Research and Publications - Department of Communicative Disorders

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Rationale for the tinnitus retraining therapy trial
(Wolters Kluwer, 2013) TRTT Study Grp; Formby, Craig; Scherer, Roberta; University of Alabama Tuscaloosa; Johns Hopkins University; Johns Hopkins Bloomberg School of Public Health
The Tinnitus Retraining Therapy Trial (TRTT) is a National Institutes of Health-sponsored, multi-centered, placebo-controlled, randomized trial evaluating the efficacy of tinnitus retraining therapy (TRT) and its component parts, directive counseling and sound therapy, as treatments for subjective debilitating tinnitus in the military. The TRTT will enroll 228 individuals at an allocation ratio of 1: 1: 1 to: (1) directive counseling and sound therapy using conventional sound generators; (2) directive counseling and placebo sound generators; or (3) standard of care as administered in the military. Study centers include a Study Chair's Office, a Data Coordinating Center, and six Military Clinical Centers with treatment and data collection standardized across all clinics. The primary outcome is change in Tinnitus Questionnaire (TQ) score assessed longitudinally at 3, 6, 12, and 18-month follow-up visits. Secondary outcomes include: Change in TQ sub-scales, Tinnitus Handicap Inventory, Tinnitus Functional Index, and TRT interview visual analog scale; audiometric and psychoacoustic measures; and change in quality of life. The TRTT will evaluate TRT efficacy by comparing TRT (directive counseling and conventional sound generators) with standard of care; directive counseling by comparing directive counseling plus placebo sound generators versus standard of care; and sound therapy by comparing conventional versus placebo sound generators. We hypothesize that full TRT will be more efficacious than standard of care, directive counseling and placebo sound generators more efficacious than standard of care, and conventional more efficacious than placebo sound generators in habituating the tinnitus awareness, annoyance, and impact on the study participant's life.
Pulmonary Function in Infants with Swallowing Dysfunction
(PLOS, 2015) Tutor, James D.; Srinivasan, Saumini; Gosa, Memorie M.; Spentzas, Thomas; Stokes, Dennis C.; University of Tennessee Health Science Center; St Jude Children's Research Hospital; University of Alabama Tuscaloosa
Background Swallowing dysfunction can lead to recurring aspiration and is frequently associated with chronic symptoms such as cough and wheezing in infants. Our objective was to describe the characteristics of infants with swallowing dysfunction, determine if pulmonary function abnormalities are detectable, and if they improve after therapy. Methods We studied 38 infants with a history of coughing and wheezing who had pulmonary function tests performed within two weeks of their diagnosis of swallowing dysfunction. The raised lung volume rapid thoracoabdominal compression technique was used. After 6 months of therapy, 17 of the infants repeated the tests. Results Initially, 25 had abnormal spirometry, 18 had abnormal plethysmography, and 15 demonstrated bronchodilator responsiveness. Six months later test were repeated for seventeen patients. Ten patients had continued abnormal spirometry, two patients remained normal, three patients' abnormal spirometry had normalized, and two patients' previously normal studies became abnormal. Eight of the 17 patients had continued abnormal plethysmography, six had continued normal plethysmography, and three patients' normal plethysmography became abnormal. After 6 months of treatment, eight patients demonstrated bronchodilator responsiveness, of which five continued to demonstrate bronchodilator responsiveness and three developed responsiveness. The remainder either continued to be non-bronchodilator responsive (two) or lost responsiveness (three.) The findings of the abnormal tests in most infants tested is complicated by frequent occurrence of other co-morbidities in this population, including gastroesophageal reflux in 23 and passive smoke exposure in 13 of the infants. Conclusions The interpretation of lung function changes is complicated by the frequent association of swallowing dysfunction with gastroesophageal reflux and passive smoke exposure in this population. Six months of medical therapy for swallowing dysfunction/gastroesophageal reflux did not significantly improve pulmonary function in these infants. Long-term studies will be necessary to determine which of these changes persists into adulthood.
Addressing phonological memory in language therapy with clients who have Down syndrome: Perspectives of speech-language pathologists
(Wiley, 2016) Faught, Gayle G.; Conners, Frances A.; Barber, Angela B.; Price, Hannah R.; University of Alabama Tuscaloosa
BackgroundPhonological memory (PM) plays a significant role in language development but is impaired in individuals with Down syndrome (DS). Without formal recommendations on how to address PM limitations in clients with DS, it is possible speech-language pathologists (SLPs) find ways to do so in their practices. AimsThis study asked if and how SLPs address PM in language therapy with clients who have DS. It also asked about SLPs' opinions of the importance, practicality and difficulty of addressing PM in clients with DS. Methods & ProceduresSLPs participated in an online survey that asked if they address PM in clients with DS and, if so, how often and with which techniques. The survey also asked SLPs to rate their opinions of addressing PM in clients with DS with Likert scales. To contrast clients with DS, SLPs were asked about their practices and opinions with clients who have specific language impairment (SLI) and autism spectrum disorders (ASD). SLPs were recruited through e-mails sent from state organizations and researchers. To compare SLPs' practices and opinions across client types, frequency analyses and analyses of variance (ANOVAs) were run. Outcomes & ResultsIn all, 290 SLPs from 28 states completed the survey. Nearly all SLPs were currently practising at the time data were collected, and all worked with at least one of the three client types. Findings indicated SLPs less often addressed PM and used less variety when addressing PM with clients who have DS compared with clients who have SLI or ASD. Further, SLPs considered it less important, less practical and more difficult to address PM in clients who have DS when compared with clients who have SLI, whereas a similar pattern was found with clients who have ASD. Conclusions & ImplicationsSLPs' opinions could be one reason they under-address PM with clients who have DS. Other reasons include there are no evidence-based practice (EBP) guidelines on this topic, and there is not enough familiarity with the DS phenotype among SLPs. Future research on ways to address PM in clients with DS successfully are essential so that EBP guidelines can be established and language therapy can be made more effective.
Altered brain network dynamics in youths with autism spectrum disorder
(2016) Malaia, Evguenia; Bates, Erik; Seitzman, Benjamin; Coppess, Katherine; University of Alabama Tuscaloosa
Narrative Language Sampling in Typical Development: Implications for Clinical Trials
(American Speech-Language-Hearing Association, 2018) Channell, Marie Moore; Loveall, Susan J.; Conners, Frances A.; Harvey, Danielle J.; Abbeduto, Leonard; University of Illinois Urbana-Champaign; University of Mississippi; University of Alabama Tuscaloosa; University of California Davis
Purpose: This study examined cross-sectional age-related trajectories of expressive language variables (syntactic complexity, lexical diversity, unintelligibility, dysfluency, and talkativeness) derived from a narrative language sampling procedure. Method: Narrative samples were analyzed from 103 typically developing individuals, ages 4-21 years. Results: Results showed that this procedure was effective for the entire age range, with participants producing an utterance on virtually every page of the wordless picture books used to prompt the narrative. Importantly, the cross-sectional trajectories for syntactic complexity and lexical diversity showed age-related increases through the age of 18 years, although measures of other dimensions of language showed different relationships with age. Conclusions: These data inform developmental work and document the extent to which the narrative procedure can be used to characterize expressive language over a wide age range. This procedure has been proposed as an outcome measure for clinical trials and interventions involving individuals with intellectual and developmental disabilities. The present data document the developmental levels for which the procedure and metrics derived are appropriate.
Interaction between topic marking and subject preference strategy in sign language processing
(Routledge, 2019) Krebs, Julia; Malaia, Evie; Wilbur, Ronnie B.; Roehm, Dietmar; Salzburg University; University of Alabama Tuscaloosa; Purdue University System; Purdue University; Purdue University West Lafayette Campus
The preference of the human parser for interpreting syntactically ambiguous sentence-initial arguments as the subject of a clause (i.e. subject preference) has been documented for spoken and sign languages. Recent research (He, Y. [2016]. Interactive processing within and beyond sentence-level: An ERP investigation of simple and complex Chinese sentences (Unpublished doctoral dissertation). University of Mainz, Mainz) suggests that the subject preference can be eliminated by manipulating information structure (topicalisation). To investigate the effects of interaction between syntax and information structure on language processing, we tested the role of topic marking in sentence processing in Austrian Sign Language (oGS). We examined whether non-manual topic marking on the sentence-initial argument eliminates the subject preference using event-related brain potentials. We replicated the finding of the subject preference in oGS by identifying an N400-family response to object-first sentences. Further, topic marking in oGS influenced the processing of the topic argument itself and later processing stages. This suggests that interpretation of topic marking imposes additional processing costs, relative to syntactic reanalysis.
Preterm and full term infant vocalization and the origin of language
(Nature Portfolio, 2019) Oller, D. Kimbrough; Caskey, Melinda; Yoo, Hyunjoo; Bene, Edina R.; Jhang, Yuna; Lee, Chia-Cheng; Bowman, Dale D.; Long, Helen L.; Buder, Eugene H.; Vohr, Betty; University of Memphis; Kaiser Permanente; University of Alabama Tuscaloosa; Chung Shan Medical University; Portland State University; Women & Infants Hospital Rhode Island; Brown University
How did vocal language originate? Before trying to determine how referential vocabulary or syntax may have arisen, it is critical to explain how ancient hominins began to produce vocalization flexibly, without binding to emotions or functions. A crucial factor in the vocal communicative split of hominins from the ape background may thus have been copious, functionally flexible vocalization, starting in infancy and continuing throughout life, long before there were more advanced linguistic features such as referential vocabulary. 2-3 month-old modern human infants produce "protophones", including at least three types of functionally flexible non-cry precursors to speech rarely reported in other ape infants. But how early in life do protophones actually appear? We report that the most common protophone types emerge abundantly as early as vocalization can be observed in infancy, in preterm infants still in neonatal intensive care. Contrary to the expectation that cries are the predominant vocalizations of infancy, our all-day recordings showed that protophones occurred far more frequently than cries in both preterm and full-term infants. Protophones were not limited to interactive circumstances, but also occurred at high rates when infants were alone, indicating an endogenous inclination to vocalize exploratorily, perhaps the most fundamental capacity underlying vocal language.
The Tinnitus Retraining Therapy Trial's Standard of Care Control Condition: Rationale and Description of a Patient-Centered Protocol
(American Speech-Language-Hearing Association, 2019) Erdman, Sue Ann; Scherer, Roberta W.; Sierra-Irizarry, Benigno; Formby, Craig; Johns Hopkins University; Johns Hopkins Bloomberg School of Public Health; University of Alabama Tuscaloosa
Purpose: The selection and design of control conditions are critical factors in minimizing the influence of unwanted variables in randomized controlled trials (RCTs). This article describes the rationale, design, and content of a standard of care control condition in a Phase III RCT of tinnitus retraining therapy. Method: Existing tinnitus practices at military hospitals were identified and aligned with the American Speech-Language-Hearing Association's (2006) preferred practice patterns for tinnitus management and counseling and embedded in a patient-centered protocol to ensure uniformity and treatment fidelity. Results: For those involved in the design of behavioral RCTs, the article identifies options and methods to consider in the selection and design of control conditions. Conclusion: For those who provide tinnitus services, the standard of care protocol developed for the tinnitus retraining therapy trial constitutes a patient-centered approach to intervention that can be implemented clinically.
Linguistic Contributions to Word-Level Spelling Accuracy in Elementary School Children With and Without Specific Language Impairment
(American Speech-Language-Hearing Association, 2019) Werfel, Krystal L.; Schuele, C. Melanie; Reed, Paul; University of South Carolina Columbia; Vanderbilt University; University of Alabama Tuscaloosa
Purpose: Children with specific language impairment (SLI) are more likely than children with typical language (TL) to exhibit difficulties in word-level spelling accuracy. More research is needed to elucidate the contribution of linguistic knowledge to word-level spelling accuracy in this population. The purpose of this study was to explore the contributions of linguistic knowledge to spelling accuracy in a group of 2nd- to 4th-grade children with SLI and a group of 2nd- to 4th-grade children with TL. Method: Participants were 32 children with SU and 32 children with TL in Grades 2 through 4. Five areas of linguistic knowledge were assessed: phonological awareness, morphological knowledge, orthographic pattern knowledge, mental grapheme representation knowledge, and vocabulary knowledge. Mixed-effects logistic regression models were utilized to address the research aim. Results: Mental grapheme representation knowledge was selected as a significant predictor in both models; however, phonological awareness was the only additional significant predictor in the model for children with SLI, whereas morphological knowledge was the only other significant predictor in the model for children with TL. Orthographic pattern knowledge and vocabulary knowledge were not significant for either group. Conclusions: The results suggest that spelling instruction and intervention for children with SLI should take linguistic knowledge into account and explicitly relate linguistic knowledge to spelling. Additionally, future research should consider if instructional targets for children with SU should differ from targets for children with TL and if these findings represent a delay or a disorder in spelling acquisition for children with SLI.
Social and endogenous infant vocalizations
(PLOS, 2020) Long, Helen L.; Bowman, Dale D.; Yoo, Hyunjoo; Burkhardt-Reed, Megan M.; Bene, Edina R.; Oller, D. Kimbrough; University of Memphis; University of Alabama Tuscaloosa
Research on infant vocal development has provided notable insights into vocal interaction with caregivers, elucidating growth in foundations for language through parental elicitation and reaction to vocalizations. A role for infant vocalizations produced endogenously, potentially providing raw material for interaction and a basis for growth in the vocal capacity itself, has received less attention. We report that in laboratory recordings of infants and their parents, the bulk of infant speech-like vocalizations, or "protophones", were directed toward no one and instead appeared to be generated endogenously, mostly in exploration of vocal abilities. The tendency to predominantly produce protophones without directing them to others occurred both during periods when parents were instructed to interact with their infantsandduring periods when parents were occupied with an interviewer, with the infants in the room. The results emphasize the infant as an agent in vocal learning, even when not interacting socially and suggest an enhanced perspective on foundations for vocal language.
Age of acquisition effects differ across linguistic domains in sign language: EEG evidence
(Elsevier, 2020) Malaia, Evie A.; Krebs, Julia; Roehm, Dietmar; Wilbur, Ronnie B.; University of Alabama Tuscaloosa; Salzburg University; Purdue University West Lafayette Campus; Purdue University
One of the key questions in the study of human language acquisition is the extent to which the development of neural processing networks for different components of language are modulated by exposure to linguistic stimuli. Sign languages offer a unique perspective on this issue, because prelingually Deaf children who receive access to complex linguistic input later in life provide a window into brain maturation in the absence of language, and subsequent neuroplasticity of neurolinguistic networks during late language learning. While the duration of sensitive periods of acquisition of linguistic subsystems (sound, vocabulary, and syntactic structure) is well established on the basis of L2 acquisition in spoken language, for sign languages, the relative timelines for development of neural processing networks for linguistic sub-domains are unknown. We examined neural responses of a group of Deaf signers who received access to signed input at varying ages to three linguistic phenomena at the levels of classifier signs, syntactic structure, and information structure. The amplitude of the N400 response to the marked word order condition negatively correlated with the age of acquisition for syntax and information structure, indicating increased cognitive load in these conditions. Additionally, the combination of behavioral and neural data suggested that late learners preferentially relied on classifiers over word order for meaning extraction. This suggests that late acquisition of sign language significantly increases cognitive load during analysis of syntax and information structure, but not word-level meaning.
Frontline Interventions: Considerations for Modifying Fluids and Foods for Management of Feeding and Swallowing Disorders Across the Life Span
(American Speech-Language-Hearing Association, 2020) Gosa, Memorie M.; Dodrill, Pamela; Robbins, JoAnne; University of Alabama Tuscaloosa; Harvard University; Brigham & Women's Hospital; University of Wisconsin Madison
Purpose: Individuals with dysphagia across the age continuum may require dietary modifications of fluids and foods for safe and adequate oral intake. Considerations of this frontline intervention are presented in this clinical forum dedicated to the discussion of dysphagia. Method: This clinical focus article reviews the technical challenges of providing modified fluids and foods across the life span as well as the literature specific to its origins, efficacy, challenges and solutions to standardization, and the methods for ensuring quality service delivery. Conclusion: Dietary modification is an often-used method of dysphagia management that presents unique challenges to the clinician for successful application. Speech-language pathologists in clinical practice across all settings must remain dedicated to evidence-based practice as they navigate service delivery of this strategy to individuals with dysphagia across the life span.
The Tinnitus Retraining Therapy Counseling Protocol as Implemented in the Tinnitus Retraining Therapy Trial
(American Speech-Language-Hearing Association, 2021) Gold, Susan L.; Formby, Craig; Scherer, Roberta W.; University of Maryland Baltimore; University of Alabama Tuscaloosa; Johns Hopkins University; Johns Hopkins Bloomberg School of Public Health
Purpose: This clinical focus article is a companion to the work of Erdman et al. (2019), in which we described the rationale, development, and implementation of the standard-of-care protocol used in the Tinnitus Retraining Therapy Trial (TRTT), a multicenter, placebo-controlled, randomized, definitive efficacy trial of tinnitus retraining therapy (TRT). We now describe the historical background, development, and standardized implementation and delivery of the TRT counseling protocol (tinnitus counseling [TC]) used in the TRTT. TC is conjectured to be the key component in the TRT protocol for initiating the habituation process that reduces the response to the tinnitus signal and, ultimately, reduces its impact. In the TRTT, participants assigned to receive TC achieved > 30% reduction in the impact of tinnitus. Method and Results: The design and implementation of standardized treatments in multisite randomized controlled trials presents many challenges for investigators. Here, subsequent to presenting the background, rationale, and the TRT protocol model, we describe the development, refinement, and training/certification for standardized delivery of TC in the TRTT. The primary challenges encountered while distilling and streamlining TC for standardized delivery across multiple clinicians and their replacements at six participating military treatment centers in the TRTT are considered, and the resulting counseling protocol is detailed. Conclusions: The standardized and streamlined TC used in the TRTT was successful for treating debilitating tinnitus among persons with functionally adequate unaided hearing sensitivity. The structured TC protocol described here appears to be the main determinant of the significant and sizable TRT treatment effects measured in the TRTT, thus bolstering the merits of this standardized counseling approach as one model for the clinical implementation of TRT for the treatment of primary tinnitus.
Contributions of Counseling and Sound Generator Use in Tinnitus Retraining Therapy: Treatment Response Dynamics Assessed in a Secondary Analysis of a Randomized Trial
(American Speech-Language-Hearing Association, 2022) Tinnitus Retraining Therapy Trial; Formby, Craig; Yang, Xin; Scherer, Roberta W.; University of Alabama Tuscaloosa; Johns Hopkins University; Johns Hopkins Bloomberg School of Public Health
Purpose: Tinnitus retraining therapy (TRT) has been widely used for 30 years, but its efficacy and the component contributions from counseling and sound therapy remain controversial. The purpose of this secondary analysis from the Tinnitus Retraining Therapy Trial (TRTT) was to compare treatment response dynamics for TRT (counseling and conventional sound generators) with partial TRT (pTRT; counseling and placebo sound generators) and standard of care (SOC; a patient-centered counseling control). Method: The TRTT randomized 151 participants with primary tinnitus (no signifi-cant hearing or sound tolerance problems) to TRT, pTRT, or SOC, each of which encouraged use of enriched environmental sound. The primary outcome, mean change in Tinnitus Questionnaire score assessed at baseline and follow-up across 18 months, was normalized for a common baseline and fitted with an exponential model. Time constants were estimated to quantify and compare the treatment response dynamics, which were evaluated for statistical significance using bootstrap analyses. Results: The change in response to TRT took less time to achieve than that for either pTRT or SOC, as demonstrated by time for normalized Tinnitus Question-naire scores to decline to 63% and 99% of baseline TRT values: 1.2 months (95% CI [0.2, 1.9]) and 5.7 months (95% CI [0.9, 9.0]), respectively. Correspond-ing SOC values were 2.7 months (95% CI [1.5, 4.1]) and 12.4 months (95% CI [6.9, 19.0]), while those for pTRT were 2.2 months (95% CI [1.2, 3.4]) and 10.1 months (95% CI [5.7, 15.9]). The differences were significant for TRT ver-sus SOC (p = .020), borderline significant for TRT versus pTRT (p = .057), but nonsignificant for pTRT versus SOC (p = .285). The magnitude of the asymp-totic treatment response did not differ significantly among groups. Conclusion: Sound generator use in TRT increases treatment efficiency (beyond any advantage from enriched environmental sound) without affecting treatment efficacy (determined by counseling).
Audiology, Medicine, and Pharmacy Interprofessional Preliminary Interviews and Discussions: Improving Hearing Health Care in Rural Alabama
(American Speech-Language-Hearing Association, 2022) Brothers, Emma B.; Hay-McCutcheon, Marcia J.; Hughes, Peter J.; Friend, M. Louanne; University of Alabama Tuscaloosa; Samford University
Purpose: Access and affordability of hearing health care varies depending on residency and individual financial means. Those living in rural areas have limited health care resources and experience higher levels of poverty compared to those living in urban regions. The purpose of this study was to determine the feasibility of interprofessional collaboration among physicians and audiologists and pharmacists and audiologists to improve access and affordability of hearing health care in rural communities. Method: Sixteen family physicians and medicine residents and 15 community pharmacists participated in the study. Physicians and residents completed an online survey to assess education regarding hearing health care and their understanding of hearing loss intervention. They also participated in small virtual focus group discussions. Pharmacists participated in virtual discussions based on guided questions. Results: The discussions with both physicians and pharmacists highlighted the need for more education, resources, and awareness of the negative impact of hearing loss on overall quality of life. Comments from these discussions were placed within the socio-ecological model of health behavior to increase understanding of hearing health behavior. Conclusions: Increased collaboration among medical professionals has the potential to improve access to hearing health care for those living in audiologically underserved regions of the country. Further research will identify how to increase effective and sustainable hearing health care resources in rural communities.
Visual form of ASL verb signs predicts non- signer judgment of transitivity
(PLOS, 2022) Bradley, Chuck; Malaia, Evie A.; Siskind, Jeffrey Mark; Wilbur, Ronnie B.; Purdue University West Lafayette Campus; Purdue University; University of Alabama Tuscaloosa
Longstanding cross-linguistic work on event representations in spoken languages have argued for a robust mapping between an event's underlying representation and its syntactic encoding, such that-for example-the agent of an event is most frequently mapped to subject position. In the same vein, sign languages have long been claimed to construct signs that visually represent their meaning, i.e., signs that are iconic. Experimental research on linguistic parameters such as plurality and aspect has recently shown some of them to be visually universal in sign, i.e. recognized by non-signers as well as signers, and have identified specific visual cues that achieve this mapping. However, little is known about what makes action representations in sign language iconic, or whether and how the mapping of underlying event representations to syntactic encoding is visually apparent in the form of a verb sign. To this end, we asked what visual cues non-signers may use in evaluating transitivity (i.e., the number of entities involved in an action). To do this, we correlated non-signer judgments about transitivity of verb signs from American Sign Language (ASL) with phonological characteristics of these signs. We found that non-signers did not accurately guess the transitivity of the signs, but that non-signer transitivity judgments can nevertheless be predicted from the signs' visual characteristics. Further, non-signers cue in on just those features that code event representations across sign languages, despite interpreting them differently. This suggests the existence of visual biases that underlie detection of linguistic categories, such as transitivity, which may uncouple from underlying conceptual representations over time in mature sign languages due to lexicalization processes.
The Acoustic Voice Quality Index (AVQI) in People with Parkinson's Disease Before and After Intensive Voice and Articulation Therapies: Secondary Outcome of a Randomized Controlled Trial
(2022) Moya-Galé, Gemma; Spielman, Jennifer; Ramig, Lorraine A.; Campanelli, Luca; Maryn, Youri
Sex differences in infant vocalization and the origin of language
(Cell Press, 2023) Oller, D. Kimbrough; Gilkerson, Jill; Richards, Jeffrey A.; Hannon, Steve; Griebel, Ulrike; Bowman, Dale D.; Brown, Jane A.; Yoo, Hyunjoo; Warren, Steven F.; University of Memphis; University of Alabama Tuscaloosa; University of Kansas
Seeking to discern the earliest sex differences in language-related activities, our focus is vocal activity in the first two years of life, following up on recent research that unexpectedly showed boys produced significantly more speech-like vocalizations (protophones) than girls during the first year of life.We now bring a much larger body of data to bear on the comparison of early sex differences in vocali-zation, data based on automated analysis of all-day recordings of infants in their homes. The new evidence, like that of the prior study, also suggests boys produce more protophones than girls in the first year and offers additional basis for informed speculation about biological reasons for these differences. More broadly, the work offers a basis for informed speculations about foundations of language that we propose to have evolved in our distant hominin ancestors, foun-dations also required in early vocal development of modern human infants.

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