Comparison of the computer–aided articulation therapy application with printed material in children with speech sound disorders

Abstract

Objectives

The aim of the present study was to develop an iPad application for computer–aided articulation therapy called the Turkish Articulation Therapy Application (TARTU), and make comparisons between the efficacy of TARTU and printed material.

Method

A single subject research design, adapted alternating treatments model, was used for this purpose. The study was carried out with 2 children, at the age of 5; 1 and 5; 11, both of whom have a speech sound disorder. The comparison between TARTU and printed material effectiveness was compared for three target sounds (/k/, /ʃ/ and /l/). 12 therapy sessions were carried out three times a week using the behavioural approach. One participant received therapy targeting the sound /k/ using TARTU, while printed material used for the sound /ʃ/. The targeted sounds were switched for the second participant. Sound /l/ was left without any intervention.

Result

The target sound met the criterion with TARTU in one participant, and with printed material in the other participant.

Conclusion

The presentation type of the materials did not play an important role in the success of the therapy on the participants.

Introduction

Speech sound disorder (SSD) is a developmental disorder which affects children's intelligibility and is characterized by articulation difficulties or phonological difficulties [1]. SSD, which constitutes a significant portion of the case–loads of speech and language therapists working with children [2], is seen among 15% of three year olds [3]. Prevalence rates of SSD, which differ between genders, is 4.5% in boys while only 3% in females [4].

In the preschool period, early diagnosis and intervention of SSD is very important considering its high prevalence rates. SSD, which is not treated in preschool years, can negatively affect academical, verbal, grammatical, occupational, social and emotional abilities [5,6]. Effective interventions will enable us to eliminate this disorder, improve children's quality of life and academical skills; such as reading and writing. For this reason, early diagnosis of SSD and choosing an effective intervention method are crucial to prevent developmental and socio–emotional problems that may arise in children [7].

Studies show that, of all the SSD intervention methods, the traditional approach [8] and behavioural approach [9] that describes place and manner of articulation are the most preferred approaches by speech and language therapists [10]. In the following section, behavioural approach, which is highly preferred by speech and language therapists in Turkey and also embraced in the current study, will be discussed.

The behavioural approach chooses a single speech sound appropriate to the developmental level of a child, divides the treatment of a speech sound into smaller steps; in isolation, in syllables, in words, in sentences, and in spontaneous speaking situations [11]. Furthermore, this approach requires great amount of drill and practice. These aspects are similar to the traditional approach [8]. However, of the two motor–based approaches, the behavioural approach differs from the traditional approach by means of reinforcement schedules and the criteria to move on to the next level. Moreover, the behavioural approach doesn't have sensory–perceptual training (ear training) unlike the traditional approach [8,9].

In SSD, regardless of participant characteristics, the factors that determine the efficacy of the intervention are i) therapy approach, ii) therapy intensity [12] and iii) presentation type of stimuli [13].

Therapy approaches used for SSD are different from each other in terms of the following procedures, goal attack strategies, and emphases (e.g. speech perception, speech production, metalinguistic skills) [14]. Given the heterogeneous nature of SSD [15,16], it is not quite possible to state that one therapy approach is more effective than the other. Because in SSD, different intervention approaches can be effective in different subgroups [2]. Gierut [17] suggested that goal of the therapy is more important than the intervention approach. Thus, the intervention approach must be carefully selected in accordance with the therapy goal.

Concerning the therapy intensity of the treatment of SSD – although it changes according to the therapeutic approach applied – sessions usually take place one or two times in a week and last 30–60 min [10,18,19]. The benefit from therapy increases with the therapy intensity [9].

Finally, the presentation of stimulus may vary according to the activities (drill, drill–play, play) and the materials. In speech and language therapies, materials are mostly obtainable in the form of photographs, illustrations or small pictures [4]. These materials can be presented in printed or computer–aided way. The way of presentation can make a difference in terms of the efficacy of the therapy.

Computer–Aided Speech Therapy (CAST) is the use of applications aided with sounds and animations unlike printed materials [19]. CAST provides an updated environment to 21st century born children. Recently, new CAST applications were developed in many languages. Among a few examples of these applications are APLo [20], OLP (Ortho–Logo–Pedia) Project [21], Vocaliza [22], Speco [23], TERAPERS [24], Telelogos [25].

Gradually, printed materials are replaced by CAST since they are incapable of handling the case–loads, inability for remote and domiciliary use and lack of standardization [26].

Making the resources and information more accessible, CAST increases client satisfaction and quality of services. Also, the interactive communication process in therapy sessions ensured by CAST strengthens the interaction between the therapist and the child [26]. Children who received CAST stated that the e–learning activities are easy to use, fun, enjoyable and motivating [27].

CAST has a positive influence on the normal or delayed speech and language skills of children [28,29]. The studies investigated the efficiency of CAST found that auditory and visual materials make speech and language therapy easier to integrate with the clients, easier to reach therapy goals, improves the emotional skills and imagination of children [24,30]. Allowing children to record and listen their own sounds enable recognition and correction of phonological errors by means of immediate auditory feedback [30]. Also, it was reported that the use of e–learning activities in preschoolers' articulation therapies increases therapy success [27].

Although there are numerous studies on the efficacy of CAST applications, very few of them focused on comparing the efficacy of printed materials with CAST applications in articulation therapy. The first studies on this subject were conducted by Shriberg and colleagues to search about the efficacy of computer assisted speech management procedure in different learning phases such as naming, stabilization, response evocation [26,31,32]. In their very first study, Shriberg and colleagues [31] investigated the efficacy of word naming activities by comparing the printed material with CAST. As a result of this study, they found that the presentation type, whether printed or computer–based, does not have an effect on the articulation performance of the participants. In their second study, Shriberg and colleagues [32] compared the effect of printed material with CAST on response stabilization stage of speech management and again did not find any significant difference. The last study of Shriberg and colleagues [26] on this subject focused on the response evocation phase while evaluating the method of presentation. As with the previous two studies, in this study they also concluded that the use of CAST or printed material does not have a significant effect on therapy success.

Another study concerning the CAST application was conducted by Wren and Roulstone [33]. They tested the efficacy of the CAST application on phonological disorder therapies. For this purpose, they compared the percentage of correct production of the target sounds on three groups who received different methods of presentation: i) printed material, ii) CAST application and iii) no therapy group. Although Wren and Roulstone did not find any significant differences between groups in terms of the method of their presentation they retained gender and stimulability as possible predictors of correct production of target sounds. Female children and the children who had a greater number of consonants produced in isolation showed significant progress in their speech output.

The most recent study about the efficacy of CAST applications was conducted by McLeod and colleagues (2017) with 123 participants [34]. In their cluster-randomized controlled study, Mcleod and colleagues aimed to evaluate the effectiveness of Phoneme Factory Sound Sorter, a computer-based intervention program used for working on input processing and phonological awareness skills of children with SSD, applied by educators. They used typical classroom activities on a control group and compared their speech production accuracy, emergent-literacy skills, phonological-processing skills and children's participation and well-being. There were no significant differences between the scores the children obtained in the computer-assisted input-based intervention and typical classroom activities. Although, they found statistically significant improvements on many skills especially in speech production and emergent-literacy, other measurements such as most of the well-being measurements were not significant over time or between groups. The authors discussed their findings by questioning the meaning of statistical, clinical, and personal significance.

To conclude, there are many factors which can affect the efficacy of CAST applications:

• The efficacy of CAST applications is directly proportional to the efficacy of the underlying therapy approach [4]. Therefore, the results of a CAST application that was developed according to a specific approach cannot be generalized.

• CAST application may target different phases of sound production. For instance, Shriberg and colleagues [24] suggested that it is more effective to use printed material at the isolated production phase of the target phoneme while CAST applications are more effective at the later phases.

• Individual differences resulting from a variety of cognitive and motivational needs can be another factor. Furthermore, variables such as age, gender and stimulability affects the accuracy of sound production [13,26,33].

• Eventually, the features of the application like ease of use, colourful interfaces, possibility of navigation by children, sound and video support can change the efficacy of CAST applications.

In the clinical decision making process, evidence–based practice is needed to guide practitioners to choose more effective methods [35].

The high prevalence rate of SSD in the preschool period, and its negative effect on daily life which may lead to isolation from social and educational environments necessitating immediate and effective intervention methods. However, families cannot reach speech and language therapy services as a result of the limited number of speech and language therapists in Turkey. The first university program which awards a degree in SLP was established in 2000 at master's level [36]. This was followed by the foundation of the first undergraduate program in 2012. Currently there are six universities which have speech and language undergraduate programs but as of today only two of them graduated students. According to Speech and Language Therapists Association 2018 records [37], only 27 cities have registered speech therapists in the whole country (i.e. 81 cities) and in some cities, there are only one or two therapists who provide services to the whole city and sometimes to the neighbouring cities. When there only less than 300 SLPs providing services to a population of over 80 million (Turkish Statistical Institute, 2018) [38], it is inevitable to search for new solutions to ameliorate long waiting lists of clients and the high therapy costs. At the moment, there are no evidence-based CAST applications compatible with Turkish phonetics and phonotactics available for SSD therapies. Although speech and language therapists attempt to adapt many foreign–based applications to overcome the aforementioned problems, they could not succeed due to the language difference.

The aim of this study was to develop a Turkish Articulation Therapy Application (TARTU) compatible with Turkish phonetics and phonotactics based on the behavioural approach, and make comparison between the efficacy of this application and printed material. In accordance with the results of the current study, the material developed with the efficient way of presentation will be released either in the form of an application for tablets/mobile devices or as books/cards. Thus, SLPs will be able to integrate a systematic approach to their therapies through this effective material.