Therapy for Residual Errors

As a child progresses through speech therapy, their speech becomes more intelligible and they become a more competent communicator. There are some speech sounds that seem to be harder for children to acquire (not just those with CAS). These sounds include /r/, /l/, /s/, and /z/. A child with CAS may have acquired motor plans for production of all but 1 or 2 sounds. Usually, their speech is mostly understood by others, but these residual errors are noticeable. A child may not acquire these last sounds until late elementary, middle or high school, or even into young adulthood.

Therapy to acquire these last sounds is similar to their previous therapy. It requires specific remediation which includes many practice trials and can be difficult, leading to frustration, and perhaps the child loses the motivation to continue trying. Other factors for being able to acquire these residual sounds include what sound is in error, any co-occurring disorders, severity of the CAS, and progress made thus far in treatment.

Even though progress is likely to be slow, incorporating different approaches at this stage may be helpful. It is hard to see what the tongue is doing in the mouth when we produce the /r/ sound. There are several types of biofeedback which provides visualization of the speech sound produced, or of tongue movements, in order to produce accurate speech movements.

One type is through computer programs or apps that listen to the speech production of a sound the child produces and provide information about how closely the production matches the target (correct) production. The information can be in the form of a game – the correct production by the child will cause the dolphin to put a ball through the hoop. Or the computer can produce visual graphs of how the production matches the target sound. The speech-language therapist (SLP) sits with the child and provides cues to help the child move their tongue correctly in order to produce the sound correctly. The picture below shows the computer screen of the lingWaves program by TheraVox for remediation of speech and voice errors.

Another type is real time ultrasound biofeedback. An ultrasound is taken while the child produces the sound so that the position of the tongue can be seen on a screen. The SLP provides verbal instruction and visual guides on where the tongue needs to be and the child can then move their tongue to match and produce the correct sound. This article has more in-depth information on ultrasound biofeedback.

The third type of biofeedback involves electropalatography (EPG) which involves use of a custom-made artificial palate molded to fit on the roof of a child’s mouth. The artificial palate has electrode sensors that send signals to a computer which then shows the tongue movements in real time based on the tongue’s contact with the sensors. Then the SLP can provide verbal instruction on where the tongue needs to move in order to produce the sound correctly. The picture below shows the LinguGraph system for electropalatography.

Each of these types of biofeedback require the SLP to be specially trained, and the equipment is very costly. There are few clinics that have the ability to provide biofeedback; however, university speech-language and hearing centers often have the capability for one or more of these options. There are evidence-based studies showing the success of these types of programs in remediating residual errors and they can be motivating for an older child/teen to use. The child will still need to have intensive therapy, but with lots of practice, the residual errors can be corrected.