Phoneme Perception Research Articles

The developmental pattern of native and non-native speech perception during the 1st year of life in Japanese infants

Language development during the 1st year of life is characterized by perceptual attunement: following language-general perception, a decline in the perception of non-native phonemes and a parallel increase in or maintenance of the perception of native phonemes. While this general pattern is well established, there are still many gaps in the literature. First, most evidence documenting these patterns comes from “Minority world countries” with only a limited number of studies from “Majority world countries”, limiting the range of languages and contrasts assessed. Second, few studies test both the developmental patterns of native and non-native speech perception in the same group of infants, making it hard to draw conclusions on simultaneous decline in non-native and increase in native speech perception. Such limitations are in part due to the effort that goes into testing developing speech sound perception, where usually only discrimination of one contrast per infant can be tested at a time. The present study thus set out to assess the feasibility of assessing a given infant on their discrimination of two speech sound contrasts during the same lab visit. It leveraged the presence of documented patterns of the improvement of native and the decline of non-native phoneme discrimination abilities in Japanese, therefore assessing native and non-native speech perception in Japanese infants from 6 to 12 months of age. Results demonstrated that 76 % of infants contributed discrimination data for both contrasts. We found a decline in non-native speech perception evident in discrimination of the non-native /ɹ/-/l/ consonant contrast at 9–11, but not at 11–13 months of age. Additionally, a parallel increase in native speech perception was demonstrated evident in an absence of native phonemic vowel length discrimination at 6–7 and 9–11 months and a discrimination of this contrast at 11–13 months of age. These results, based on a simultaneous assessment of native and non-native speech perception in Japanese-learning infants, demonstrate the feasibility of assessing the discrimination of two contrasts in one testing session and corroborate theoretical proposals on two hallmarks of perceptual attunement: a decrease in non-native and a facilitation in native speech perception during the first year of life.

Cortical Generators and Connections Underlying Phoneme Perception: A Mismatch Negativity and P300 Investigation.

The cortical generators of the pure tone MMN and P300 have been thoroughly studied. Their nature and interaction with respect to phoneme perception, however, is poorly understood. Accordingly, the cortical sources and functional connections that underlie the MMN and P300 in relation to passive and active speech sound perception were identified.An inattentive and attentive phonemic oddball paradigm, eliciting a MMN and P300 respectively, were administered in 60 healthy adults during simultaneous high-density EEG recording. For both the MMN and P300, eLORETA source reconstruction was performed. The maximal cross-correlation was calculated between ROI-pairs to investigate inter-regional functional connectivity specific to passive and active deviant processing.MMN activation clusters were identified in the temporal (insula, superior temporal gyrus and temporal pole), frontal (rostral middle frontal and pars opercularis) and parietal (postcentral and supramarginal gyrus) cortex. Passive discrimination of deviant phonemes was aided by a network connecting right temporoparietal cortices to left frontal areas. For the P300, clusters with significantly higher activity were found in the frontal (caudal middle frontal and precentral), parietal (precuneus) and cingulate (posterior and isthmus) cortex. Significant intra- and interhemispheric connections between parietal, cingulate and occipital regions constituted the network governing active phonemic target detection. A predominantly bilateral network was found to underly both the MMN and P300.While passive phoneme discrimination is aided by a fronto-temporo-parietal network, active categorization calls on a network entailing fronto-parieto-cingulate cortices. Neural processing of phonemic contrasts, as reflected by the MMN and P300, does not appear to show pronounced lateralization to the language-dominant hemisphere.

Do Linguistic Factors Impact Phonological Awareness in L2? A Study of Phonological Awareness of English by Adult Saudi Learners

The study explores the impact of certain linguistic factors on phonological awareness ability in the second language. This study examines the effect of three linguistic factors on Saudi university students’ L2 phonological awareness: the linguistic environment (single vs. clustered), the linguistic affiliation of the phoneme (novel vs. non-novel), and the phonological representation of the lexical item that contains the target phoneme (real-word vs. non-word). The linguistic factors that are examined and controlled in this study represented essential differences between the participants’ L1 and L2, hence highlighting the effect of L1-L2 distance. The participants were 48 university students majoring in English language. Two phonological awareness tasks were administered, a phoneme deletion task and a phonological judgement task, to test phonological awareness at the phonemic and phonotactic levels. The results showed that the linguistic environment of the phoneme had a significant impact on the participants’ L2 phonological awareness. The linguistic affiliation of the target phoneme was another linguistic factor that affected the participants’ L2 phonological awareness. Their perception of novel L2 phonemes was considerably poorer than non-novel phonemes. This result confirms the validity of the linguistic affiliation hypothesis in explaining phonemic awareness in L2. Additionally, the results revealed that the quality of the phonological representation plays a significant role in the participants’ performance on the phonological awareness tasks in L2 and that the lexical status of the item affected this underlying phonological representation. The findings of this study offer theoretical and practical implications for the acquisition and teaching of a second language.

Features of speech disorders in children with epileptic encephalopathies

Introduction. Speech disorders are a common problem in childhood. Speech disorders of various types are, in particular, the most common complications of epilepsy.
 Objective. The clinical manifestations of speech disorders in children with epileptic encephalopathies were studied.
 Materials and methods. The study included eighty nine children with epileptic encephalopathies. All patients underwent a detailed study of the anamnesis of life and disease, assessment of neurological and somatic, analysis of the semiotics of seizures, assessment of the therapy received, articulatory praxis, phonemic perception, game activity, expressive speech, impressive speech.
 Results. Speech in the examined patients had the character of a gross violation after the stage of normal development (37.1%), speech development delay was noted in 38.2% of patients from birth. Phonemic perception was impaired in 73 (82.0%) patients, a violation of articulatory praxis was detected in 63 (70.8%) patients, coherent speech was not formed in 78 (87.6%) patients, play activity did not correspond to the age of the child in 50 ( 56.2%) cases, violation of the account was detected in 69 (77.5%) patients, violation of sound pronunciation was observed in 30 (33.7%) patients. 
 Conclusion. Articulatory apraxia and motor alalia are the most common types of speech disorders in children with epileptic encephalopathies.

Exploring individual differences in native phonetic perception and their link to nonnative phonetic perception.

Adults differ considerably in their perception of both native and nonnative phonemes. For instance, when presented with continua of native phonemes on two-alternative forced choice (2AFC) or visual analog scaling (VAS) tasks, some people show sudden changes in responses (i.e., steep identification slopes) and others show gradual changes (i.e., shallow identification slopes). Moreover, some adults are more successful than others at learning unfamiliar phonemes. The predictors of these individual differences and the relationships between them are poorly understood. It also remains unclear to what extent different tasks (2AFC vs. VAS) may reflect distinct individual differences in perception. In two experiments, we addressed these questions by examining the relationships between individual differences in performance on native and nonnative phonetic perception tasks. We found that shallow 2AFC identification slopes were not related to shallow VAS identification slopes but were related to inconsistent VAS responses. Additionally, our results suggest that consistent native perception may play a role in promoting successful nonnative perception. These findings help characterize the nature of individual differences in phonetic perception and contribute to our understanding of how to measure such differences. This work also has implications for encouraging successful acquisition of new languages in adulthood. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Long-term Functional Connectivity Alterations in the Mismatch Negativity, P300 and N400 Language Potentials in Adults with a Childhood Acquired Brain Injury

ABSTRACT Objective To investigate whether alterations in the functional connectivity of networks underlying phoneme perception and semantic-categorical processing persist in adulthood following childhood acquired brain injury (cABI). Methods EEG was recorded in seven adults with a cABI and seven matched controls during the administration of an inattentive and attentive phoneme-level oddball task and a categorical priming task. Functional connections underlying the mismatch negativity (MMN), P300 and N400 were compared between participant groups in five frequency bands by calculating the weighted phase lag index between 32 × 32 electrode pairs. Network modularity and path length were compared between the cABI and control group. Results We observed a positive network for MMN deviant processing in the low gamma band and N400 related processing in the alpha band, but a negative network for P300 standard processing in the theta band in cABI compared to control adults. No differences in graph measures of functional networks were observed between participant groups. Conclusions Alterations in the functional connectivity of speech perception and semantic-categorical processing networks persist in adulthood following cABI. Nevertheless, normal-like network properties in terms of local segregation and global integration are observed.

The effect of native language and bilingualism on multimodal perception in speech: A study of audio-aerotactile integrationa).

Previous studies of speech perception revealed that tactile sensation can be integrated into the perception of stop consonants. It remains uncertain whether such multisensory integration can be shaped by linguistic experience, such as the listener's native language(s). This study investigates audio-aerotactile integration in phoneme perception for English and French monolinguals as well as English-French bilingual listeners. Six step voice onset time continua of alveolar (/da/-/ta/) and labial (/ba/-/pa/) stops constructed from both English and French end points were presented to listeners who performed a forced-choice identification task. Air puffs were synchronized to syllable onset and randomly applied to the back of the hand. Results show that stimuli with an air puff elicited more "voiceless" responses for the /da/-/ta/ continuum by both English and French listeners. This suggests that audio-aerotactile integration can occur even though the French listeners did not have an aspiration/non-aspiration contrast in their native language. Furthermore, bilingual speakers showed larger air puff effects compared to monolinguals in both languages, perhaps due to bilinguals' heightened receptiveness to multimodal information in speech.

Особенности фонематического восприятия речи у обучающихся с билингвизмом

<p>According to various sources, from 277 to 295 different languages are used in the Russian Federation, which makes it very important to assess the impact of bilingualism on speech perception, for example, in the context of school education. There is conflicting evidence about how bilingual children recognize individual phonemes. We compared the perception of phonemes of the Russian language by ear in children of early school age from a monolingual (Russian-speaking) and bilingual (Russian-speaking and Ossetian-speaking) environment using the speech test "Clinical assessment of the development of basic linguistic competencies" and psychophysical tasks for distinguishing words in noise. Bilingual children were found to be worse at repeating pseudowords and recognizing phonemes in stationary noise. The reasons for the difficulties may be related to the fact that children growing up in a bilingual environment have a much wider list of phonemes that need to be recognized than children growing up in a monolingual environment. This can lead to reduced speech recognition in the language of instruction and, consequently, a possible decrease in the quality of education.</p>

Effect of occlusion effects by bone-conduction sound on speech perception assessed by monosyllable articulation test and confusion in phoneme perception

Bone conduction (BC) has been applied to hearing aids for conductive hearing loss, earphones, and other audio devices including ones presenting sound to the face. One of the important characteristics of BC is the "occlusion effect (OE)", a phenomenon that low-frequency sound are perceived as being enhanced when the ear canal is occluded. Our previous study examining OE in facial parts reported that the OE in some facial parts was larger than OE in parts conventionally used. In this study, we conducted monosyllable articulation tests using bone-conducted speech with subjects' ear canal open and occluded, and investigated confusion in phoneme perception to evaluate the effect of OE on perception in the mastoid process, condylar process, nasal bone, and infraorbital region. The results showed that OE increased articulation. However, its effect varied depending on stimulus location and acoustic characteristics of the phonemes, and even confusions among unvoiced consonants even increased by OE. These findings are useful for optimizing BC devices using OE.

Phonological discrimination and contrast detection in pupillometry.

The perception of phonemes is guided by both low-level acoustic cues and high-level linguistic context. However, differentiating between these two types of processing can be challenging. In this study, we explore the utility of pupillometry as a tool to investigate both low- and high-level processing of phonological stimuli, with a particular focus on its ability to capture novelty detection and cognitive processing during speech perception. Pupillometric traces were recorded from a sample of 22 Danish-speaking adults, with self-reported normal hearing, while performing two phonological-contrast perception tasks: a nonword discrimination task, which included minimal-pair combinations specific to the Danish language, and a nonword detection task involving the detection of phonologically modified words within sentences. The study explored the perception of contrasts in both unprocessed speech and degraded speech input, processed with a vocoder. No difference in peak pupil dilation was observed when the contrast occurred between two isolated nonwords in the nonword discrimination task. For unprocessed speech, higher peak pupil dilations were measured when phonologically modified words were detected within a sentence compared to sentences without the nonwords. For vocoded speech, higher peak pupil dilation was observed for sentence stimuli, but not for the isolated nonwords, although performance decreased similarly for both tasks. Our findings demonstrate the complexity of pupil dynamics in the presence of acoustic and phonological manipulation. Pupil responses seemed to reflect higher-level cognitive and lexical processing related to phonological perception rather than low-level perception of acoustic cues. However, the incorporation of multiple talkers in the stimuli, coupled with the relatively low task complexity, may have affected the pupil dilation.

Combined multi-session transcranial alternating current stimulation (tACS) and language skills training improves individual gamma band activity and literacy skills in developmental dyslexia

Developmental dyslexia is characterized by the pathologically diminished ability to acquire reading and spelling skills. Accurate processing of acoustic information at the phonemic scale is crucial for successful sound-to-letter-mapping which, in turn, is elemental in reading and spelling. Altered activation patterns in the auditory cortex are thought to provide the neurophysiological basis for the inaccurate phonemic perception. Recently, transcranial electrical stimulation has been shown to be an effective method to ameliorate cortical activation patterns in the auditory cortex. In a sample of children and adolescents with dyslexia, we investigated the effect of multi-session transcranial alternating current stimulation delivered concurrently with a phonological training and in combination with a behavioral literacy skills training. Over a 5-week period the participants received 10 training sessions while gamma-tACS was administered over bilateral auditory cortex. We found that gamma-tACS shifted the peak frequency of auditory gamma oscillations reflecting a more fine-grained processing of time-critical acoustic information. This amelioration was accompanied by increased phonemic processing skills. Moreover, individuals who received gamma-tACS showed significant improvements in their spelling skills four months after the intervention. Our results demonstrate that multi-session gamma-tACS enhances the effects of a behavioral intervention and induces long-term improvement on literacy skills in dyslexia.

Vowel perception in multilingual speakers: ERP evidence from Polish, English and Norwegian.

Research on Mismatch Negativity (MMN) in monolingual and bilingual speakers has shown significant differences in L1 versus L2 phonemic perception. In this study, we examined whether the MMN response is sensitive to the differences between L1, L2 and L3/Ln. We compared bioelectrical brain activity in response to changes in pairs of vowels produced in three different languages. Specifically, multilingual participants listened to selected vowel contrasts in their L1 Polish, L2 English and L3/Ln Norwegian presented within the passive-oddball paradigm. Results revealed that the MMN was modulated by language: we observed significant differences between L2 English and L3/Ln Norwegian as well as between L1 Polish and L3/Ln Norwegian. For L3/Ln Norwegian, the MMN response had a lower amplitude when compared with L2 English and L1 Polish. Such findings suggest that foreign language status (i.e., L2 vs. L3/Ln) modulates early auditory processing.

Investigating the effects of phonological neighborhood density, word frequency, and phoneme confusability on the English word recognition by native speakers of Japanese

This study aims to bridge the gap between previous research on the impact of phonological neighborhood density on word identification, which did not consider phoneme confusability, and studies on phoneme identification and discrimination, which did not account for the effects of phonological neighborhood density. Native Japanese listeners participated in this study, where they were tasked with identifying monosyllabic and disyllabic English words. The words varied in both phonological neighborhood density and word frequency and were produced by native speakers of American English and Japanese. Participants responded by typing the words they heard. The findings of this study indicated that there were no significant effects of phonological neighborhood density on word identification. However, frequent words were identified with greater accuracy compared to infrequent words. Moreover, words produced by native speakers of American English were more accurately identified than those produced by Japanese speakers. Japanese listeners' inaccurate perception of phonemes has resulted in word identification errors in both dense and sparse phonological neighborhoods. For example, they often mistakenly identify /l/ as /r/ and vice versa. Low and central vowels /æ, ɑ, ʌ/ are frequently misidentified as one another. These confusions are commonly observed among Japanese learners of English.

Pre- to Postoperative Longitudinal Follow-up of Phoneme Perception in Glioma Patients: Evidence from the Mismatch Negativity and P300

ABSTRACT Background and Aims Glioma growth in eloquent language areas induces adaptive activation changes in the language network. The present study aimed to (1) investigate the pre- to postoperative evolution of neural phoneme perception processes in glioma patients and (2) assess if event-related potentials (ERPs) reflecting phoneme perception can provide added value to the diagnostic approach in individuals undergoing awake surgery. Methods and Procedures In five persons undergoing an awake craniotomy for the resection of a glioma, pre- and postoperative behavioural language assessment (Aachen Aphasia Test, Comprehensive Aphasia Test and Boston Naming Test) and electrophysiological investigation of phoneme perception was performed. For the latter, ERPs were obtained through the administration of an inattentive (Mismatch Negativity; MMN) and attentive (P300) oddball paradigm containing a phonemic articulation place contrast during EEG recording. Outcomes and Results Aberrant phoneme categorization processing was evidenced in all five participants preoperatively based on the MMN and P300 amplitude and latency. Moreover, mild behavioural impairments were found in four participants at this time. Postoperatively, three out of five participants reached behavioural ceiling effects, while four individuals displayed normalization of electrophysiological measures. Conclusions While neural processing of phoneme contrasts was preoperatively affected by glioma-induced disturbances, a high potential for postsurgical plasticity was shown. As four participants presented with a high grade glioma, tumour grade might partially account for this pattern. Addition of electrophysiological tests to the language assessment could provide benefits in both the pre- and postoperative clinical diagnostic approach in glioma patients. These preliminary results need validation in a larger sample.

Outline of the problem of developing the phonetic level of speech in older preschool children with logopathology

The scientific article presents the theoretical position of modern research on the content of the phonetic level of speech. Attention has been focused on the problem of studying the components of the phonetic level of speech in older preschool children with normotypical psychophysical development and speech disorders. The phonetic level of speech in children with logopathology was experimentally investigated and a comparative analysis was carried out with peers with normotypical psychophysical development. The purpose of the study is to study the current state of formation of the phonetic level of speech in older preschool children with speech pathology. The task of the research: scientific and theoretical substantiation of scientific positions regarding the development of the phonemic level of speech in children with normotypical psychophysical development and outlining the features of its development in children with logopathology; definition of tasks and evaluation criteria for studying the phonemic level of speech; carrying out a comparative analysis of the results of the study of the state of formation on the development of the phonemic level of speech in children of older preschool age with normotypical psychophysical development and with logopathology. The methods of research are tasks aimed at researching the components of the phonetic level of speech, namely phonetic perception (the ability to differentiate phonemes that are similar in sound, distinguish a sound from a group of sounds, determine the sound in a word), phonetic analysis (the ability to determine the first and last sounds in a word, as well as the number of sounds in a word) and phonetic representation (the ability to correlate sounds with the name of an object) in older preschool children with normotypical psychophysical development and speech disorders. The results of the ascertainment experiment indicate that there are significant differences in the formation of the phonemic level of speech between the groups of the studied older preschool children with logopathology and those with normotypical psychophysical development. Phonemic processes in preschoolers with logopathology, as compared with normotypical indicators, develop with a delay, which leads to a number of errors: during phonemic perception, children do not recognize close-sounding sounds; do not know how to distinguish a sound from a group of sounds or in a word; during phonetic analysis – they incorrectly detect the first and last sounds in a word (name the first syllable or part of a word), make a mistake in determining the number of sounds in a word; during phonemic representation - cannot find the sound in the name of the object.

Aging and sex effects on phoneme perception: An exploratory mismatch negativity and P300 investigation

Background & aimsThe mismatch negativity (MMN) and P300 event-related potentials (ERPs) have been studied in relation to phoneme discrimination and categorization, respectively. Although the effects of aging and sex on pure-tone perception have been widely investigated using these ERPs, evidence relating to phoneme perception is scarce. The current study aimed to provide insight into the effects of aging and sex on phoneme discrimination and categorization, as measured through the MMN and P300. MethodAn inattentive and attentive oddball paradigm containing a phonemic articulation place contrast were administered during EEG registration in sixty healthy individuals (thirty males and females), of which an equal number of young (20–39 years), middle-aged (40–59 years) and elderly (60+ years) subjects were included. The amplitude, onset latency and topographical distribution of the MMN and P300 effect, as well as the amplitude of the P1-N1-P2 complex, were analyzed for age group and sex differences. ResultsWith respect to aging, elderly subjects demonstrated a reduced MMN and P300 amplitude compared to the young group, whereas the scalp distribution of both components was unaffected. No aging effects on the P1-N1-P2 complex were found. In elderly individuals, the P300 was found to be delayed compared to the young group, while no such effect on MMN latency could be observed. No differences in MMN and P300 measures could be identified between males and females. ConclusionDifferential effects of aging were found on the MMN and P300, specifically in terms of latency, in relation to phoneme perception. In contrast, sex was found to scarcely affect both processes.

CONSULTATION FOR EDUCATORS "DEVELOPMENT OF COHERENT SPEECH IN OLDER PRESCHOOL CHILDREN"

The work on the sound culture of speech in the senior preschool age is aimed at solving the problems of cultural and speech education and at preparing preschoolers for literacy. Work continues on the formation of phonemic hearing, children's awareness of the sound composition of the word, the formation of phonemic perception of the word.

Development of perceptual similarity and discriminability: the perception of Russian phonemes by Chinese learners

This study explored the perceptual assimilation and discrimination of Russian phonemes by three groups of Chinese listeners with differing Russian learning experience. A perceptual assimilation task (PAT) and a perceptual discrimination test (PDT) were conducted to investigate if/how L1-L2 perceptual similarity would vary as a function of increased learning experience, and the development of assimilation-discrimination relations. The PAT was analyzed via assimilation rates, dispersion K' values, goodness ratings and assimilation patterns. Results revealed an intriguing phenomenon that the perceived Mandarin-Russian similarity first increased from naïve listeners to intermediate learners and then decreased slightly in relatively advanced learners. This suggests that L1-L2 perceptual similarity is subject to learning experience and could follow a potential "rise and fall" developmental pattern. The PDT results were mostly in line with the assimilation-discrimination correspondence with more experience bringing out better discriminability in general. Yet the overall sensitivity d' values from the Chinese groups were relatively low, implying acoustic/articulatory effects on L2 discriminability aside from perceptual assimilation. The results were discussed under the frameworks of L2 Perceptual Assimilation Model, Speech Learning Model and L2 Linguistic Perception Model.

Production and perception of prevelar merger: Two-dimensional comparisons using Pillai scores and confusion matrices

Vowel merger production is quantified with gradient acoustic measures, while phonemic perception methods are often coarser, complicating comparisons within mergers in progress. This study implements a perception experiment in two-dimensional formant space (F1 × F2), allowing unified plotting, quantification, and statistics with production data. Production and perception are compared within 20 speakers for a two-part prevelar merger in progress in Pacific Northwest English, where mid-front /ɛ, e/ approximate or merge before voiced velar /ɡ/ (leg–vague merger), and low-front prevelar /æɡ/ raises toward them (bag-raising). Distributions are visualized with kernel density plots and overlap quantified with Pillai scores and confusion matrices from linear discriminant analysis models. Results suggest that leg–vague merger is perceived as more complete than it is produced (in both the sample and community), while bag-raising is highly variable in production but rejected in perception. Relationships between production and perception varied by age, with raising and merger progressing across two generations in production but not perception, followed by younger adults perceiving leg–vague merger but not producing it and varying in (minimal) raising perception while varying in bag-raising in production. Thus, prevelar raising/merger may be progressing among some social groups but reversing in others.

Three-Dimensional Speech Profiles in Stroke Aphasia and Apraxia of Speech.

Behaviorally, acquired apraxia of speech (AOS) is a multidimensional syndrome that the experienced clinician recognizes based on impaired articulation and abnormal temporal prosody. We conducted this study to determine the extent to which three core features of AOS-when defined quantitatively-distinguish categorically among aphasia with no or minimal speech sound involvement, aphasia with AOS, and aphasia with phonemic paraphasia (APP). The study involved retrospective analysis of 195 participants with stroke-induced aphasia. We used three quantitative measures (phonemic error frequency, distortion error frequency, and word syllable duration [WSD]) to divide the sample into four participant groups according to the most likely speech diagnosis: aphasia with minimal speech sound errors, AOS, APP, and a borderline group with mixed profiles. We then conducted nonparametric comparisons across groups for which the measures were not defined and visualized all three measures in a three-dimensional graph. The measures distributed as multidimensional spectra rather than discrete diagnostic entities, and there was considerable behavioral overlap among participant groups. Thirty percent of participants presented with aphasia with minimal sound production difficulties, and they were statistically indistinguishable from the APP group on distortion frequency and WSD. Distortion frequency and WSD were in a borderline region between AOS and APP for 29% of participants. Compared to all other groups, participants with AOS produced significantly more errors that affected listeners' phonemic perception. The results suggest that the current AOS-APP dichotomy has limited validity. We conclude that a continuous multidimensional view of speech variation would be a constructive perspective from which to understand how the left cerebral hemisphere produces speech and that quantitative and normed speech measures should be used to inform differential diagnosis in clinical settings. https://doi.org/10.23641/asha.21807609.