- Email: [email protected]
Comparison of the computer–aided articulation therapy application with printed material in children with speech sound disorders
Accepted Manuscript Comparison of the computer–aided articulation therapy application with printed material in children with speech sound disorders Rana Dural, Özlem Ünal–Logacev PII:
S0165-5876(18)30155-1
DOI:
10.1016/j.ijporl.2018.03.029
Reference:
PEDOT 8947
To appear in:
International Journal of Pediatric Otorhinolaryngology
Received Date: 8 December 2017 Revised Date:
13 March 2018
Accepted Date: 23 March 2018
Please cite this article as: R. Dural, Ö. Ünal–Logacev, Comparison of the computer–aided articulation therapy application with printed material in children with speech sound disorders, International Journal of Pediatric Otorhinolaryngology (2018), doi: 10.1016/j.ijporl.2018.03.029. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Comparison of the computer–aided articulation therapy application with
Rana Dural
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printed material in children with speech sound disorders
Center of Sensory Integration and Counseling Yamaç sokak 24/5 Florya Istanbul
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Email: [email protected]
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Phone number: +905063453483
Corresponding author: Özlem Ünal–Logacev
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İstanbul Medipol University School of Health Sciences Department of Speech and Language Therapy Kavacık, Istanbul, Turkey
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Email: [email protected]
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Phone number: +905326700450
Running Title: Computer aided articulation therapy Conflict of Interest: There are no potential conflicts of interest to disclose. Keywords: Computer–aided articulation therapy, evidence–based practice, speech therapy
ACCEPTED MANUSCRIPT COMPARISON OF THE COMPUTER AIDED ARTICULATION THERAPY APPLICATION WITH PRINTED MATERIAL IN CHILDREN WITH SPEECH SOUND DISORDERS Abstract
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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.
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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
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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/.
intervention.
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The targeted sounds were switched for the second participant. Sound /l/ was left without any
Result: The target sound met the criterion with TARTU in one participant, and with printed
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material in the other participant.
Conclusion: The presentation type of the materials did not play an important role in the
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success of the therapy on the participants.
Keywords: Computer–aided articulation therapy, evidence–based practice, speech therapy
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ACCEPTED MANUSCRIPT 1. Introduction Speech sound disorder (SSD) is a developmental disorder which affects children’s intelligibility and is characterized by articulation difficulties or phonological difficulties [1].
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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].
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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
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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–
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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
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preferred approaches by speech and language therapists [10]. In the following section,
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behavioural approach, which is highly preferred by speech and language therapists in Turkey and also embraced in the current study, will be discussed. 1.1.Behavioural Approach in SSD Therapies 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
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ACCEPTED MANUSCRIPT 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 [9, 8].
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1.2.Efficacy of SSD Therapies 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
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stimuli [13].
Therapy approaches used for SSD are different from each other in terms of the following
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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]
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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
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the therapeutic approach applied – sessions usually take place one or two times in a week and
[9].
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last 30-60 minutes [18, 10, 19]. The benefit from therapy increases with the therapy intensity
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. 1.3.Computer–Aided Speech Therapy
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ACCEPTED MANUSCRIPT 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)
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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].
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Making the resources and information more accessible, CAST increases client satisfaction and quality of services. Also, the interactive communication process in therapy sessions
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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
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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 [30, 24].
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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
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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 [31, 32, 26]. In their very first study,
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ACCEPTED MANUSCRIPT 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
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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
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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.
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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
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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.
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Female children and the children who had a greater number of consonants produced in
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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-
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ACCEPTED MANUSCRIPT 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
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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:
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1. The efficacy of CAST applications is directly proportional to the efficacy of the
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underlying therapy approach [4]. Therefore, the results of a CAST application that was developed according to a specific approach cannot be generalized. 2. 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
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more effective at the later phases.
3. Individual differences resulting from a variety of cognitive and motivational needs can
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be another factor. Furthermore, variables such as age, gender and stimulability affects
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the accuracy of sound production [13, 26, 33]. 4. 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 6
ACCEPTED MANUSCRIPT 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
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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
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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.
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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
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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
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due to the language difference.
The aim of this study was to develop a Turkish Articulation Therapy Application (TARTU)
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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. 2. METHOD 2.1.Participants 7
ACCEPTED MANUSCRIPT Participants of the current study were recruited among the preschoolers attending the Education, Research and Training Centre for Speech and Language Pathology (DİLKOM) in Anadolu University. The inclusion criteria for the participants were: Being a native Turkish speaker,
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No language comprehension or language production deficits as confirmed by the
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results of Turkish Early Language Development Test (TEDİL) [39], No neurological impairments as reported by a child neurologist,
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Developmentally appropriate oral–motor skills,
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No hearing impairment detected by audiological tests,
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No intervention was taken for speech sound disorders before,
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Having similar phonetic inventory,
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Being at preschool age.
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This study was conducted with participants who met the inclusion criteria mentioned above.
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While Subject 1 (S1) was 5;1 years old male and Subject 2 (S2) was 5;11 years old female.
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The detailed information about the participants and the results of the standardized tests can be found in Table I.
While S1 was missing twelve speech sounds from his phonetic inventory, S2 was missing nine. The most common phonological processes were fronting, voicing and gliding of liquids for both participants. The explanation of the used standardized tests can be found in the “tools used for data collection” section.
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ACCEPTED MANUSCRIPT 2.2.Research Model In this study, a single subject design called “adapted alternating treatments model” was used in order to compare the efficacy of TARTU with printed material. This model enables
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comparisons between the effect of two or more independent variables on two or more irreversible dependent variables [40].
For both of the participants, /k/ and /ʃ/ sounds are selected as targets, but different therapy
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materials are used (Table 2). A control behaviour is added to the model to control the factors affecting internal validity (e.g. testing and maturation). No therapy was provided for the
sessions.
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control behaviour determined as production of /l/ sound, but data was collected on the probe
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2.3.Tools Used for Data Collection
1. Consent Form: Via this form families were informed about the content of the study and their consent for participation and camera recordings were taken.
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2. DİLKOM Parent Interview Form: This form is used for getting information about the child’s prenatal and perinatal period, postnatal development, medical history, self–care
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and communication skills. 3. Turkish Articulation and Phonology Test (SST) [41]: SST is a standardized test whose validity and reliability has been established. It aims to identify and diagnose the children with SSD. SST is composed of three sub–tests, which are Assessment of Articulation Sub– test, Phonological Analysis Sub–test and Auditory Discrimination Sub–test.
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ACCEPTED MANUSCRIPT 4. Turkish Early Language Development Test (TEDİL): Developed for the assessment of receptive and expressive language skills of children aged from 2;00 to 7;11. TEDİL is a norm–referenced test whose validity and reliability has been established [39].
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5. Probe lists: Probe lists, consisting of 17 words for each targeted sounds, were used in baseline, intervention, and follow up sessions. The target sounds were placed in different positions of the words: word initial, syllable initial within word, syllable final within word, word final. Photographs which represent these words were used to gather probe
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data from the participants. These words were chosen among the words which were not
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used in the intervention session (see “tools used in intervention sessions” section). 6. Reinforcement Assessment Form: In order to choose the right reinforcements to promote motivation, reinforcement assessment form was used. This form contains objects, games and toys that children may like. Families were asked to sort the objects, games and toys
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included in the list one to ten. Moreover, if the reinforcements that child likes was not in the list, families were asked to write them down. 7. Therapy Process Observer Information Form: This form is used by an observer who
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watched the 20% of the intervention sessions and transcribed the probe words that named
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by the participants. Via this from interrater reliability was calculated. 2.4.Tools Used in Intervention Sessions 2.4.1. TARTU
TARTU is developed as a CAST application in order to be used in the therapies of children with SSD. It consists of two main levels which are word and sentence.
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ACCEPTED MANUSCRIPT At the word level, target sounds were used in the words which consist of a single syllable, two syllables and multi–syllables. Not only the length of the words was changed but also the target sounds were placed in different word positions in this level (Figure 1).
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When the application starts, firstly, the length of the words was chosen, and then the position of the target sound within the word. After determining word position in which the target sound
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is embedded, the pictures representing these words appears on the screen one by one on a white background.
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At sentence level, taking Turkish word order into consideration, we prepared a template which allowed us to create subject+object+verb sequence. All the sentences consist of these three elements (subject, object and verb). Each element of the sentence has corresponding visuals. All the subjects and objects were chosen from among the ones which were already
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studied at word level. While all subjects and objects were photos the verbs were icons. It is possible to change the elements of a sentence independently from each other. For instance, at the sentence level of /ʃ/ sound, [tʃʌːdʌʃ ʃuɾubu sɛʋdi] ‘Çağdaş liked the syrup’ sentence can be
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turned into [tʃʌːdʌʃ tʌʋʃʌnɯ sɛʋdi] ‘Çağdaş liked the rabbit’ sentence by changing the object picture; or [ɯʃɯɫ ʃuɾubu sɛʋdi] ‘Işıl liked the syrup’ sentence by changing the subject picture;
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or [tʃʌːdʌʃ ʃuɾubu ʌɫdɯ] ‘Çağdaş bought the syrup’ sentence by changing the icon corresponding to the verb of the initial sentence (Figure 2).
The application records the productions of the children both at word and sentence levels and provides immediate auditory feedback by allowing them to listen to their own voices. Also, at word and sentence levels, it is possible to score correct and incorrect productions of the child manually with the help of the buttons on the screen, and then obtain a table that shows the
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ACCEPTED MANUSCRIPT performance of the child. Therefore, a database including the target sound, the date the application was used, and child’s performance is attained. Data storage in the digital media prevented data loss.
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2.4.2. Printed Material The same pictures used in TARTU laminated with transparent plastic and presented as printed material to the participants one by one in word level. Therefore, difficulty level and the word
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positions were the same as in TARTU.
At the sentence level of the printed material, the same procedure was followed but this time
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participants changed the elements which are printed on a paper. Correct and incorrect responses were recorded manually on a table. 2.5.Procedure
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This study was conducted as a master thesis in the department of Speech and Language Therapy Department of Anadolu University. All the sessions within the scope of this study were carried out by the first author of this study who is a SLP. Prior to the study an ethical
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board permission was obtained from Anadolu University’s Ethical Committee.
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All the sessions were carried out in the 6 square–meter therapy rooms in DİLKOM. A table and two chairs of appropriate size for children were used. All therapy and probe sessions were recorded with a camera during the research process. 2.5.1. The Baseline Probe Sessions At the baseline stage of the research, three sessions were carried out with each participant, and “probe lists” were used to gather data. It was evaluated whether the participants produce the target sounds correctly in the probe lists. Additionally, in order to ensure participants get used
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ACCEPTED MANUSCRIPT to the therapy environment, a variety of games were played, and information about the rules to be followed in the therapy room were given. 2.5.2. Intervention Sessions
behavioural approach, and the following steps were taken:
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At the intervention sessions, therapies were carried out following the principles of the
1. The target sound has been worked on in isolation, in syllable, in word and in sentence
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levels, respectively.
2. If correct production was not achieved; auditory, verbal, visual and tactile cues were
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used, respectively.
3. Criterion for participants to pass one level to another was set at 90% accuracy of sound production.
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4. Correct production of target sound by participants was rewarded with verbal and social reinforcements. If participants could not produce the target sound correctly, therapist modelled the correct production and children were asked to imitate.
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5. Prior to the study, TARTU and printed material were assigned randomly to the two
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consecutive sessions (both lasted 30 minutes) which took place on the same day and the schedule was prepared according to this randomization.
6. 12 therapy sessions were carried out three times a week. One participant received therapy targeting the sound /k/ using TARTU in one of the consecutive sessions, while printed material used for the sound /ʃ/ in the other consecutive sessions. 7. At the beginning of every consecutive session, related probe lists were applied. The probe list of sound /l/ was applied randomly in these sessions.
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ACCEPTED MANUSCRIPT 8. 30–minute breaks were given between two sessions and an activity that was selected among the items on the “Reinforcement Assessment Form” according to the child’s interest.
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9. As soon as participants reached the 90% success criterion from the probe lists, in three consecutive intervention sessions, the therapy was terminated and moved to follow up sessions.
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2.5.3. Follow–up and Generalization Sessions
There were two follow–up sessions. The first follow–up session was conducted four weeks
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after terminating the intervention sessions and the second six weeks later. In these sessions, only the probe lists were applied to gather data and some games unrelated with therapy aims were played with the participants.
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2.6.Data Collection and Analysis
Probe lists prepared for /k/ and /ʃ/ sounds were presented to the participant at the beginning of each session. The generalization of targeted sounds was determined by using these lists which
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did not contain any words that were included in the intervention sessions. Probe list of each target sound was presented with the same material (TARTU or printed material) used in
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intervention sessions. On the other hand, probe lists of the /l/ sound that received no intervention were randomly presented alternating between either TARTU or printed material. To calculate the percentage of correct production, the number of correct productions of the target sound was divided by the total number of words in the probe form and multiplied by a hundred. The data was transformed into charts, and then it was examined to see if the data had changed in the baseline stage and the intervention stage.
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ACCEPTED MANUSCRIPT 2.6.1. Collection of Interrater Reliability Data In this study, for interrater reliability analysis, 20% of all sessions were randomly selected, watched and data collection forms were filled by an observer (a speech and language
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therapist). In order to analyse interrater reliability; “[consensus / (consensus + dissensus)] x 1000” formula was used [42]. The lowest interrater reliability coefficient of the study was 94%, while the highest inter–rater reliability was 100%.
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2.6.2. Reliability Data Collection
In order to collect reliability data, 20% of video recordings of the therapy sessions were
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randomly selected, and again by the same observer, it was evaluated if the therapist acted in accordance with the plan during the data collection and therapy process, and noted on this form. The data collected for reliability was obtained with “observed behaviour of participant / planned behaviour of participant x 100” formula [43]. The lowest and highest reliability was
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95% and %100, respectively. 3. Results
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3.1.Comparison of the efficacy of TARTU and Paper Printed Material Figure 3 and Figure 4 illustrate the correct production percentage of /k/, /ʃ/ and /l/ sounds in
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baseline, intervention and follow–up sessions. Target sounds /k/ and /ʃ/ were worked with either printed therapy material or TARTU while sound /l/ was not targeted at all and used as control sound. Please keep in mind that all the results presented here show the generalization of targeted sounds to the untrained words which contain the relevant target sound in it (assessed by probe lists). In baseline session, S1’s percentage of correct productions of /k/, /ʃ/ and /l/ sounds was found to be zero, and it was noted that these sounds were not in his phonetic inventory (Figure 3). In
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ACCEPTED MANUSCRIPT the fourth session interventions for the targeted sounds were started. In the first 4 intervention sessions, the percentage of correct productions of the targeted sounds was still zero. However, in the eighth session, S1 achieved 94% success for /ʃ/ sound with printed material, enhanced to 88% in the ninth session and reached 100% in the tenth, eleventh and twelfth sessions.
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Regarding the sound /k/ worked with TARTU, S1 did not achieve correct production in the first ten sessions, but achieved 94% success in the eleventh session, and 82% in the twelfth session. However, since criterion of 90% correct production in three successive sessions was
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already met with /ʃ/ sound, S1’s intervention sessions were terminated at the end of the 12 sessions, and then follow–up sessions were started. In the first follow–up session performed
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four weeks later, sound /ʃ/ was produced correctly 94% of the time; in the last one, performed six week later, it was produced correctly 100% of the time. On the other hand, /k/ sound was produced correctly at a rate of 100% and 94% in the follow–up sessions performed four weeks and six weeks later, respectively. Percentage of correct productions of the control
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sound /l/ in baseline, intervention and follow–up sessions was zero. S2’s percentage of correct productions of all three sounds were recorded as zero in the
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baseline session. In the first seven intervention sessions, she could not produce any target sounds in the probe lists. In the eighth session, for sound /k/ that was worked with printed
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material, probe data was 58%, and for sound /ʃ/ that was worked with TARTU, it was 76%. In the ninth session, percentage of correct production of sound /k/ increased to 76%, while correct production of sound /ʃ/ decreased to 29%. In the tenth, eleventh and twelfth weeks of the intervention, S2 achieved 100% success on the probe lists of sound /ʃ/. S2 also achieved 88%, 94% and 94% success in the sound /k/ that was worked on with TARTU. Intervention sessions were terminated and follow–up sessions were started at the end of 12 sessions after S2 met 90% success criterion consistently in three successive sessions. In the follow–up sessions performed four and six weeks after the termination of intervention sessions, S2
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ACCEPTED MANUSCRIPT showed 100% success in both TARTU and printed material. Throughout the intervention sessions, 0% success was observed in the control sound /l/, while 35% correct production in the first follow–up session, and 11% in the follow–up session performed six weeks later.
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4. Discussion and Recommendations Childhood speech disorders that are not treated effectively on time may trigger other academical, psychological and social problems. Among all the childhood speech disorders,
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SSD has the highest proportion of pediatric case–loads of SLPs [44]. In fact, maybe of all the speech problems, they are the most effectively treated with therapy. However, they are still a
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big problem due to the lack of enough speech and language therapists in Turkey. In order for this small number of therapists to have access to a large number of individuals with SSD, there is a great need for cost–effective and time–saving therapy methods. The aim of this study was to develop an application which will enable therapists to save time,
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set a standard for therapies, carry out remote therapy with the help of structured homework and to compare the efficacy of this application with printed material. Therefore, a single subject study was designed based on the behavioural approach with two participants both in
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the preschool period. As a result of the study, it was found that both of the participants met the
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90% success criterion on the target sounds worked with the iPad application named as TARTU, although only the second participant could achieve a 90% correct production level consistently in three successive sessions. However, the opposite occurred with the therapies carried out with printed material. The first participant met a 90% criterion of the target sound worked on with printed material in three consecutive sessions, yet the second participant met this criterion on only one occasion and could not keep a higher percentage of correct productions in the subsequent sessions.
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ACCEPTED MANUSCRIPT According to these results, it is hard to claim that one therapy is more effective than the another. These findings are parallel with those of Shriberg and colleagues [31, 32, 26], Wren and Roulstone [33] as well as McLeod and colleagues [34]. These studies found no difference
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between the efficacy of CAST application and printed material. Although very successful outcomes were obtained with both of the methods over a short period, one participant reached the criterion with TARTU first while the other participant did so with the printed material. Therefore, the results of the study should be interpreted in
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consideration with the individual characteristics of the participants. At the beginning of the
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study we tried to take into account as much as possible all of the variables that could affect the results (level of intelligibility, the sounds that were not produced yet, no additional disorders). Individual differences of the participants that could affect the results of the study are, in part, their genders. In their experimental study, Wren and Roulstone [33] found that gender of the participants is a predictor of therapy success, and female participants had more
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improvement in their speech skills. Also, in this study, S2 had improvement in the non–target /l/ sound (in the follow up sessions), although it does not meet the criterion (%35 and %11).
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Her family stated that she worked on the words in the probe lists of /l/ by herself in the four– week period between the intervention sessions and the first follow–up session, and she tried to
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produce them correctly in daily life. This finding is parallel with those of Wren and Roulstone [33]. In the light of these findings, it can be claimed that behavioural approach can be used in the treatment of articulation disorders, and presentation type of stimulus is not critical in achieving the therapeutic goal while applying this approach. TARTU, which does not offer a difference in terms of therapy efficacy, provides great convenience in practical terms for speech and language therapists in therapy process. Advantages of TARTU are as follows:
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ACCEPTED MANUSCRIPT 1. Preparing therapy materials is time consuming but fun part of speech and language therapy. However, not all the therapists have time or motivation for this preparation. Therefore, quality of services given by therapists may vary a lot. By the help of such
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an application, some standards can be brought up to the therapy services. 2. For the preparation of SSD therapies with printed material, SLPs are choosing word cards which has the target sound from card bundles, classifying them according to the difficulty level, and grouping them for the sentence level. Moreover, they keep
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performance record manually during therapy sessions. All of these are time consuming
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compared to computer based applications which can provide a rich library of materials and keep performance records simply by pushing a few buttons on tablets or mobile devices. We believe by releasing TARTU we can reduce the preparation time of SLPs. 3. TARTU records the speech of the children, and increase their awareness about their
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speech by allowing them to listen their own voice.
4. Repeating the drills in speech and language therapy at home increase therapy success. Computer based applications makes therapy material accessible to the clients and
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makes it easier for them to repeat homework at home. Additionally, parents who are
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unable to continue therapies regularly due to issues related to distance or financial problems will have the opportunity to revisit the activities have been done in the therapy. Moreover, using such applications will allow generalization of the targeted sound into new words which have not been introduced during the therapy sessions but provided within the application. Therefore, the required number of therapy sessions so the workload of the SLPs will decrease.
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ACCEPTED MANUSCRIPT 5. TARTU provides the therapist with convenience in the reporting process by storing the data which includes the correct production percentage of the child over the time. Also, it prevents data loss by automatically recording this progress during the therapy.
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In conclusion, TARTU can be used easily and widely. However, it has some limitations such as having only word and sentence levels. Although it was not the case in our study, most of the time, generalization of the correct production of the target sounds need additional therapy activities. Therefore, these additional generalization activities should be added to the updated
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versions of TARTU.
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Since single subject designs have low external validity, this study should be replicated with participants having different characteristics and generalizability of the results should be tested. Acknowledgements
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We would like to thank our participants for participating in our study, Pavel Logačev for programming assistance, Onur Kurt for helping with the design of the study, and Simon
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Houlton for proofreading.
This research has been carried out as part of a master’s thesis of the first author. All pictures
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were downloaded from www.shutterstock.com, and all icons were downloaded from www.iconfinder.com.
Declaration of interest
The authors report no declarations of interest.
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ACCEPTED MANUSCRIPT References [1] L.M. McGrath, C.H. Lee, A. Scott, R. Boada, L.D. Shriberg, B.F. Pennington, Children with comorbid speech sound disorder and specific language impairment are at increased risk for attention–deficit/hyperactivity disorder, J. Abnorm. Child Psychol., 36 (2007) 151-
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163.
[2] R. Mullen, T. Schooling, The national outcomes measurement system for pediatric speech–language pathology, Lang. Speech Hear. Serv. Sch., 41 (2010) 44-60.
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[3] T.F. Cambell, C.A. Dollaghan, H.E. Rockette, J.L. Paradise, H.M. Feldman, L.D. Shriberg, D.L. Sabo, M. Kurs-Lasky, Risk factors for speech delay of unknown origin in 3-year-old
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children, Child Dev., 74 (2) (2003) 346-357.
[4] L.M. Justice, Communication Sciences and Disorders: An Introduction, Pearson PrenticeHall, 2006.
[5] B.A. Lewis, A.A. Avrich, L.A. Freebairn, A.J. Hansen, L.E. Sucheston, I. Kuo, H.G.
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Taylor, S.K. Iyengar, C.M. Stein, Literacy outcomes of children with early childhood speech sound disorders: Impact of endophenotypes, J. Speech Lang. Hear. Res., 54 (2011) 1628-1643.
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[6] A.L. Williams, S. McLeod, R.J. McCauley, M.E. Fey, Intervention For Speech Sound Disorders in Children, MD: Paul H. Brookes, Baltimore, (2010).
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[7] J. Carscadden, P. Corsiatto, L. Ericson, R. Illchuk, C. Esopenko, E. Sterner, G.D. Wells, S.D. Oddie, A pilot study to evaluate a new early screening instrument for speech and language delays, CJSLPA, 34 (2) (2010) 87-95. [8] C. Van Riper, L. Emerick, Speech Correction: An Introduction to Speech Pathology and Audology, seventh ed., Engleewood Cliffs, NJ: Prentice–Hall, 1984.
21
ACCEPTED MANUSCRIPT [9] N.A. Creaghead, W.N. Newman, W.A. Secord, Assessment and Remediation of Articulatory and Phonological Disorders, second ed., Macmillian Publishing Company, New York, 1989. [10] K.M. Brumbaugh, A.B. Smit, Treating children ages 3-6 who have speech sound
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disorder: a survey, Lang. Speech Hear. Serv. Sch., 44 (2013) 306-319.
[11] D.E. Mowrer, The behavioral approach to treatment. In N. A. Creaghead, P. W. Newman,
Disorders, OH: Merrill, Colombus, 1989, pp. 159-192.
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and W. A. Secord (Eds.). Assessment and Remediation of Articulatory and Phonological
[12] M.M. Allen, Intervention efficacy and intensity for children with speech sound disorder,
M AN U
J. Speech Lang. Hear. Res. 56 (2011) 865-877.
[13] J.A. Gierut, Treatment efficacy: functional phonological disorders in children. J. Speech Lang. Hear. Res., 41 (1998) 85-100.
[14] A.G. Kamhi, Treatment decisions for children with speech–sound disorders, Lang.
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Speech Hear. Serv. Sch., 37 (2006) 271-279.
[15] L.G. Shriberg, Five subtypes of developmental phonological disorders, Clin. Commun. Disord., 4 (1994) 39-53.
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[16] S. Crosbie, A. Holm, B. Dodd, Intervention for children with severe speech disorder: A comparison of two approaches, Int. J. Lang. Commun. Disord., 40 (4) (2005) 467-491.
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[17] J.A. Gierut, The how or the what? In: Phonological Disorders in Children. Clinical Decision Making in Assessment and Intervention. Paul H. Brookes, Baltimore, 2005. [18] E. Baker, S. McLeod, Evidence based practice for children with speech sound disorders: Part 1 Narrative review, Lang. Speech Hear. Serv. Sch., 42 (4) (2011) 102-139. [19] J.F. Miller, N. Marriner, Language intervention software: Myth or reality, Child Lang. Teach. Ther., 2 (1) (1996) 85-95.
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ACCEPTED MANUSCRIPT [20] E. Toki, J. Pange, T.A. Milropoulos, An online expert system for diagnostic assessment procedures on young children’s oral speech and language, Procedia Comput. Sci., 14 (2012) 428- 437. [21] A. Protopapas, A.M. Öster, D. House, A. Hatzis, Presentatiton of a new EU project for
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speech therapy: OLP (ortho-logo-pedia), TMH-QPSR, 44, Proceedings of Fonetik, (2002). [22] C. Vaquaro, O. Saz, E. Lleida, J.M. Marcos, C. Canalis, Vocaliza: An application for computer–aided speech therapy in Spanish language. IV Jornadas en Technologia del
SC
Habla, (2006) 321-326.
[23] A. Öster, Z. Kacic, Z. Barczikay, K Vicsi, P. Roach, I. Sinka, Speco–a multimedia
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multilingual teaching and training system for speech handicapped children. Tech. Rep., Eurospeech, 6th Conference on Speech Communication and Technology, Interspeech, (1999).
[24] M. Danubianu, I. Tobolcea, S.G. Pentiuc, Advanced technology in speech disorder
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therapy of Romanian language. Journal of Computing, 1 (1) (2009). [25] M. Glykas, P. Chytas, Technology assisted speech and language therapy. In.l J. Med. Inform., 73 (2004) 529- 541.
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[26] L.G. Shriberg, J. Kwiatkowski, T. Synder, Tabletop versus microcomputer–assisted speech management: Response evocation phase, J. Speech Hear. Disord., 55 (1990) 635-
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655.
[27] E. Toki, J. Pange, E–learning activities for articulation in speech language therapy and learning for preschool children, Procedia Soc. Behav. Sci., 2 (2010) 4274-4278. [28] D. Hartas, Language and Communication Difficulties, Continuu , London, 2005. [29] T. Schery, L. O’Connor, Language intervention: computer training for young children with special needs, Br. J. Educ. Tech., 28 (4) (1997) 271-279.
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ACCEPTED MANUSCRIPT [30] W.A.A.W. Wafi, Using selected computer software in therapy of delayed language children. International Congress Series, (2003) 1311-1316. [31] L.G. Shriberg, J. Kwiatkowski, T. Synder, Articulation testing by microcomputer, J. Speech Hear. Disord., 51 (1986) 309-324.
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[32] L.G. Shriberg, J. Kwiatkowski, T. Synder, Tabletop versus microcomputer–assisted speech management: Stabilization phase, J. Speech Hear. Disord., 54 (1989) 233-248. [33] Y. Wren, S. Roulstone, A comparison between computer and taletop delivery of
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phonology therapy. Int. J. Speech Lang. Pathol., 10 (5) (2008) 346-363
[34] S. McLeod, E. Baker, J. McCormack, Y. Wren., S. Roulstone, K. Crowe, S. Masso, P.
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White, C. Howland, Cluster-randomized controlled trial evaluating the effectiveness of computer assisted intervention delivered by educators for children with speech sound disorder, J. Speech Lang. Hear. Res. , 60 (2017) 1891-1919.
[35] T. Brackenbury, E. Burroudhs, L.E. Hewiit, A qualitave examination of current
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guedelines for evidence-based practice in child language intervention. Lang. Speech Hear. Serv. Sch., 39 2008 78-88.
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[36] Topbaş, S. A Closer Look at the Developing Profession of Speech and Language Pathology (SLP) in Turkey. In Mehmet Yavas ̧ & Seyhun Topbas ̧ (eds.), Communication
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Disorders in Turkish, 26–46. London: Multilingual Matters, 2010. [37] Dil ve Konuşma Terapistleri Derneği [Speech and Language Therapist Association], http://www.tdktd.org/terapistler/ (07.03.1980). [38]
Türkiye
İstatistik
Enstitüsü
[Turkish
Statistical
Institute]
http://www.tuik.gov.tr/PreHaberBultenleri.do?id=30567 (07.03.1980). [39] S. Topbaş, S. Güven, Türkçe Erken Dil Gelişim Testi (TEDİL), Detay Yayınları, Haziran, 2011.
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ACCEPTED MANUSCRIPT [40] O. Kurt, Uyarlamalı dönüşümlü uygulamalar modeli, E. Tekin–İftar (Editör), Eğitim ve davranış bilimlerinde tek denekli araştırmalar (s. 329-349), Türk Psikologlar Derneği Yayınları, Ankara, 2012. [41] S. Topbaş, Türkçe Sesletim ve Sesbilgisi Testi, MEB Yayınları, Ankara, 4. Akşam Sanat
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Okulu, 2005.
[42] G. Kırcaali–İftar, E. Tekin, Tek denekli araştırma yöntemleri, Ankara Türk Psikologlar Derneği, (1997).
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[43] E. Tekin, G. Kırcaali İftar, Özel eğitimde yanlışsız öğretim yöntemleri, Nobel Yayın Dağıtım, Ankara, 2001.
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[44] S. McLeod, E. Baker, Children’s speech: An evidence–based approach to assessment and
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EP
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intervention, MA: Pearson Education, Boston, 2017.
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Tables
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Table 1. Results of standardized tests for each participant. Turkish Articulation and Phonology Test
Gender
Subtest
Age equivalent
Sounds excluded from the
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Age
Test of Early Language development-3: Turkish
Phonetic inventory
phonetic inventory Male
2;0
Articulation
2;0
Phonology
Female
6;11
Articulation
2;2
Phonology
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5;11
Auditory Discrimination
2;0
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S2
/t, k, c, ɡ, ɟ, z, ʃ, ʒ, tʃ, ɾ, l, ɫ/
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5;1
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S1
Auditory Discrimination
6;11
/k, c, ɡ, ɟ, ʃ, ʒ, ɾ, l, ɫ/
/p, b, m, n, d, f, v, s, dʒ, j, h/
Age appropriate receptive language Age appropriate expressive language
/p, b, t, d, m, n, f, v, s, tʃ,
Age appropriate receptive
dʒ, j, h/
language Age appropriate expressive language
ACCEPTED MANUSCRIPT Table 2. Therapy materials whose efficacy was compared in subject adapted alternating treatments model and target speech sounds. Target sound /k/ /ʃ/ /l/
Therapy material TARTU Printed material No intervention is provided, only probe data was collected.
S2
/ʃ/ /k/ /l/
TARTU Printed material No intervention is provided, only probe data was collected.
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Participant S1
2
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Figures
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Figure 1. An example screen shot of the word level in TARTU
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Figure 2: An example screen shot of the sentence level in TARTU
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Figure 3. Percentage of correct productions of S1 in baseline, in intervention and in follow–up
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sessions.
Figure 4. Percentage of correct productions of S2 in baseline, in intervention and in follow–up session
S0165-5876(18)30155-1
DOI:
10.1016/j.ijporl.2018.03.029
Reference:
PEDOT 8947
To appear in:
International Journal of Pediatric Otorhinolaryngology
Received Date: 8 December 2017 Revised Date:
13 March 2018
Accepted Date: 23 March 2018
Please cite this article as: R. Dural, Ö. Ünal–Logacev, Comparison of the computer–aided articulation therapy application with printed material in children with speech sound disorders, International Journal of Pediatric Otorhinolaryngology (2018), doi: 10.1016/j.ijporl.2018.03.029. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Comparison of the computer–aided articulation therapy application with
Rana Dural
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printed material in children with speech sound disorders
Center of Sensory Integration and Counseling Yamaç sokak 24/5 Florya Istanbul
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Email: [email protected]
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Phone number: +905063453483
Corresponding author: Özlem Ünal–Logacev
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İstanbul Medipol University School of Health Sciences Department of Speech and Language Therapy Kavacık, Istanbul, Turkey
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Email: [email protected]
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Phone number: +905326700450
Running Title: Computer aided articulation therapy Conflict of Interest: There are no potential conflicts of interest to disclose. Keywords: Computer–aided articulation therapy, evidence–based practice, speech therapy
ACCEPTED MANUSCRIPT COMPARISON OF THE COMPUTER AIDED ARTICULATION THERAPY APPLICATION WITH PRINTED MATERIAL IN CHILDREN WITH SPEECH SOUND DISORDERS Abstract
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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.
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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
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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/.
intervention.
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The targeted sounds were switched for the second participant. Sound /l/ was left without any
Result: The target sound met the criterion with TARTU in one participant, and with printed
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material in the other participant.
Conclusion: The presentation type of the materials did not play an important role in the
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success of the therapy on the participants.
Keywords: Computer–aided articulation therapy, evidence–based practice, speech therapy
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ACCEPTED MANUSCRIPT 1. Introduction Speech sound disorder (SSD) is a developmental disorder which affects children’s intelligibility and is characterized by articulation difficulties or phonological difficulties [1].
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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].
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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
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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–
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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
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preferred approaches by speech and language therapists [10]. In the following section,
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behavioural approach, which is highly preferred by speech and language therapists in Turkey and also embraced in the current study, will be discussed. 1.1.Behavioural Approach in SSD Therapies 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
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ACCEPTED MANUSCRIPT 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 [9, 8].
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1.2.Efficacy of SSD Therapies 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
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stimuli [13].
Therapy approaches used for SSD are different from each other in terms of the following
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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]
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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
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the therapeutic approach applied – sessions usually take place one or two times in a week and
[9].
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last 30-60 minutes [18, 10, 19]. The benefit from therapy increases with the therapy intensity
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. 1.3.Computer–Aided Speech Therapy
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ACCEPTED MANUSCRIPT 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)
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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].
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Making the resources and information more accessible, CAST increases client satisfaction and quality of services. Also, the interactive communication process in therapy sessions
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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
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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 [30, 24].
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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
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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 [31, 32, 26]. In their very first study,
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ACCEPTED MANUSCRIPT 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
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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
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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.
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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
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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.
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Female children and the children who had a greater number of consonants produced in
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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-
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ACCEPTED MANUSCRIPT 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
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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:
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1. The efficacy of CAST applications is directly proportional to the efficacy of the
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underlying therapy approach [4]. Therefore, the results of a CAST application that was developed according to a specific approach cannot be generalized. 2. 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
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more effective at the later phases.
3. Individual differences resulting from a variety of cognitive and motivational needs can
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be another factor. Furthermore, variables such as age, gender and stimulability affects
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the accuracy of sound production [13, 26, 33]. 4. 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 6
ACCEPTED MANUSCRIPT 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
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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
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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.
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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
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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
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due to the language difference.
The aim of this study was to develop a Turkish Articulation Therapy Application (TARTU)
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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. 2. METHOD 2.1.Participants 7
ACCEPTED MANUSCRIPT Participants of the current study were recruited among the preschoolers attending the Education, Research and Training Centre for Speech and Language Pathology (DİLKOM) in Anadolu University. The inclusion criteria for the participants were: Being a native Turkish speaker,
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No language comprehension or language production deficits as confirmed by the
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results of Turkish Early Language Development Test (TEDİL) [39], No neurological impairments as reported by a child neurologist,
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Developmentally appropriate oral–motor skills,
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No hearing impairment detected by audiological tests,
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No intervention was taken for speech sound disorders before,
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Having similar phonetic inventory,
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Being at preschool age.
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This study was conducted with participants who met the inclusion criteria mentioned above.
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While Subject 1 (S1) was 5;1 years old male and Subject 2 (S2) was 5;11 years old female.
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The detailed information about the participants and the results of the standardized tests can be found in Table I.
While S1 was missing twelve speech sounds from his phonetic inventory, S2 was missing nine. The most common phonological processes were fronting, voicing and gliding of liquids for both participants. The explanation of the used standardized tests can be found in the “tools used for data collection” section.
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ACCEPTED MANUSCRIPT 2.2.Research Model In this study, a single subject design called “adapted alternating treatments model” was used in order to compare the efficacy of TARTU with printed material. This model enables
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comparisons between the effect of two or more independent variables on two or more irreversible dependent variables [40].
For both of the participants, /k/ and /ʃ/ sounds are selected as targets, but different therapy
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materials are used (Table 2). A control behaviour is added to the model to control the factors affecting internal validity (e.g. testing and maturation). No therapy was provided for the
sessions.
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control behaviour determined as production of /l/ sound, but data was collected on the probe
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2.3.Tools Used for Data Collection
1. Consent Form: Via this form families were informed about the content of the study and their consent for participation and camera recordings were taken.
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2. DİLKOM Parent Interview Form: This form is used for getting information about the child’s prenatal and perinatal period, postnatal development, medical history, self–care
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and communication skills. 3. Turkish Articulation and Phonology Test (SST) [41]: SST is a standardized test whose validity and reliability has been established. It aims to identify and diagnose the children with SSD. SST is composed of three sub–tests, which are Assessment of Articulation Sub– test, Phonological Analysis Sub–test and Auditory Discrimination Sub–test.
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ACCEPTED MANUSCRIPT 4. Turkish Early Language Development Test (TEDİL): Developed for the assessment of receptive and expressive language skills of children aged from 2;00 to 7;11. TEDİL is a norm–referenced test whose validity and reliability has been established [39].
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5. Probe lists: Probe lists, consisting of 17 words for each targeted sounds, were used in baseline, intervention, and follow up sessions. The target sounds were placed in different positions of the words: word initial, syllable initial within word, syllable final within word, word final. Photographs which represent these words were used to gather probe
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data from the participants. These words were chosen among the words which were not
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used in the intervention session (see “tools used in intervention sessions” section). 6. Reinforcement Assessment Form: In order to choose the right reinforcements to promote motivation, reinforcement assessment form was used. This form contains objects, games and toys that children may like. Families were asked to sort the objects, games and toys
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included in the list one to ten. Moreover, if the reinforcements that child likes was not in the list, families were asked to write them down. 7. Therapy Process Observer Information Form: This form is used by an observer who
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watched the 20% of the intervention sessions and transcribed the probe words that named
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by the participants. Via this from interrater reliability was calculated. 2.4.Tools Used in Intervention Sessions 2.4.1. TARTU
TARTU is developed as a CAST application in order to be used in the therapies of children with SSD. It consists of two main levels which are word and sentence.
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ACCEPTED MANUSCRIPT At the word level, target sounds were used in the words which consist of a single syllable, two syllables and multi–syllables. Not only the length of the words was changed but also the target sounds were placed in different word positions in this level (Figure 1).
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is embedded, the pictures representing these words appears on the screen one by one on a white background.
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At sentence level, taking Turkish word order into consideration, we prepared a template which allowed us to create subject+object+verb sequence. All the sentences consist of these three elements (subject, object and verb). Each element of the sentence has corresponding visuals. All the subjects and objects were chosen from among the ones which were already
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studied at word level. While all subjects and objects were photos the verbs were icons. It is possible to change the elements of a sentence independently from each other. For instance, at the sentence level of /ʃ/ sound, [tʃʌːdʌʃ ʃuɾubu sɛʋdi] ‘Çağdaş liked the syrup’ sentence can be
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turned into [tʃʌːdʌʃ tʌʋʃʌnɯ sɛʋdi] ‘Çağdaş liked the rabbit’ sentence by changing the object picture; or [ɯʃɯɫ ʃuɾubu sɛʋdi] ‘Işıl liked the syrup’ sentence by changing the subject picture;
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or [tʃʌːdʌʃ ʃuɾubu ʌɫdɯ] ‘Çağdaş bought the syrup’ sentence by changing the icon corresponding to the verb of the initial sentence (Figure 2).
The application records the productions of the children both at word and sentence levels and provides immediate auditory feedback by allowing them to listen to their own voices. Also, at word and sentence levels, it is possible to score correct and incorrect productions of the child manually with the help of the buttons on the screen, and then obtain a table that shows the
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ACCEPTED MANUSCRIPT performance of the child. Therefore, a database including the target sound, the date the application was used, and child’s performance is attained. Data storage in the digital media prevented data loss.
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2.4.2. Printed Material The same pictures used in TARTU laminated with transparent plastic and presented as printed material to the participants one by one in word level. Therefore, difficulty level and the word
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positions were the same as in TARTU.
At the sentence level of the printed material, the same procedure was followed but this time
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participants changed the elements which are printed on a paper. Correct and incorrect responses were recorded manually on a table. 2.5.Procedure
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This study was conducted as a master thesis in the department of Speech and Language Therapy Department of Anadolu University. All the sessions within the scope of this study were carried out by the first author of this study who is a SLP. Prior to the study an ethical
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board permission was obtained from Anadolu University’s Ethical Committee.
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All the sessions were carried out in the 6 square–meter therapy rooms in DİLKOM. A table and two chairs of appropriate size for children were used. All therapy and probe sessions were recorded with a camera during the research process. 2.5.1. The Baseline Probe Sessions At the baseline stage of the research, three sessions were carried out with each participant, and “probe lists” were used to gather data. It was evaluated whether the participants produce the target sounds correctly in the probe lists. Additionally, in order to ensure participants get used
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ACCEPTED MANUSCRIPT to the therapy environment, a variety of games were played, and information about the rules to be followed in the therapy room were given. 2.5.2. Intervention Sessions
behavioural approach, and the following steps were taken:
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At the intervention sessions, therapies were carried out following the principles of the
1. The target sound has been worked on in isolation, in syllable, in word and in sentence
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levels, respectively.
2. If correct production was not achieved; auditory, verbal, visual and tactile cues were
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used, respectively.
3. Criterion for participants to pass one level to another was set at 90% accuracy of sound production.
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4. Correct production of target sound by participants was rewarded with verbal and social reinforcements. If participants could not produce the target sound correctly, therapist modelled the correct production and children were asked to imitate.
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5. Prior to the study, TARTU and printed material were assigned randomly to the two
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consecutive sessions (both lasted 30 minutes) which took place on the same day and the schedule was prepared according to this randomization.
6. 12 therapy sessions were carried out three times a week. One participant received therapy targeting the sound /k/ using TARTU in one of the consecutive sessions, while printed material used for the sound /ʃ/ in the other consecutive sessions. 7. At the beginning of every consecutive session, related probe lists were applied. The probe list of sound /l/ was applied randomly in these sessions.
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ACCEPTED MANUSCRIPT 8. 30–minute breaks were given between two sessions and an activity that was selected among the items on the “Reinforcement Assessment Form” according to the child’s interest.
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9. As soon as participants reached the 90% success criterion from the probe lists, in three consecutive intervention sessions, the therapy was terminated and moved to follow up sessions.
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2.5.3. Follow–up and Generalization Sessions
There were two follow–up sessions. The first follow–up session was conducted four weeks
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after terminating the intervention sessions and the second six weeks later. In these sessions, only the probe lists were applied to gather data and some games unrelated with therapy aims were played with the participants.
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2.6.Data Collection and Analysis
Probe lists prepared for /k/ and /ʃ/ sounds were presented to the participant at the beginning of each session. The generalization of targeted sounds was determined by using these lists which
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did not contain any words that were included in the intervention sessions. Probe list of each target sound was presented with the same material (TARTU or printed material) used in
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intervention sessions. On the other hand, probe lists of the /l/ sound that received no intervention were randomly presented alternating between either TARTU or printed material. To calculate the percentage of correct production, the number of correct productions of the target sound was divided by the total number of words in the probe form and multiplied by a hundred. The data was transformed into charts, and then it was examined to see if the data had changed in the baseline stage and the intervention stage.
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ACCEPTED MANUSCRIPT 2.6.1. Collection of Interrater Reliability Data In this study, for interrater reliability analysis, 20% of all sessions were randomly selected, watched and data collection forms were filled by an observer (a speech and language
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therapist). In order to analyse interrater reliability; “[consensus / (consensus + dissensus)] x 1000” formula was used [42]. The lowest interrater reliability coefficient of the study was 94%, while the highest inter–rater reliability was 100%.
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2.6.2. Reliability Data Collection
In order to collect reliability data, 20% of video recordings of the therapy sessions were
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randomly selected, and again by the same observer, it was evaluated if the therapist acted in accordance with the plan during the data collection and therapy process, and noted on this form. The data collected for reliability was obtained with “observed behaviour of participant / planned behaviour of participant x 100” formula [43]. The lowest and highest reliability was
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95% and %100, respectively. 3. Results
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3.1.Comparison of the efficacy of TARTU and Paper Printed Material Figure 3 and Figure 4 illustrate the correct production percentage of /k/, /ʃ/ and /l/ sounds in
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baseline, intervention and follow–up sessions. Target sounds /k/ and /ʃ/ were worked with either printed therapy material or TARTU while sound /l/ was not targeted at all and used as control sound. Please keep in mind that all the results presented here show the generalization of targeted sounds to the untrained words which contain the relevant target sound in it (assessed by probe lists). In baseline session, S1’s percentage of correct productions of /k/, /ʃ/ and /l/ sounds was found to be zero, and it was noted that these sounds were not in his phonetic inventory (Figure 3). In
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ACCEPTED MANUSCRIPT the fourth session interventions for the targeted sounds were started. In the first 4 intervention sessions, the percentage of correct productions of the targeted sounds was still zero. However, in the eighth session, S1 achieved 94% success for /ʃ/ sound with printed material, enhanced to 88% in the ninth session and reached 100% in the tenth, eleventh and twelfth sessions.
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Regarding the sound /k/ worked with TARTU, S1 did not achieve correct production in the first ten sessions, but achieved 94% success in the eleventh session, and 82% in the twelfth session. However, since criterion of 90% correct production in three successive sessions was
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already met with /ʃ/ sound, S1’s intervention sessions were terminated at the end of the 12 sessions, and then follow–up sessions were started. In the first follow–up session performed
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four weeks later, sound /ʃ/ was produced correctly 94% of the time; in the last one, performed six week later, it was produced correctly 100% of the time. On the other hand, /k/ sound was produced correctly at a rate of 100% and 94% in the follow–up sessions performed four weeks and six weeks later, respectively. Percentage of correct productions of the control
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sound /l/ in baseline, intervention and follow–up sessions was zero. S2’s percentage of correct productions of all three sounds were recorded as zero in the
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baseline session. In the first seven intervention sessions, she could not produce any target sounds in the probe lists. In the eighth session, for sound /k/ that was worked with printed
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material, probe data was 58%, and for sound /ʃ/ that was worked with TARTU, it was 76%. In the ninth session, percentage of correct production of sound /k/ increased to 76%, while correct production of sound /ʃ/ decreased to 29%. In the tenth, eleventh and twelfth weeks of the intervention, S2 achieved 100% success on the probe lists of sound /ʃ/. S2 also achieved 88%, 94% and 94% success in the sound /k/ that was worked on with TARTU. Intervention sessions were terminated and follow–up sessions were started at the end of 12 sessions after S2 met 90% success criterion consistently in three successive sessions. In the follow–up sessions performed four and six weeks after the termination of intervention sessions, S2
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ACCEPTED MANUSCRIPT showed 100% success in both TARTU and printed material. Throughout the intervention sessions, 0% success was observed in the control sound /l/, while 35% correct production in the first follow–up session, and 11% in the follow–up session performed six weeks later.
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4. Discussion and Recommendations Childhood speech disorders that are not treated effectively on time may trigger other academical, psychological and social problems. Among all the childhood speech disorders,
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SSD has the highest proportion of pediatric case–loads of SLPs [44]. In fact, maybe of all the speech problems, they are the most effectively treated with therapy. However, they are still a
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big problem due to the lack of enough speech and language therapists in Turkey. In order for this small number of therapists to have access to a large number of individuals with SSD, there is a great need for cost–effective and time–saving therapy methods. The aim of this study was to develop an application which will enable therapists to save time,
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set a standard for therapies, carry out remote therapy with the help of structured homework and to compare the efficacy of this application with printed material. Therefore, a single subject study was designed based on the behavioural approach with two participants both in
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the preschool period. As a result of the study, it was found that both of the participants met the
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90% success criterion on the target sounds worked with the iPad application named as TARTU, although only the second participant could achieve a 90% correct production level consistently in three successive sessions. However, the opposite occurred with the therapies carried out with printed material. The first participant met a 90% criterion of the target sound worked on with printed material in three consecutive sessions, yet the second participant met this criterion on only one occasion and could not keep a higher percentage of correct productions in the subsequent sessions.
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ACCEPTED MANUSCRIPT According to these results, it is hard to claim that one therapy is more effective than the another. These findings are parallel with those of Shriberg and colleagues [31, 32, 26], Wren and Roulstone [33] as well as McLeod and colleagues [34]. These studies found no difference
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between the efficacy of CAST application and printed material. Although very successful outcomes were obtained with both of the methods over a short period, one participant reached the criterion with TARTU first while the other participant did so with the printed material. Therefore, the results of the study should be interpreted in
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consideration with the individual characteristics of the participants. At the beginning of the
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study we tried to take into account as much as possible all of the variables that could affect the results (level of intelligibility, the sounds that were not produced yet, no additional disorders). Individual differences of the participants that could affect the results of the study are, in part, their genders. In their experimental study, Wren and Roulstone [33] found that gender of the participants is a predictor of therapy success, and female participants had more
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improvement in their speech skills. Also, in this study, S2 had improvement in the non–target /l/ sound (in the follow up sessions), although it does not meet the criterion (%35 and %11).
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Her family stated that she worked on the words in the probe lists of /l/ by herself in the four– week period between the intervention sessions and the first follow–up session, and she tried to
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produce them correctly in daily life. This finding is parallel with those of Wren and Roulstone [33]. In the light of these findings, it can be claimed that behavioural approach can be used in the treatment of articulation disorders, and presentation type of stimulus is not critical in achieving the therapeutic goal while applying this approach. TARTU, which does not offer a difference in terms of therapy efficacy, provides great convenience in practical terms for speech and language therapists in therapy process. Advantages of TARTU are as follows:
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ACCEPTED MANUSCRIPT 1. Preparing therapy materials is time consuming but fun part of speech and language therapy. However, not all the therapists have time or motivation for this preparation. Therefore, quality of services given by therapists may vary a lot. By the help of such
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an application, some standards can be brought up to the therapy services. 2. For the preparation of SSD therapies with printed material, SLPs are choosing word cards which has the target sound from card bundles, classifying them according to the difficulty level, and grouping them for the sentence level. Moreover, they keep
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performance record manually during therapy sessions. All of these are time consuming
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compared to computer based applications which can provide a rich library of materials and keep performance records simply by pushing a few buttons on tablets or mobile devices. We believe by releasing TARTU we can reduce the preparation time of SLPs. 3. TARTU records the speech of the children, and increase their awareness about their
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speech by allowing them to listen their own voice.
4. Repeating the drills in speech and language therapy at home increase therapy success. Computer based applications makes therapy material accessible to the clients and
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makes it easier for them to repeat homework at home. Additionally, parents who are
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unable to continue therapies regularly due to issues related to distance or financial problems will have the opportunity to revisit the activities have been done in the therapy. Moreover, using such applications will allow generalization of the targeted sound into new words which have not been introduced during the therapy sessions but provided within the application. Therefore, the required number of therapy sessions so the workload of the SLPs will decrease.
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ACCEPTED MANUSCRIPT 5. TARTU provides the therapist with convenience in the reporting process by storing the data which includes the correct production percentage of the child over the time. Also, it prevents data loss by automatically recording this progress during the therapy.
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In conclusion, TARTU can be used easily and widely. However, it has some limitations such as having only word and sentence levels. Although it was not the case in our study, most of the time, generalization of the correct production of the target sounds need additional therapy activities. Therefore, these additional generalization activities should be added to the updated
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versions of TARTU.
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Since single subject designs have low external validity, this study should be replicated with participants having different characteristics and generalizability of the results should be tested. Acknowledgements
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We would like to thank our participants for participating in our study, Pavel Logačev for programming assistance, Onur Kurt for helping with the design of the study, and Simon
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Houlton for proofreading.
This research has been carried out as part of a master’s thesis of the first author. All pictures
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were downloaded from www.shutterstock.com, and all icons were downloaded from www.iconfinder.com.
Declaration of interest
The authors report no declarations of interest.
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ACCEPTED MANUSCRIPT References [1] L.M. McGrath, C.H. Lee, A. Scott, R. Boada, L.D. Shriberg, B.F. Pennington, Children with comorbid speech sound disorder and specific language impairment are at increased risk for attention–deficit/hyperactivity disorder, J. Abnorm. Child Psychol., 36 (2007) 151-
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163.
[2] R. Mullen, T. Schooling, The national outcomes measurement system for pediatric speech–language pathology, Lang. Speech Hear. Serv. Sch., 41 (2010) 44-60.
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[3] T.F. Cambell, C.A. Dollaghan, H.E. Rockette, J.L. Paradise, H.M. Feldman, L.D. Shriberg, D.L. Sabo, M. Kurs-Lasky, Risk factors for speech delay of unknown origin in 3-year-old
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children, Child Dev., 74 (2) (2003) 346-357.
[4] L.M. Justice, Communication Sciences and Disorders: An Introduction, Pearson PrenticeHall, 2006.
[5] B.A. Lewis, A.A. Avrich, L.A. Freebairn, A.J. Hansen, L.E. Sucheston, I. Kuo, H.G.
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Taylor, S.K. Iyengar, C.M. Stein, Literacy outcomes of children with early childhood speech sound disorders: Impact of endophenotypes, J. Speech Lang. Hear. Res., 54 (2011) 1628-1643.
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[6] A.L. Williams, S. McLeod, R.J. McCauley, M.E. Fey, Intervention For Speech Sound Disorders in Children, MD: Paul H. Brookes, Baltimore, (2010).
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[7] J. Carscadden, P. Corsiatto, L. Ericson, R. Illchuk, C. Esopenko, E. Sterner, G.D. Wells, S.D. Oddie, A pilot study to evaluate a new early screening instrument for speech and language delays, CJSLPA, 34 (2) (2010) 87-95. [8] C. Van Riper, L. Emerick, Speech Correction: An Introduction to Speech Pathology and Audology, seventh ed., Engleewood Cliffs, NJ: Prentice–Hall, 1984.
21
ACCEPTED MANUSCRIPT [9] N.A. Creaghead, W.N. Newman, W.A. Secord, Assessment and Remediation of Articulatory and Phonological Disorders, second ed., Macmillian Publishing Company, New York, 1989. [10] K.M. Brumbaugh, A.B. Smit, Treating children ages 3-6 who have speech sound
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disorder: a survey, Lang. Speech Hear. Serv. Sch., 44 (2013) 306-319.
[11] D.E. Mowrer, The behavioral approach to treatment. In N. A. Creaghead, P. W. Newman,
Disorders, OH: Merrill, Colombus, 1989, pp. 159-192.
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and W. A. Secord (Eds.). Assessment and Remediation of Articulatory and Phonological
[12] M.M. Allen, Intervention efficacy and intensity for children with speech sound disorder,
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J. Speech Lang. Hear. Res. 56 (2011) 865-877.
[13] J.A. Gierut, Treatment efficacy: functional phonological disorders in children. J. Speech Lang. Hear. Res., 41 (1998) 85-100.
[14] A.G. Kamhi, Treatment decisions for children with speech–sound disorders, Lang.
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Speech Hear. Serv. Sch., 37 (2006) 271-279.
[15] L.G. Shriberg, Five subtypes of developmental phonological disorders, Clin. Commun. Disord., 4 (1994) 39-53.
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[16] S. Crosbie, A. Holm, B. Dodd, Intervention for children with severe speech disorder: A comparison of two approaches, Int. J. Lang. Commun. Disord., 40 (4) (2005) 467-491.
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[17] J.A. Gierut, The how or the what? In: Phonological Disorders in Children. Clinical Decision Making in Assessment and Intervention. Paul H. Brookes, Baltimore, 2005. [18] E. Baker, S. McLeod, Evidence based practice for children with speech sound disorders: Part 1 Narrative review, Lang. Speech Hear. Serv. Sch., 42 (4) (2011) 102-139. [19] J.F. Miller, N. Marriner, Language intervention software: Myth or reality, Child Lang. Teach. Ther., 2 (1) (1996) 85-95.
22
ACCEPTED MANUSCRIPT [20] E. Toki, J. Pange, T.A. Milropoulos, An online expert system for diagnostic assessment procedures on young children’s oral speech and language, Procedia Comput. Sci., 14 (2012) 428- 437. [21] A. Protopapas, A.M. Öster, D. House, A. Hatzis, Presentatiton of a new EU project for
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speech therapy: OLP (ortho-logo-pedia), TMH-QPSR, 44, Proceedings of Fonetik, (2002). [22] C. Vaquaro, O. Saz, E. Lleida, J.M. Marcos, C. Canalis, Vocaliza: An application for computer–aided speech therapy in Spanish language. IV Jornadas en Technologia del
SC
Habla, (2006) 321-326.
[23] A. Öster, Z. Kacic, Z. Barczikay, K Vicsi, P. Roach, I. Sinka, Speco–a multimedia
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multilingual teaching and training system for speech handicapped children. Tech. Rep., Eurospeech, 6th Conference on Speech Communication and Technology, Interspeech, (1999).
[24] M. Danubianu, I. Tobolcea, S.G. Pentiuc, Advanced technology in speech disorder
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therapy of Romanian language. Journal of Computing, 1 (1) (2009). [25] M. Glykas, P. Chytas, Technology assisted speech and language therapy. In.l J. Med. Inform., 73 (2004) 529- 541.
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[26] L.G. Shriberg, J. Kwiatkowski, T. Synder, Tabletop versus microcomputer–assisted speech management: Response evocation phase, J. Speech Hear. Disord., 55 (1990) 635-
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655.
[27] E. Toki, J. Pange, E–learning activities for articulation in speech language therapy and learning for preschool children, Procedia Soc. Behav. Sci., 2 (2010) 4274-4278. [28] D. Hartas, Language and Communication Difficulties, Continuu , London, 2005. [29] T. Schery, L. O’Connor, Language intervention: computer training for young children with special needs, Br. J. Educ. Tech., 28 (4) (1997) 271-279.
23
ACCEPTED MANUSCRIPT [30] W.A.A.W. Wafi, Using selected computer software in therapy of delayed language children. International Congress Series, (2003) 1311-1316. [31] L.G. Shriberg, J. Kwiatkowski, T. Synder, Articulation testing by microcomputer, J. Speech Hear. Disord., 51 (1986) 309-324.
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[32] L.G. Shriberg, J. Kwiatkowski, T. Synder, Tabletop versus microcomputer–assisted speech management: Stabilization phase, J. Speech Hear. Disord., 54 (1989) 233-248. [33] Y. Wren, S. Roulstone, A comparison between computer and taletop delivery of
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phonology therapy. Int. J. Speech Lang. Pathol., 10 (5) (2008) 346-363
[34] S. McLeod, E. Baker, J. McCormack, Y. Wren., S. Roulstone, K. Crowe, S. Masso, P.
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White, C. Howland, Cluster-randomized controlled trial evaluating the effectiveness of computer assisted intervention delivered by educators for children with speech sound disorder, J. Speech Lang. Hear. Res. , 60 (2017) 1891-1919.
[35] T. Brackenbury, E. Burroudhs, L.E. Hewiit, A qualitave examination of current
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guedelines for evidence-based practice in child language intervention. Lang. Speech Hear. Serv. Sch., 39 2008 78-88.
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[36] Topbaş, S. A Closer Look at the Developing Profession of Speech and Language Pathology (SLP) in Turkey. In Mehmet Yavas ̧ & Seyhun Topbas ̧ (eds.), Communication
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Disorders in Turkish, 26–46. London: Multilingual Matters, 2010. [37] Dil ve Konuşma Terapistleri Derneği [Speech and Language Therapist Association], http://www.tdktd.org/terapistler/ (07.03.1980). [38]
Türkiye
İstatistik
Enstitüsü
[Turkish
Statistical
Institute]
http://www.tuik.gov.tr/PreHaberBultenleri.do?id=30567 (07.03.1980). [39] S. Topbaş, S. Güven, Türkçe Erken Dil Gelişim Testi (TEDİL), Detay Yayınları, Haziran, 2011.
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ACCEPTED MANUSCRIPT [40] O. Kurt, Uyarlamalı dönüşümlü uygulamalar modeli, E. Tekin–İftar (Editör), Eğitim ve davranış bilimlerinde tek denekli araştırmalar (s. 329-349), Türk Psikologlar Derneği Yayınları, Ankara, 2012. [41] S. Topbaş, Türkçe Sesletim ve Sesbilgisi Testi, MEB Yayınları, Ankara, 4. Akşam Sanat
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Okulu, 2005.
[42] G. Kırcaali–İftar, E. Tekin, Tek denekli araştırma yöntemleri, Ankara Türk Psikologlar Derneği, (1997).
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[43] E. Tekin, G. Kırcaali İftar, Özel eğitimde yanlışsız öğretim yöntemleri, Nobel Yayın Dağıtım, Ankara, 2001.
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[44] S. McLeod, E. Baker, Children’s speech: An evidence–based approach to assessment and
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intervention, MA: Pearson Education, Boston, 2017.
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Tables
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Table 1. Results of standardized tests for each participant. Turkish Articulation and Phonology Test
Gender
Subtest
Age equivalent
Sounds excluded from the
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Age
Test of Early Language development-3: Turkish
Phonetic inventory
phonetic inventory Male
2;0
Articulation
2;0
Phonology
Female
6;11
Articulation
2;2
Phonology
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5;11
Auditory Discrimination
2;0
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S2
/t, k, c, ɡ, ɟ, z, ʃ, ʒ, tʃ, ɾ, l, ɫ/
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5;1
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S1
Auditory Discrimination
6;11
/k, c, ɡ, ɟ, ʃ, ʒ, ɾ, l, ɫ/
/p, b, m, n, d, f, v, s, dʒ, j, h/
Age appropriate receptive language Age appropriate expressive language
/p, b, t, d, m, n, f, v, s, tʃ,
Age appropriate receptive
dʒ, j, h/
language Age appropriate expressive language
ACCEPTED MANUSCRIPT Table 2. Therapy materials whose efficacy was compared in subject adapted alternating treatments model and target speech sounds. Target sound /k/ /ʃ/ /l/
Therapy material TARTU Printed material No intervention is provided, only probe data was collected.
S2
/ʃ/ /k/ /l/
TARTU Printed material No intervention is provided, only probe data was collected.
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Participant S1
2
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Figures
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Figure 1. An example screen shot of the word level in TARTU
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Figure 2: An example screen shot of the sentence level in TARTU
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Figure 3. Percentage of correct productions of S1 in baseline, in intervention and in follow–up
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sessions.
Figure 4. Percentage of correct productions of S2 in baseline, in intervention and in follow–up session