1. Treating /r/ Distortions Using a Combined Approach of Visual Spectrographic Feedback, Articulation Therapy, and Oral Motor Awareness
By: Leigha Graham
Faculty Chairs: Dr. Rebecca Throneburg Mrs. Beth Bergstrom

2. Background Why is the /r/ phoneme difficult to remediate?
Involves different parts of the tongue that are not easy to see and describe
Tongue placement varies depending on the type of /r/ (e.g., consonantal or vocalic)
Coarticulation: Surrounding phonemes have an affect on how /r/ sounds and how /r/ is produced
The /r/ phoneme is difficult for speech-language pathologists to remediate due the involvement of different parts of the tongue that are not easy to see and describe.
There are also varying positions the tongue can be in when producing words containing /r/.
The surrounding phonemes will also have an affect on how /r/ is produced and how /r/ sounds.

3. Two Ways to Produce /r/ Retroflex Bunched
There are two ways to produce /r/: Retroflexed, which is also known as tip-up /r/, and bunched, which is also known as back /r/.
When producing the retroflex /r/, the tip of the tongue is raised and curled upward near the alveolar ridge, with minimal lip rounding. The body of the tongue is also slightly raised near the hard palate.
When producing /r/ using the bunched approach, the body of the tongue also approximates the hard palate while the lateral sides of the tongue touch the back upper molars and the tip of the tongue is in a downward position.

4. Traditional Therapy Approaches for /r/
Discrimination
Facilitating Contexts
Progressive Approximation/Sound Modification
Shriberg (1975) 8-step /l/ to /r/ program
Phonetic Placement Training/Moto-kinesthetic Stimulation
Marshalla (2004, 2007) and Shriberg (1980) bite stick/stabilize jaw to assist /r/ establishment
To facilitate correct productions of /r/, SLPs often rely on using traditional therapy approaches such as auditory discrimination, use of facilitating contexts, phonetic placement training, moto-kinesthetic stimulation, progressive approximation, and sound modification.
Shriberg (1975) developed an eight-step program for eliciting /r/ that involved successive approximation and not mentioning to the child that /r/ is the target.
Marshalla and Shriberg suggested using a bite block to stabilize the jaw because it may be helpful to assist in establishing /r/ production.
Both Marshalla and Shriberg’s suggestions and intervention programs were included in the intervention for this study.

5. Research Studies Remediating /r/
Several studies have attempted to provide tactile or visual feedback to assist accurate production of /r/
Tactile - (Clark et al., 1993) demonstrated successful /r/ treatment with 18 elementary school children who received a specially made /r/-appliance (retainer-like apparatus)
Visual - (Adler-Bock et al., 2007) used ultrasound equipment to allow subjects to see their tongue shape and placement during /r/ treatment. This form of visual feedback was useful in helping the subjects attain tongue shapes that were similar to adult productions of /r/
Visual - (Shuster et al 1992, 1995) used a Kay Elemetrics Model real-time spectrograph to treat /r/ distortions in one college-age student and two elementary school children. Also used spectrograph with Shriberg’s /l/ to /r/ technique.
Only four treatment studies for remediating /r/ distortions were found, and all involved expensive appliances or equipment.
One study (Clark et al., 1993) demonstrated successful /r/ treatment with 18 subjects who received a specially made /r/-appliance (retainer-like apparatus) by an orthodontist. The removable appliance had a small block in the posterior portion to help subjects attain correct tongue position for /r/ during the intervention program
Another study (Adler-Bock et al., 2007) with two subjects used ultrasound equipment to allow subjects to see their tongue shape and placement during /r/ treatment. This form of visual feedback was useful in helping the subjects attain tongue shapes that were similar to adult productions of /r/.
Two studies by Shuster and colleagues (1992, 1995) used a Kay Elemetrics Model 5500 real-time spectrograph to treat /r/ distortions in one college-age student and two elementary school children. The spectrographic /r/ treatment was successful in improving /r/ distortions in these two published studies with all three of the participants.

6. Purpose of the Current Study
The purpose of the current study was to build upon the two spectrograph studies remediating /r/ that were conducted by Shuster (1992, 1995).
The current study used free computer software rather than Kay Elemetrics equipment that was used by Shuster (1992, 1995).
The spectrograph was the primary treatment teqnique, but oral motor awareness activities and traditional articulation approaches were implemented as needed to elicit and stabilize /r/ productions.

7. Subjects Formal and Informal Assessments Results 10 108 r s z 12 121
Age
PPVT- 4 Standard Score
GFTA Sounds in Error
Oral-Peripheral Examination G 10
108
r s z
Poor tongue jaw isolation; extraneous jaw movement
Poor ability to spread/flatten the tongue N 12
121
r s l
Lack tongue-jaw isolation; extraneous jaw movement
Very stimulable for oral motor movements C 11
111 r
Lack tongue-jaw isolation; Extraneous jaw movement
Difficulty with tongue height and tension  R 95
Reduced ability to spread/flatten tongue but stimulable J 7
106
r, sh, th
Poor isolation tongue-jaw; Extraneous jaw movement
Five subjects participated in the study in two phases.
In Phase I, two subjects were treated during the summer term by a certified speech-language pathologist (SLPs) at the Eastern Illinois University Speech-Language-Hearing Clinic and they were a 10 year old female and a 12 year old male.
Two participants from a local elementary school and one participant from the EIU Clinic are currently participating in Phase II of the study.
The three participants are currently being treated by myself under the supervision of two SLPs.
The chart on the right is the results from the two formal assessments that were administered during Phase I. Both G and N scored within normal limits on the PPVT and had two other sounds in error besides /r/. Both G and N also displayed extraneous jaw movement and poor isolation between the jaw and the tongue.

8. Methods - 3 Part Intervention
Approximately hours of treatment in 5-7 weeks
1) Spectrgraph – RTGRAM Training
2) Phonetic Placement Training and Shaping
3) Oral-Motor Awareness Training

9. Spectrograph – RTGRAM Training
Speech, Hearing, and Phonetics Sciences University College London Division of Psychology and Language Sciences website at
RTGRAM Settings
Sampling Rate: 16,000 samples per second
Analysis Bandwidth: Wideband (300) Hz
Time per pixel: 10 milliseconds (ms)
Dynamic Range: 70 decibels (dB)
Color Map: Grayscale

10. RTGRAM Procedures The SLP modeled three correct productions of /er/
The lines and darkness of the productions were pointed out.
SLP modeled a correct /er/ and incorrect /er/ next to each other to compare the differences in lines
Subjects were asked to make their best /er/ productions and to compare it to the SLP’s production of /er/.
Were the lines in the same position?
Were the lines dark like the SLP’s lines?
Subjects were asked to move different parts of the tongue, lips, and jaw to make the image look like a correct /er/ image.

11. Good Versus “Weak” /er/
Spectrogram of GOOD /er/
Spectrogram of “Weak” /er/
Here are spectrograms of a good, strong /er/ and a poor, weak /er/. In a good /er/ production there are two lines that are dark and below the second red line. There is also lightness above the two lines.
In a spectrogram of a weak /er/, there is no clear distinction between the two dark lines and there is extra darkness above.

12. Phonetic Placement Training and Shaping
Verbal description of tongue placement
Use of mirror
Tongue depressor/dental floss holder to facilitate raising of the back of the tongue
Shriberg’s (1975) 8-Step /l/ to /er/ shaping technique was used

13. Oral-Motor Awareness Training
Isolate the jaw fro tongue movement
Placing the hand on the jaw to stabilize extraneous movement
Biting on tongue depressors while moving the tongue tip up and down
Tongue movement awareness
Placing the finger on the tip of the tongue to facilitate back placement of the tongue
Placing a candy mint on the middle of the tongue and pushing the tongue up to the roof of the mouth

14. Progress Measures The Entire World of R Advanced Screening
Pre and post intervention measure
Secord Contextual Articulation Test (S-CAT) Storytelling Probe of Articulation Competence
Probe measure administered each week containing two stories with vocalic /r/ and consonantal /r/
There were two measures that were used to document progress.
The Entire World of R was used to monitor progress before and after intervention while the Secord Contextual Test of Articulation Storytelling Probe was used to monitor weekly progress. Images of /r/ productions were also recorded each week to compare and contrast visual progress from week to week

15. Results

16. Results

17. Results

18. Discussion Impressions
The spectrograph was very helpful for visual feedback when children had the oral motor skills to produce /r/ (may have helped overcome faulty auditory image of correct /r/).
However for those participants without pre-requisite oral motor skills (e.g., tongue-jaw disassociation, tongue placement, and tension) the spectrograph alone was not sufficient for improving /r/ productions. Specific oral motor activities to improve awareness and position were necessary to facilitate change

19. Discussion
Participants G, C, and J had lower levels of initial /r/ accuracy as well as lower percent accuracies from week to week.
Might have been due to more specific oral motor difficulties such as the inability to raise the tongue high in the back of the mouth
We found that the more specific and in-depth oral-motor assessment revealed each participant’s specific /r/ difficulties, which helped plan the /r/ intervention.

20. QUESTIONS???

21. References
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, doi: / (2007/017)
Clark, C. E., Schwarz, I. E., & Blakely, R. W. (1993). The removable R-appliance as a practice device to facilitate correct production of /r/. American Journal of Speech-Language Pathology, 2(1),
Dunn, L., & Dunn, D. (2007). Peabody Picture Vocabulary Test, Fourth Edition (PPVT-4). Pearson.
Goldman, R., & Fristoe, M. (2000). Goldman-Fristoe Test of Articulation, Second Edition (G-FTA-2). Pearson.
Marshalla, P. (2004). Successful R therapy. Kirkland, WA: Pam Marshalla.
Marshalla, P. (2007). Oral motor techniques in articulation and phonological therapy. Marshalla Speech and Language.
Marshalla, P. (2008). Marshalla Oral-Sensorimotor Test (MOST). Super Duper Publications, Inc.
Secord, A, & Shine, R. (1997). Secord Contextual Articulation Test (S-CAT). Super Duper Publications.
Shriberg, L. (1975). A response evocation program for /ɚ/. Journal of Speech an d Hearing Disorders, 40,
Shriberg, L. (1980). An intervention procedure for children with persistent /r/ errors. Language, Speech, and Hearing Services in Schools, 11,
Shuster, L. I., Ruscello, D. M., & Smith, K. D. (1992). Evoking /r/ using visual feedback. American Journal of Speech- Language Pathology, 1,
Shuster, L. I., Ruscello, D. M., & Toth, A. R. (1995). The use of visual feedback to elicit correct /r/. American Journal of Speech-Language Pathology, 4(2),