual articulations) of 15 monolingual and bilingual Canadian English and Québecois French speakers. While there was variation within and across speakers of the two languages, the group means provided evidence supporting different ASs for the two languages in tongue tip height, lip protrusion and narrowing. AS may affect individual segments in different ways. For instance, some segments may be susceptible to the parameters of a person’s AS and, therefore, show mismatches with the ambient language target(s) (Laver, 1980); thus, someone who has a more forward tongue resting position may produce alveolar targets with notable dentalization or as interdentals. The general AS may need to be reversed in order to enable accurate production of the target segment (Laver, 1980). Alternatively, AS may be redundant for the performance of a given segment; for someone with a forward AS, the AS would be redundant for interdental fricatives. Ball et al. (2004) addressed the atypical AS of a child aged 3;10, who had severely unintelligible speech and minimal change after traditional articulatory drills. The authors determined through videofluorography that the child was overusing the velum and tongue dorsum during speech production (Ball et al., 2004, p. 156). The child could produce a limited number of high frequency words with labial and alveolar nasals and a palatal glide correctly (e.g. “yeah”, “no”), and thus a purely motoric explanation seemed unlikely. Their remediation approach did not directly instruct the participant about AS awareness but was informed by the necessity of redefining his AS in order to remediate the speech sound errors. In the intervention study reported in Ball et al. (2004), the researchers engaged in natural playbased oral-motor exercises to increase velar coordination (blowing balloons), raising awareness through intense modeling of correct articulations of both their own speech and the child’s spontaneous unintelligible utterances. As the child’s ability increased to approximations of single words, the clinicians requested that the child should repeat spontaneous utterances, modeled the client’s spontaneous utterances with additional words, moved onto different phonemes and increased the level of abstraction in play. After a 6-month period of naturalistic modeling and play-based exercises, the child was more intelligible and was able to be discharged successfully with ageappropriate speech, except for /s/-clusters. The authors concluded that, for speakers with highly unintelligible speech, it is necessary to have an exact description of how the client is producing speech through direct or indirect imaging techniques in order to address the underlying issues/AS. They further suggest that meaningful, contextually based therapy is essential for carry-over of goals into spontaneous speech. Instrumental visual biofeedback Another adjunct to traditional therapy in recent years has been the utilization of instrumental visual biofeedback. Instruments can provide information on- or off-line to the speaker about speech acoustics (spectrograms), tongue shapes, movements or positions (ultrasound, videofluorography as above) or tongue–palate contacts (electropalatography). For example, Shuster et al. (1995) treated


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2 children aged 10 and 14 years with residual /r/ errors using biofeedback from real-time spectrography. Both participants correctly produced /r/ by the conclusion of the study. Ertmer and Maki (2000) studied the use of spectrograms as articulatory feedback for children, adolescents and adults who are deaf or hard of hearing as a complement to non-instrumental speech articulation training. They found that adolescents who are deaf benefited from both non-instrumental instruction and spectrographic feedback in learning and maintaining new speech sounds. Furthermore, independent practice by adolescents using spectrographic displays resulted in better maintenance of performance at follow-up. Technologies such as electropalatography and ultrasound have also been shown to help at least some children and adolescents with persistent errors achieve more intelligible, typical speech patterns (Adler-Bock, Bernhardt, Gick, & Bacsfalvi, 2007; Bernhardt, Gick, Bacsfalvi, & Ashdown, 2003; Bernhardt et al., 2005; Gibbon & Wood, 2010; Modha, Bernhardt, Church, & Bacsfalvi, 2008). The technologies are used to model the accurate tongue position and movements for participants and to give feedback on their own attempts. The research question: AS as a component of a remediation approach for a frontal lisp? This intervention case study sought to determine whether several alternative approaches could complement traditional therapy to help an adolescent with a residual lisp and frontal AS acquire more accurate alveolar fricative and post-alveolar affricate production. One of the main goals of the intervention was to shift the participant’s “frontal” AS to facilitate correct placement of alveolar fricatives and affricates. It was predicted that if he could shift his AS posteriorly, then with very little fine-tuning, he would be able to produce alveolar fricatives and post-alveolar affricates accurately. Method This single-subject two-phase case study sought to educate the participant about general concepts of speech production in phase 1 and to use the awareness acquired in phase 1 in the context of articulatory drills and increased self-monitoring during phase 2. The two phases were intended to be complementary. This approach included a consideration of and direct intervention in all aspects of the speech mechanism, including AS, respiration, voice quality and prosody. Participant The participant (P) was a 15-year old male who had previously been diagnosed with autism spectrum disorder as a preschooler. The participant’s speech and language skills at age 15 were within normal limits, except for a residual frontal lisp that was observable in dentalization of alveolar fricatives and post-alveolar affricates in over 60% of target words. The participant’s first language was English. His parents were also fluent English speakers who spoke English at home, although their first language was Mandarin. P did not speak or understand Mandarin. P had speech therapy as a preschooler with a focus on language development, rather than on phonology. He also had applied behavioral analysis therapy from age 3;6 to 6;0 years. In Grade 2, he had phonological intervention for approximately 1 year. From age 13;0 to 14;6 years, he had speech therapy sessions every 2 weeks that included oral-motor exercises, therapy focusing on a mature swallowing pattern and articulation therapy for the frontal lisp. Sessions were held every 2 weeks. The therapy ended over a year before this study began. At the commencement of the study, the participant was 15;9 and a successful grade 10 student in a regular high school program. He played piano and saxophone and was a member of the school choir and band. His speech was highly intelligible notwithstanding his residual lisp. His voice


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quality was somewhat creaky and nasalized. He expressed that he did not like the “sound” of his own voice and had experienced some teasing because of his lisp. P was able to produce accurate alveolar fricatives and post-alveolar affricates in certain contexts (e.g. /s/ in word-initial consonant clusters), which indicated that his speech difficulty was not strictly motoric, and that there was potential for further change.


Procedures A total of 11 intervention sessions occurred over two phases separated by a 10-week break. Intervention sessions were 60 min each and were held both at the university and the participant’s home with the first author, a Master of Science student in speech-language pathology and often the second author, an experienced clinician in phonological intervention and professor of speechlanguage pathology. Phase 1 of intervention consisted of 6 sessions over a period of 8 weeks. Phase 2 consisted of 5 sessions over a period of 4 weeks (Appendix 1). Homework exercises were assigned and completed following each intervention session. P was asked to provide a short written reflection on the various components of therapy, giving his perspectives. His mother attended each treatment session, but he did his homework on his own. Sessions were video-recorded with the assistance of the participant’s mother using a Aiptek HD-DV 1080P video-recorder. Phase 1. Phase 1 focused on general awareness of AS using ultrasound imagery, palatography, vocal anatomy and voice training. Direct education was provided using diagrams and models of the articulators, vocal folds, trachea, lungs and diaphragm. Voice training included exercises to relax the jaw and articulators, postural demonstrations for safe vocal use and vocal stretches used in voice training (Laukkanen, Titze, Hoffman, & Finnegan, 2008; Rammage, 1996; Titze, 2006). Voice training techniques included demonstrating and practicing abdominal breathing, co-ordinated voice onset and facial relaxation exercises. The researchers followed the workbook protocols in Rammage (1996), which include drawings and scripts written for lay people on changing habitual vocal postures. The researchers demonstrated the semi-occluded vocal tract technique to stretch the vocal folds (Laukkanen et al., 2008; Titze, 2006). This technique requires the participant to blow bubbles through a straw into a glass of water while vocalizing and changing intensity ranges or pitch ranges. A portable Sonosite 180 Plus with a Sonosite C15/4-2MHz MCX transducer ultrasound machine was used during phase 1 for less than 20 min each in the second and third sessions. The transducer was held under the speaker’s chin, either by the participant or by the researcher. As described in Bernhardt et al. (2003), “echo patterns from sound waves returning from the tongue surface were converted to moving images” (p. 206). Coronal and mid-sagittal views of the tongue shape and movement patterns were displayed on the screen of the ultrasound machine. Demonstrations of how the shape and movement of the tongue affects sound were given using ultrasound, vowel vocalizations and tongue–palate contact awareness exercises (using chocolate milk powder and mirrors to observe where the tongue made contact in the oral cavity for various speech sounds) (refer to Appendix 1). (Electropalatography was not used in this intervention.) General information was given on sound wave forms and the manner in which sound is shaped by different configurations of the vocal tract using schematic drawings and internet models (Appendix 1). The ultrasound machine was also used for diagnostic information. Ultrasound images of the participant’s attempted fricative productions indicated that the participant appeared to have adequate tongue grooving for the sibilants. The ultrasound was also used to observe P while he played his saxophone; the ultrasound showed that he was able to maintain a controlled and more posterior or central posture while playing the instrument than in speech production.


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In intervention, AS was described as the tongue’s habitual “posture” during speech. AS was equated to hand position while playing piano: the analogy that posture and muscular tension make a difference to the ease and ability to play complex pieces and to the sound of the notes played. The clinician also demonstrated changes in vowel vocalizations as she retracted her tongue. For example, an anterior /i/ sound was modeled, then prolonged while moving the tongue posteriorly. The participant was asked to make judgments about the quality of the clinician’s vowels as the AS changed. He then practiced changing his own AS for the vowels /i, u, a/, starting from his customary position for the vowel and then moving his tongue in a posterior direction while listening to and commenting on his productions. Homework assignments required the participant to observe and reflect on ultrasound images of /u/, /i/, /a/, /t/, /s/ and /ʃ/ and to practice vocal training exercises from Rammage (1996) and Titze (2006) (refer to Appendix 2 for examples of homework assignments). Phase 2. Phase 2 focused on specific target phonemes using traditional therapy hierarchies and visual–acoustic feedback for self-monitoring (i.e. real-time spectrograms). Target phonemes were introduced in isolation and in CV, VC and CVC format in each session. As soon as the participant was able to produce the sound consistently in isolation (90% of the time), the target sound was introduced in words and in phrases, as well as in consonant clusters in all positions. Word-final morphologically important /Cz/ and /Cs/ were specifically targeted. The iPod application SpectrumView™ (Oxford Wave Research Ltd., 2011) was used to provide acoustic spectrographic feedback. Consonants were targeted in the following order: /ʃ/; /z/; /s/ (in word-final /ts/ clusters and in word-initial position); word-initial /s/-clusters; word-final /z/-clusters; and /ʧ/ post-vocalically. The palato-alveolar fricative /ʃ/ was targeted first because the participant was producing /ʧ/ in word-initial position more accurately than other phonemes prior to intervention, and it was decided that the /ʃ/ could be shaped from the /ʧ/. The interdental fricatives /θ/ and /ð/ were not targeted specifically, although they were used in sessions in contrast to /s/ and /z/ on SpectrumView™ real-time spectrographic displays and in minimal pair exercises. Once the participant was able to approximate the phoneme, the researchers used SpectrumView™ to show the participant how to self-monitor his productions using a visual–acoustic display. The participant and researcher produced the sounds consecutively; hence, both could be viewed on SpectrumView™ in the same screen. The participant was not given specific frequency numbers to self-monitor; he was asked rather to look at the general frequency range of one of his own correct productions and aim for that range when practicing. Minimal pairs were used in most sessions to contrast the difference in meaning between words that only differed by one phoneme. For example, the researcher gave the participant a list of seven pairs of word-initial /s/ and /t/ minimal pairs (e.g. “sigh” vs. “tie”) and the participant was asked to say them all in whatever order he chose, with the researcher writing down what she heard him say. The principles covered in phase 1 were re-introduced in summary form as they were relevant to the specific target in phase 2 (e.g. P was asked to “try it with your tongue further back”). These principles included adequate postural and respiratory support, a posterior tongue position and relaxed orofacial musculature. The researchers included more than one target in each therapy session (except for session 7), with the second target generally a repeated target from the previous session. Homework assignments in phase 2 included massed practice of phonemes in isolation, within words and sentences. Homework included more complex word forms and high frequency, salient words that were difficult for the participant to produce without a lisp (e.g. “is”, “she”, “six”) in the context of scripted and self-generated sentences to foster generalization and carry-over. The participant reported that he spent approximately 10 min a day on homework. In each of the final three sessions, the participant and researcher held 2-min timed mock interviews at the beginning and middle or end of the session. P was asked to focus on three strategies:


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“keep your tongue back; slow down; and grade yourself out of 10 at the end”. After P gave himself a grade, he was asked to justify his evaluation (i.e. “why was that an 8 out of 10?”), which was followed by the researchers’ feedback. At the conclusion of phase 2, the participant was given a sheet with maintenance suggestions (Appendix 3).


Data analysis Speech assessments were conducted 3 weeks prior to phase 1, and immediately before phase 2 (the delay in this assessment was due to the logistics of winter vacations and the participant’s school commitments) and 1 week after phase 2 ended. A follow-up assessment was conducted 4 months after phase 2. Assessment included: (a) a picture-stimuli elicitation list of 76 words that included words from the Computerized Articulation and Phonology Evaluation System (CAPES: Masterson & Bernhardt, 2001) with additional words so that a greater number of target phonemes were represented; (b) a reading passage (“The Grandfather Passage”, [Hall & Mueller, 1998]), with the phrase “smoke less” omitted (because the participant was an adolescent and the researchers did not want to include references to smoking); (c) a 5-min interview; (d) participant-generated sentences with target words; and (e) insertion of target words in carrier phrases (“I want a ____”; “I see a _____”; “I choose a ______”; “I wish I had a ______”). The first author transcribed the target words in all four assessments phonetically (pre-intervention, post-phase 1, post-phase 2 and follow-up: narrow transcription). Another speech-language pathology student transcribed 10% of samples randomly selected from the various assessments. Inter-rater reliability for the specific targets /s, z, ʃ, ʧ, ʤ, θ and ð/ was 86%. There was no formal assessment of voice quality. Descriptions of observed changes in voice quality were subjective. Results The following consonants were evaluated across assessment points: /s/, /z/, /ʃ/, /ʒ/, /ʧ/, /ʤ/, /θ/ and /ð/ because all were produced inaccurately in at least one context pre-treatment (Table 1). Baseline assessment Table 1 summarizes the match and mismatch patterns of the pre-intervention single-word picturestimuli assessment. Phonemes are categorized by word position and whether they became targets of treatment in the intervention study. The proportion of accurate productions is summarized in the columns that indicate matches, in addition to notation of the types of substitutions. As can be observed in Table 1, the participant dentalized/degrooved most tokens of /s/, /z/, /ʃ/ and /ʧ/ (with a total of 17 accurate productions out of 82 possible productions). The participant was relatively more accurate at producing word-initial /s/ clusters (/spr/, /skw/ and /st/) and some instances of word-initial /ʃ/ and /ʧ/. Word-final /s/ and /z/ were sometimes omitted when occurring as the final segment in a cluster (e.g. plurals), especially in spontaneous speech. Word-medial and word-final /ʧ/ and /ʃ/ were frequently preceded by an epenthetic /ʔ/. The interdental fricatives /θ/ and /ð/ were frequently produced accurately, but in certain contexts, were produced as dentalized alveolar fricatives, for example, “thousand” [ˈθaʊznd] was produced as [ˈs̪oʊz̪n̩d] and “soothing” [ˈsuðĩŋ] was produced as [ˈs̪uz̪ə˜ŋ]. Notwithstanding the participant’s noticeable frontal lisp, his speech was intelligible. Post-phase 1/pre-phase 2 results The participant’s production of fricatives and affricates changed minimally between the pre-intervention and post-phase 1 assessments. Before intervention, the participant inserted a /ʔ/ before

Word-initial Tx/non Tx

Non-Tx

Intervocalic

Word-final

Consonants

Matches

Subst.

Matches

Subst.

Matches

Subst.

/s/ /z/ /ʃ/ /ʧ/ /sC(C)/ /(C)Cs/ /(C)Cz/ /ʒ/ /ʤ/ /ð/ /θ/

1/8 0/4 4/5 4/5 5/7

θ, s̪ ð, z̪ ʧ ʃ̪ s̪

0/5 0/5 1/2 0/5 1/2

θ, s̪ ð, z̪ ʔʃ ʧ̪, ʔʧ̪ s̪

0/7 1/14 0/3 0/4

θ, s̪ ð ʔʃ, ʃ ̪ ʔʧ̪, ʔʧ

0/3 0/5 0/1 2/3 n.a. 2/2

θ, s̪ ð, z̪ ʤ ʤ̪

4/4 1/1 2/3

s̪

0/2 1/3 1/2

Note: Singleton and clusters were targeted in treatment. Subst., substitution; n.a., not elicited.

ʤ̪ Z S

Total Match 1/20 1/23 5/10 4/14 6/9 0/3 0/3 0/1 6/9 2/4 5/7



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Table 1. The participant’s treatment (Tx) and non-treatment (non-Tx) test consonants at pre-treatment assessment based on picture-stimuli single-word targets.



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Figure 1. Type of mismatches in picture-stimuli single-word assessments pre-intervention, post-phase 1 and post-phase 2.

word-medial and word-final /ʧ/ and /ʃ/. After phase 1, this pattern did not appear in the sample. However, the extent to which P dentalized these phonemes increased a concomitant amount. There was perceptible improvement in the participant’s voice quality when he attempted a “back” AS following phase 1. His voice was subjectively judged to be less creaky and his resonance less hypernasal at times. Figure 1 describes the extent to which specific error patterns occurred in productions of single words pre-intervention, post-phase 1 and post-phase 2. The notable difference between pre-intervention assessment and post-phase 1 assessment was the reduction in /ʔ/ epenthesis. Reductions in dentalization and assimilation (interdental to alveolar placement) occurred following phase 2, while increased jaw tension was occasionally noted post-phase 2 (in less than 10% of productions). Post-phase 2 results The participant improved his productions of fricatives and affricates notably after phase 2, achieving 95% or better correct productions in the post-treatment assessment. He had also almost entirely eliminated his frontal lisp in a single-word picture-naming task, although he did have visible tension in his jaw for approximately 7% of targets (4 of 76 words), which was not previously present. To measure generalization, an additional 49 picture stimuli that had not been previously assessed or treated were presented in the post-phase 2 assessment and the participant achieved 48 correct productions (98% match to target fricatives and affricates). P matched 97% of target phonemes on reading “The Grandfather Passage” and matched 89% of target phonemes on the previously untested reading “The North Wind and the Sun” (International Phonetic Association, 1999). He matched over 90% of target phonemes during an unscripted interview. Figure 2 illustrates the improvement in accuracy in all types of assessment post-phase 2 by showing the percentage of targets matched by the type of assessment task. The gains in accuracy were substantially maintained during follow-up in all three types of assessment administered (picture stimuli, Grandfather reading passage and interview). Follow-up assessment 4 months later The follow-up assessment included 76 picture stimuli, “The Grandfather Passage” and a short interview. P matched 86% of targets for picture stimuli, 93.75% of targets in “The Grandfather Passage” and 85.9% of targets in the interview. Subjectively, P’s voice quality was qualitatively observed to


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Figure 2. Percentage of fricatives and affricates matched by assessment task pre-intervention, post-phase 1, post-phase 2 and at 4-month follow-up.

be “deeper”, less creaky and less hypernasal during the follow-up. Table 2 displays the number of matching phonemes for the picture-stimuli single-word targets at the four assessment points (pre-intervention, post-phase 1, post-phase 2 and 4-month follow-up). As illustrated, generalization to nontreatment phonemes appears to have occurred following phase 2 although non-treatment phonemes were more accurate before the intervention commenced. Qualitative observations The participant appeared to have acquired at least some knowledge of general principles of speech production during phase 1 that he retained until at least the beginning of phase 2. This was determined using a written true–false questionnaire about the concepts covered in phase 1, which was administered immediately before phase 2 began (Appendix 4). About 12 out of 13 true–false questions were answered correctly. In both phases, but especially in phase 2, P asked questions about less direct speech production issues, such as prosody or jaw tension, including questioning why jaw tension was important and whether he was engaging in appropriate prosody. Table 2. The number of matched tokens for picture-stimuli single-word targets at pre-phase 1, pre-phase 2, post-phase 2 and 4month follow-up assessments. Tx/non Tx

Non-Tx

∗

Consonants

Pre-phase 1

Pre-phase 2

Post-phase 2

4-month follow-up

Total targets∗

/s/ /z/ /ʃ/ /ʧ/ Word-initial /sC(C)/ Word-final /(C)Cs/ Word-final /(C)Cz/ /ʒ/ /ʤ/ /ð/ /θ/

1 1 5 4 5 0 0 0 6 1 5

5 6 7 8 5 2 0 1 5 1 6

20 17 11 13 7 3 6 1 8 4 7

19 18 6 11 7 3 4 1 8 3 7

20 20 11 14 7 3 6 1 9 4 7

Some words had more than one target token (e.g. “thousand”).


Multimodal approach to lisp remediation 11 The extent to which the participant was receptive to self-monitoring changed notably over the course of intervention. For much of phase 1 and the beginning of phase 2, the participant was reluctant to monitor his own productions, saying he did not like listening to recordings of his speech. However, by the final four sessions of phase 2, the participant was actively self-monitoring his own productions as evidenced by self-correction. The extent to which the participant’s awareness changed was difficult to quantify but was observable both in reference to his self-initiated corrections and his comments about his speech. Before phase 2 commenced, the participant rarely self-corrected. By the final two sessions of phase 2 intervention, the participant was initiating corrections of the relatively few inaccurate articulations he did make. There was a pivotal therapeutic breakthrough in the second session of phase 2 that may have contributed to the participant’s change in perspective. During the session, the participant articulated a scripted sentence, while focusing on moving his tongue position back, which resulted in a dramatic change in his voice to a lower more appropriate pitch, with greater resonance and no lisp. The participant chose not to attempt this technique again in that session, but in subsequent sessions was willing to self-monitor and accepted the need to alter his overall AS. For example, in session following this “breakthrough”, the participant was actively monitoring his tongue position without prompting. He commented: “I thought my tongue was sticking out a bit” and “Yah, I was trying to keep my tongue back”. In the final session, the participant was problem-solving why he lisped on one word, stating: “I was moving too fast to be aware of the “s” sound”. In a written reflection on what had occurred in the session, he wrote: “…. I’m more self-aware about keeping my tongue back”. In the 4-month follow-up assessment, P commented that after the conclusion of intervention, he did not “practice per se”, but was constantly aware of his speech sounds. He reported: “I don’t have to think about where my tongue goes now” and that this was at the “almost sub-conscious” level. His mother reported that she sometimes asked him to “say it again”, but P stated that this was “occasional”. Discussion The difference between the participant’s speech before and after phase 2 intervention was marked. At the post-phase 2 assessment, the participant was able to maintain approximately 90% matches to target fricatives and affricates in several different tasks. He and his mother reported that he was self-monitoring his speech at home. When he focused on his speech, he was able to speak without lisping, something he could not do before intervention. His voice quality had improved with reduced creakiness and nasality. Inherent to the overall success of treatment was the ability to determine the nature of the participant’s AS (Ball et al., 2004). The use of imaging techniques allowed the researchers to determine what was and was not affecting the client’s atypical speech. Macro video-recording of P’s lower face permitted researchers to determine that the client’s tongue tip was frequently extending in front of his teeth during all speech. Ultrasound imaging allowed the researchers to visualize that the client had sufficient tongue grooving for the production of fricatives. This initial assessment of the client’s AS permitted the researchers to focus therapy approaches on the underlying cause of the lisp. Researchers did not do any therapy geared towards tongue grooving. The participant’s use of the ultrasound machine demonstrated that he was capable of controlling his tongue movement and keeping his tongue further “back” at least when he was playing his saxophone. The knowledge and visual “evidence” that he could control his tongue movement appeared to boost his confidence. The research design involved several different types of intervention. There are several possible explanations for the changes that occurred: (1) treatment effect, (2) maturation, (3) one or both of the phases of intervention.

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Treatment effect P was highly intelligent, motivated, committed to and invested in the research process. It is therefore possible that his success was due to a general treatment effect, rather than the interventions (Adair, 1984). There are several reasons why this is likely not the case. The participant had relatively stable performance on assessments before and after phase 1. Although not intended as such, phase 1 may be seen as a type of a within-subject control intervention, in which P’s lisp did not improve as a result of intervention alone. As well, this participant had previously had unsuccessful direct and indirect therapies to remediate his lisp: swallowing therapy to correct his posterior to anterior swallowing pattern and direct phonological intervention. Maturation effect It is also unlikely that the observed change was the result of maturation, because, before the research commenced, the participant’s speech had been stable for several years. Evidence from Johnson et al. (2001) indicates that following the age of normalization (8–9 years of age), speech sound errors rarely improve spontaneously and are in fact “resistant to change” (Johnson et al., 2001; Preston & Edwards, 2009; Veríssimo et al., 2012). The participant’s age may have played a role in that he had greater cognitive maturity to understand and apply speech production and acoustic training in order to increase his metalinguistic awareness. He was also possibly more motivated to change his speech patterns in his mid-teens, because of internal issues of self-esteem and external pressures from social groups. One or both of the phases of intervention were effective On the basis of the data alone, it is tempting to conclude that the intervention delivered in phase 2 was the cause of the observed change and that phase 1 was ineffective. However, there is a strong argument that some parts of phase 1 intervention were an important basis for the intervention offered in phase 2. Phase 1 involved education and exercises aimed at enhancing the participant’s understanding of the speech production process without which the participant would have been essentially in the same position he was in when he received direct intervention for his lisp several years earlier. One of the goals of the research was to see whether multi-modal interventions would have had a better result than only one type of intervention. The two phases were intended to be complementary and multiple treatments were attempted in each phase. Homework was assigned in the break between phases. P reported that he completed homework exercises and he showed improvement in targets from one session to the next in phase 2. The speed with which change occurred in phase 2 lends some support to the notion that P benefited from the knowledge that he had acquired in phase 1, perhaps as a type of “priming” for the more direct intervention of phase 2. The stability of the change post-phase 2, as evidenced by the 4-month follow-up assessment, during which interval P reported that he did not practice, but was constantly “aware” of his speech sounds lends support to the notion that awareness training played a role in maintenance. The most noticeable reduction in the participant’s lisp occurred after traditional training with visual–acoustic feedback, a change which occurred in only five 60-min sessions over a 4-week period. While there are no studies that specifically enumerate average treatment times, Shriberg et al. (1994) found that for elementary school-aged children with phonological delays over a year long period, over 50% received direct intervention services for 6 months or longer. The study did not specify the average number of sessions or actual treatment time over this period. However, the 11 sessions provided in this intervention study is likely within the low range of


Multimodal approach to lisp remediation 13 services typically received by children or adolescents with this type of persistent frontal lisp and it would seem that the difference in success might be attributable to the inclusion of awareness building in phase 1. Notwithstanding the lack of progress in phase 1, there is a theoretical basis and evidence to suggest that metalinguistic awareness training can from the basis for subsequent lasting change in direct therapy for younger children (Dean et al., 1995; Hesketh et al., 2000). Concepts that were covered in phase 1, which were aimed at increasing awareness, were reinforced during phase 2. The use of real-time spectrographic displays through SpectrumView™ monitoring was predicated upon an understanding of acoustic principles that were learned in phase 1. Visual–acoustic feedback allowed P to practice phonemes independently and may have served as a facilitator for P’s ability to self-monitor through auditory channels. The rate of improvement in accuracy in phase 2 suggests that visual–acoustic feedback through online spectrograms had a greater impact than the use of ultrasound images. However, the order in which interventions were presented is a confounding factor: P already had the knowledge acquired in phase 1 when he made gains using different technology in phase 2. The notion of AS as a habitual posture that could be manipulated appeared to be important to the overall success of the interventions. At times, during phase 2 interventions, P was asked to “keep your tongue back” before attempting a phrase. During these “experiments”, there was no focus on individual sounds and the participant was able to eliminate his frontal lisp and change his voice quality by moving his tongue position posteriorly. A major turning point occurred when the participant attempted to keep his tongue back and heard his speech become lisp-free and his voice become deeper and highly resonant. This brief change in AS was based on perceptual judgments by both researchers in the session. Over the course of the study, P’s move towards a more posterior AS was evident from the extent to which P’s tongue protruded anterior to his teeth and lips. P’s tongue position was visually evident on video-recordings from pre-intervention and phase 1 sessions – his tongue protruded anterior to his teeth and lips during speech. Following phase 2, his tongue did not protrude to the same degree. AS was incorporated in the timed interviews in phase 2, when one of the three instructions given was “keep your tongue back”. These interviews accorded with Ball et al.’s (2004) emphasis on the importance of naturalistic, meaning-based approaches to therapy for enhancing carry-over to spontaneous speech production. The focus on slower rate of speech, keeping his tongue back and selfevaluating was an important means of demonstrating how he could try these strategies outside of the intervention sessions in order to produce lisp-free speech. Another important factor was that the participant played an active role in the process of remediation. On several occasions, the researchers adjusted the task or expectations in response to the participant’s reluctance to attempt the original task or as a result of suggestions as to what types of activities would be more natural for him. Approximately half of the sessions were held at the participant’s home, a more natural environment than the university clinic. The inclusion of phonological awareness exercises such as minimal pair contrast drills was useful to increase the participant’s understanding of the importance of place of articulation to meaning. This concurs with Ball et al.’s (2004) hypothesis that articulation errors may have become a part of the child’s phonological system. The remediation of the participant’s phonological judgments of his own productions was important for generalization to occur. Evidence that this did occur appeared in the participant’s qualitative statements during the 4-month follow-up assessment that, after intervention, he was aware of his speech, but that it was now “almost sub-conscious”. While he was redefining his AS, the participant’s rate of speech seemed to have an effect on the accuracy of his fricatives during phase 2. For example, “The Grandfather Passage” had 64 target phonemes (including /θ/ and /ð/). In pre-treatment and post-phase-1 assessments, the participant

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matched fewer than 50% of the target phonemes and read the passage relatively quickly (between 158 and 176 words per minute). In contrast, in the post-phase 2 assessment, the participant matched 97% of the target phonemes with a speech rate of 141 words per minute. However, during the 4-month follow-up, P matched 93.75% of target phonemes at a speech rate of 168 words per minute, indicating that he was able to maintain accuracy while increasing his speech rate to his previous typical level. The strategy of using slower speech may have helped him “reset” his default, and was subsequently abandoned without significant detriment to accuracy.

Conclusions This case study attempted to demonstrate that multi-modal alternative approaches to intervention have potential for remediating a residual frontal lisp. The goal of the intervention was to increase the participant’s awareness of the vocal mechanism and to give him the tools to self-monitor and self-correct his speech sounds. Awareness and AS training did not remediate the participant’s frontal lisp after phase 1. However, the rapid change in the participant’s production of alveolar fricatives and post-alveolar affricates in phase 2 was likely facilitated by his willingness to consciously adjust his articulatory posture and his greater depth of knowledge of the speech process. The participant’s ability to maintain change following intervention through heightened awareness highlights the potential importance of metalinguistic change for lasting remediation. Further research needs to be conducted to determine the efficacy of alternative, multi-modal approaches to remediating residual errors and into the viability of introducing AS awareness training into therapy for adolescents and adults, as well as younger children. Utilizing these alternative techniques may provide for an effective and efficient means of delivering services.

Acknowledgements The authors thank the participant and his family, Bryan Gick, Penelope Bacsfalvi, Shelagh Davies, Linda Rammage, Haley Tsui and the anonymous reviewers who provided insightful comments on drafts of this article. Declaration of Interest: The second author is a co-author of the test used for elicitation of single words, that is, the Computerized Articulation and Phonology Evaluation System (CAPES, Masterson & Bernhardt, 2001).

References Adair, J. G. (1984). The Hawthorne effect: A reconsideration of the methodological artifact. Journal of Applied Psychology, 69(2), 334–345. Adler-Bock, M., Bernhardt, B. M., Gick, B., & Bacsfalvi, P. (2007). The use of ultrasound in remediation of North American English /r/ in 2 adolescents. American Journal of Speech-Language Pathology, 16, 128–139. Baker, E. (2010). Minimal pair intervention. In A. L. Williams, S. McLeod, & R. J. McCauley (Eds.), Interventions for speech sound disorders in children (pp. 41–72). Baltimore, MD: Paul H. Brookes. Ball, M., Manuel, R., & Müller, N. (2004). An atypical articulatory setting as learned behaviour: A videofluorographic study. Child Language Teaching and Therapy, 20(2), 153–162. Bernhardt, B., & Major, E. (2005). Speech, language and literacy skills three years later: A follow-up study of early phonological and metaphonological intervention. International Journal of Language & Communication Disorders, 40(1), 1–27. Bernhardt, B. M., Gick, B., Bacsfalvi, P., & Adler-Bock, M. (2005). Ultrasound in speech therapy with adolescents and adults. Clinical Linguistics and Phonetics, 19(6/7), 605–617. Bernhardt, B. M., 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 and Phonetics, 17(3), 199–216.


Multimodal approach to lisp remediation 15 Cleland, J., Gibbon, F. E., Peppe, S. J. E., O’hare, A., & Rutherford, M. (2010). Phonetic and phonological errors in children with high functioning autism and Asperger syndrome. International Journal of Speech-Language Pathology, 12(1), 69–76. Dagenais, P. A., Critz-Crosby, P., & Adams, J. B. (1994). Defining and remediating persistent lateral lisps in children using electropalatography: Preliminary findings. American Journal of Speech-Language Pathology, 3, 67–76. Dean, E. C., Howell, J., Waters, D., & Reid, J. (1995). Metaphon: A metalinguistic approach to the treatment of phonological disorder in children. Clinical Linguistics and Phonetics, 9(1), 1–19. Ertmer, D. J., & Maki, J. E. (2000). A comparison of speech training methods with deaf adolescents: Spectrographic versus non-instrumental instruction. Journal of Speech, Language and Hearing Research, 43, 1509–1523. Gibbon, F. E., & Wood, S. E. (2010). Visual feedback therapy with electropalatography. In A. L. Williams, S. McLeod, & R. J. McCauley (Eds.), Interventions for speech sound disorders in children (pp. 509–536). Baltimore, MD: Paul H. Brookes. Hall, J. W., & Mueller, G. (1998). Audiologists’ desk reference. San Diego, CA: Singular Publishing. Hesketh, A., Adams, C., Nightingale, C., & Hall, R. (2000). Phonological awareness therapy and articulatory training approaches for children with phonological disorders: A comparative outcome study. International Journal of Language and Communication Disorders, 35(3), 337–354. International Phonetic Association (1999). International phonetic association handbook. Cambridge: Cambridge University Press. Johnson, C. J., Beitchman, J. H., Young, A., Escobar, M., Atkinson, L., Wilson, B., Brownlie, E. B., Douglas, L., Taback, N., Lam, I., & Wang, M. (2001). Fourteen-year follow-up of children with and without speech/language impairments: Speech/ language stability and outcomes. Journal of Speech, Language, and Hearing Research, 42, 744–760. Laukkanen, A., Titze, I. R., Hoffman, H., & Finnegan, E. (2008). Effects of a semi-occluded vocal tract on laryngeal muscle activity and glottal adduction in a single female subject. Folia Phoniatrics and Logopedics, 60, 298–311. Laver, J. (1980). The phonetic description of voice quality. Cambridge: Cambridge University Press. Masterson, J., & Bernhardt, B. (2001). Computerized articulation and phonology evaluation system. San Antonio, TX: The Psychological Corporation. McLeod, S., & Singh, S. (2009). Speech sounds: A pictorial guide to typical and atypical speech. San Diego, CA: Plural Publishing. Modha, G., Bernhardt, B. M., Church, R., & Bacsfalvi, P. (2008). Case study using ultrasound to treat /ɹ/. International Journal of Language and Communication Disorders, 43(3), 323–329. Oxford Wave Research Ltd. (2011). SpectrumView (Version 1.0) [Mobile application software]. Retrieved February 1, 2012, from http://itunes.apple.com/ Powell, T. W., Elbert, M., Miccio, A. W., Strike-Roussos, C., & Brasseur, J. (1998). Facilitating [s] production in young children: An experimental evaluation of motoric and conceptual treatment approaches. Clinical Linguistics and Phonetics, 12 (2), 127–146. Preston, J. L., & Edwards, M. L. (2009). Speed and accuracy of rapid speech output by adolescents with residual speech sound errors including rhotics. Clinical Linguistics and Phonetics, 23(4), 301–318. Rammage, L. (1996). Vocalizing with ease: A self-improvement guide. Vancouver, BC: Broadway Printers. Ruscello, D. M. (2003). Residual phonological errors. In R. Kent (Ed.), Encyclopedia of communication disorders (pp. 156–158). Boston: MIT Press. Shriberg, L. D., Kwiatkowski, J., & Gruber, F. A. (1994). Developmental phonological disorders. II. Short-term speech-sound normalization. Journal of Speech and Hearing Research, 37(5), 1127–1150. Shuster, L. I., Ruscello, D. M., & Toth, A. (1995). The use of visual feedback to elicit correct /r/. American Journal of SpeechLanguage Pathology, 4, 37–44. Titze, I. (2006). Voice training and therapy with a semi-occluded vocal tract: Rationale and scientific underpinnings. Journal of Speech, Language and Hearing Research, 49(2), 448–459. Van Borsel, J., Van Rentergem, S., & Verhaeghe, L. (2007). The prevalence of lisping in young adults. Journal of Communication Disorders, 40, 493–502. Veríssimo, A., Van Borsel, J., & de Britto Pereira, M. (2012). Residual /s/ and /r/ distortions: The perspective of the speaker. International Journal of Speech-Language Pathology, 14(2), 183–186. Wilson, I. L. (2006). Articulatory settings of French and English monolingual and bilingual speakers (Unpublished doctoral dissertation, University of British Columbia). Retrieved August 16, 2011, from https://circle.ubc.ca/

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Appendix 1. Treatment session summaries Phase 1

Meta-awareness of articulation and AS

Session 1

AS and vocal anatomy (ultrasound videos and model of the tongue demonstration); diagrams of vocal anatomy with source/filter theory explained; videos of people using different accents Motor practice with vowel vocalizations: demonstrating /a, i, u/ while moving tongue “back” and observing how and when the sound changes Demonstrating difference between /t/ and /ʈ/ Client uses ultrasound while playing saxophone Vocal training exercises: Rammage (1996, pp. 57–60) Vocal training exercises: Rammage (1996, pp. 61–67) Using ultrasound, experiment with anterior to posterior tongue movement while vocalizing the vowels /a, i, u/; also using /ta, ti, tu/ to show tongue position for alveolar stop; participant to make judgments about when sound changes while clinician demonstrates (only focused on AS, not specific speech sounds per se). Rammage (1996, pp. 68–71) Partially occluded vocal tract exercises (Titze, 2006) Tongue–palate awareness exercises (“chocolate palatograms”) using chocolate drink powder and mirrors to observe tongue–palate contact for /t, s, ʃ, i/ Rammage (1996, pp. 64–67) Partially occluded vocal tract exercises (Titze, 2006) Review different diagrams of tongue–palate contact for /s, t, ʃ, i/ (McLeod & Singh, 2009). Make a plasticine model of the tongue Partially occluded vocal tract exercises (Titze, 2006) Modified palatography using chocolate drink powder and mirrors, look at tongue–palate contact for /t, s, ʃ, i/; draw diagrams of tongue–palate contact


2 3

4

5

6

Phase 2

Direct articulatory therapy with emphasis on self-monitoring in naturalistic speech to promote generalization

7

/ʃ/ in isolation; using tongue depressor to hold tongue back; /ʃ/ in word and non-word single syllables with back consonants (e.g. “ash”, “cash”, “gash”, “osh”, “cosh”, “gosh”, “she”, “shell”, “shack”, “shag”) /z/ in isolation, then compare with minimal contrast /ð/ word pairs Word-initial and word-final /ʃ/ words in context “I like the _____ one”; “I wish I had (a) _____” Client initiated /ʃ/ word list: “should”, “shut” /s/ in word-final context: C1V1t, C1V1ts, C1V1s Scripted sentences with “eats”, “miss” Minimal pair contrast (word-initial /s/ vs. /t/ – for example, the participant was asked to say one of “see” or “tea” and the researcher had to guess which one was stated) Make up a sentence with words containing /ʃ/, /z/ Barrier guessing game with /ʃ/ vs. /ʧ/ minimal pairs (A barrier is put between the clinician and client and they each try to guess what the other said.) 2-Minute timed conversations with instructions: “tongue back; speak slower; grade yourself out of 10” Review /s/ clusters /s/ vs. /t/ minimal pairs guessing game Make up sentences using /s/ word list CVCz word list to practice plurals and morphological word endings 2-Minute timed conversations with instructions /s/; Word-final /t/, /ts/, /s/ and /st/ using lists of contrasting words (e.g. “get, gets, guess, guest”) Word-initial /st/ using list of single words only /ʧ/ without preceding /ʔ/ 2-Minute timed conversations with instructions Scripted sentences with multiple embedded targets

8

9

10

11

Multimodal approach to lisp remediation 17 Appendix 2. Examples of homework assignments in phase 1 Session 1 – Things to do during the week (1) Look at the ultrasounds for vowels (tense u, tense i, a) on the following website: http://www.audiospeech.ubc.ca/research/child-phonology-phonetics-and-language-acquisiton-lab/ultrasound-in-speech-training


The right side of the ultrasound image is the front of the tongue and the left side is the back of the tongue. Describe how the different tongue positions for the vowels tense u, tense i and a are similar or different for: (a) the ultrasound image; (b) the lips. Do not look at the other sounds – we will get to them eventually! (2) Practice making the vowel sounds at least four times over the week. Move your tongue (back and forward, up and down) trying to keep the sound of the vowel the same. Notice when the sound does change to something that is “really” different. If necessary, hold onto your larynx to make certain it is not doing any of the work (your larynx is your “voicebox” in your neck). (3) On Youtube, look up people speaking different languages – do British English people have a different articulatory postures than Spanish people (pick any language to compare to English)? What about people speaking different accents of English – British vs. Canadian vs. American vs. Australian? (4) Find your favourite “voice impersonator” on Youtube to show us next time. Pay attention to how one person changes when they impersonate someone else’s voice. Websites – if you want to check them out again: http://speech.umaryland.edu/funmovies.html http://www.magic.ubc.ca/artisynth/pmwiki.php?n=Demo.CoupledJaw-Tongue-HyoidModel

Appendix 3. Maintenance instructions post-phase 2 Ideas for maintaining your new habits! (1) (2) (3) (4) (5)

Slow down Keep your tongue back Listen to yourself Use SpectrumView to check a sound if you are in doubt Practice “perfect” speech for 5 min each day

Appendix 4. Post-phase 1 quiz (1) Answer true or false: (a) (b) (c) (d) (e) (f) (g) (h) (i) ( j) (k) (l) (m)

Your tongue must be in front of your teeth to make the sound “sh”. Your tongue makes full contact with the top of your mouth for all sounds. Your “voice” comes from your larynx and the sounds it makes are determined by the shape of your tongue and lips. Ultrasound images show your tongue shape, teeth and lips. Palatography (with chocolate powder) shows where your tongue makes contact on your palate when you make one sound. Ultrasound images show the shape of your tongue, but not where it is in relation to your teeth. The sound “s” is a very quiet sound without a lot of noise. Your tongue makes a groove for the sound “s”, with the sides of your tongue holding firm against your side teeth. Respiration (breathing) is not important for speech. The sound “th” is made with your tongue almost touching your teeth. The sound “sh” is made with your tongue further back in your mouth than the sounds “s” or “th”. Your jaw is irrelevant for speech. Your tongue is made up of several muscles that help move it in many different directions.