Chapter 22 Treatment Design and Implementation

NOVA Comprehensive Perspectives on Child Speech Development and Disorders

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Chapter 22Treatment Design and Implementation

Carol Ellis and Barbara Hodson


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Introduction

• This chapter addresses theoretical and practical aspects of treatment design and implementation.

• Five sections:– Intervention settings– Assessment needs/options to consider before

treatment begins– Current treatment options/approaches– Considerations for designing appropriate treatment,– Treatment implementation


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Intervention Settings• Public services based on PL 94-142 (Individuals with Disabilities Act, IDEA)

– Age 3 through 21• Public school SLP• Individualized Education Program (IEP)

– Age birth to three• SLP in birth to three programs• In child’s home, community facility, or birth-to-three center• Individual Family Service Plan (IFSP)

• University-based speech and hearing clinics• Hospitals• Private SLP services• Who pays?

– Public resources for public schools and birth-to-three services– Medicaid, if applicable– Insurances– Out-of-pocket


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Before Treatment Begins

• Assessment information is used to evaluate– Whether there actually is a communication disorder– If so, how severe (e.g., mild, moderate, severe,

profound) – Possible etiological factors (e.g., hearing loss, cleft

palate)– Effect on the child’s social, emotional, and educational

development– Prognosis for improvement– Possible direction for intervention


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• An inclusive speech assessment should include– Phonological strengths and weaknesses (e.g.,

phonetic/phonemic and phonotactic inventories, phonological deviations)

– Severity rating– Intervention targets for treatment– Baseline measures for documenting progress– Stimulability information regarding possible

targets (Hodson, 2007)


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Assessment Options

• Only a few speech sounds in error– Phoneme-oriented articulation tests– Normative data on age of acquisition for individual

phonemes• Caveat: Norms can vary substantially

• Highly unintelligible speech– Phonologically-based assessment tools


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Major Treatment Options

• Extensive list of treatment approaches• Mandate to select an approach that has been

proved to be effective• Detailed description in Williams, McLeod, and

McCauley (2010) • Chapter 1 outlines the history of treatment

approaches• Chapter 21 addresses treatment efficacy


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Phoneme-Oriented Approaches

• Phonetic Placement (Scripture, 1927)• Moto-Kinesthetic Method (Stinchfield, 1938)• Stimulus Approach (Van Riper, 1934)– Hierarchy (isolation, syllables, words, phrases, sentences,

conversation) still in use today• Sensory-Motor Approach (McDonald, 1964)• Behavior Modification (1970s)– Based on Stimulus Approach– Added reinforcers and rewards– Advancement schedule from one level to the next


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Sound Contrasts

• Minimal pairs (e.g., “key” vs. “tea”) differing by one feature (place, manner, voicing) (e.g., Fairbanks, 1960)– Can also be used to address phonological processes– “signature approach” of linguistic-based treatment

• Maximal opposition (Gierut, 1989)• Multiple Phonemic Approach (McCabe & Bradley,

1975) • Multiple Oppositions (Williams, 2000)


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Phonology-Oriented Approaches

• Distinctive Features• Natural Phonology (Stampe, 1969):

phonological processes• Cycles (Hodson, 2007; 2011)– Aligned with Gestural Phonological Theory

(Browman & Goldstein, 1992)


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Motor-Based Approaches

• PROMPT (developed by Chumpelik [Hayden] in the 1970s; Chumpelik [Hayden], 1984)

• Nuffield Dyspraxia Programme (Williams & Stephens, 2004)

• See Chapter 18 on motor speech disorders for additional information


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Whole Language

• Whole language (Hoffman, Norris, & Monjure, 1990) – Based on a story-telling task– Questions remain about the effectiveness in

severely affected children


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Metaphonological Awareness

• Integrated phonological awareness (Gillon, 2000)

• Metaphon• Can integrate metaphonological awareness

components (e.g., rhyming, syllable segmentation) into other approaches


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Nonlinear/Multilinear Approaches

• Metrical phonology (Liberman, 1975; Liberman & Prince, 1977)

• Optimality Theory (McCarthy & Prince, 1995)


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Additional Theoretical Applications

• Complexity (Gierut, 2007)• Dynamic Systems (Rvachew & Bernhardt,

2010)


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Sidebar 22.1 Target Stimulable Sounds or Non-Stimulable Sounds First?

Traditionally, SLPs have targeted sounds that are “stimulable” (e.g., the client is able to produce the sound with various auditory and visual cues when deciding on intervention goals.) It has been reported that an “optimal match” is needed to facilitate a child’s progress (Hunt, 1961). After the SLP determines a child’s current functioning level, intervention begins one step above that so the child experiences both a challenge and success. Some phonologists (e.g., Gierut), however, argue that treatment should target later-acquired, non-stimulable sounds first (e.g., /str/). The hypothesis is that targeting non-stimulable sounds will lead to greater generalization of non-targeted sounds. Some investigators have challenged this approach (Rvachew & Nowak, 2001). In addition, the operational definition of stimulability may be part of this issue (Hodson, 2007).


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Sidebar 22.2 Oral-Motor Exercises?

Oral-motor exercises have been extremely popular in treatment for children with speech sound disorders over the years even though theoretical and scientific bases have been questioned. In addition, research evidence is lacking to support their use. Lof and Watson (2008) reported that oral-motor exercises simply do not enhance speech sound development. Nevertheless, many clinicians continue to employ a number of devices (e.g., horns, straws, whistles) to treat children with speech sound disorders.


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Designing a Course of Treatment

• Challenge: selecting an approach from the numerous options

• Matching an approach to an individual child– Mild disorder with few phonemes in error: phoneme-

oriented approach– Severe to profound disorder: pattern-based approach – Switching approaches as speech production improves;

decide case by case– Phoneme-based principles (placement) are often used

initially to shape a speech sound that was absent from the inventory


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Some General Principles of Treatment

• Stoel-Gammon (1985):– Develop a plan based on all underlying factors that

may relate to the cause of the disorder– Remember that each child is an individual– Use a comprehensive framework when planning

intervention– Teach the child to monitor her/his own progress– Measure the child’s progress in a systematic way


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Mapping Treatment Components across a General Timeframe

• Goals: what the child should be able to do in a year’s time• Objectives: stepwise milestones along the way to the goals• Goals and objectives are spelled out in an Individualized

Education Plan• Parameters:

– Individual vs. group treatment– Dosage (X minutes X times weekly)– Criteria for advancing to the next objective– Criteria for achieving generalization– Criteria for dismissal from treatment

• Continuous measurement of progress, e.g., with spontaneous conversation samples


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Any School District Individual Education Program Student Name Gender: Susie Jones F

Meeting Date

Purpose of Meeting Initial Eligibility, IEP, Placement Annual Review of IEP Three Year Reevaluation Dismissal from Services Date: _______________________ Parent Request Other: __________________________________________

Social Security Number 012-345-6789

Age Grade 4 PreK

Date of Birth

Date Services Begin

Discussed evaluation results/progress/assessment method Yes ____ (Parent/Guardian initial)

Copy of evaluation results received Yes ____ (Parent initial)

District of Residence Any School District

Annual Review Date

*Transition Planning Needed No

Yes (If yes, attach applicable transition pages.)

Attendance Center Any Head Start

Parent/Guardian Name, Address, Phone Mr. and Mrs. Jones Street Address City, USA Hm: 000-000- 0000 Wk: 000-000-0000

Student is eligible for special education or special education and related services as determined by the IEP team

Yes No An annual copy of Parent/Guardian Rights was received and reviewed _______________(Date) ________ (Parent/Guardian Initial)

Date of Multidisciplinary Evaluation

Three Year Reevaluation Due Parent/Guardian Name, Address, Phone Hm: Wk:

A copy of the IEP was provided to parent/guardian

Yes _______ (Parent/Guardian Initial)

IEP Team Membership Parent/Guardian

Signature Mr. and Mrs. Jones

Date

Parent/Guardian

Student

Superintendent/Designee

Any Principal

General Classroom Teacher

Any Teacher

Special Education Teacher/Case Manager

Speech/language Pathologist

Any Therapist

Evaluator

Title

Title

Title

Sidebar 22.3Sample IEP


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Present Levels of Performance Page 2 Based on evaluation, include academic achievement and functional performance (strengths and weaknesses) in the areas affected by the student’s disability, including transition in the IEP to be in effect when the student turns 16; parent concerns; and how the student’s disability affects the student’s involvement and progress in the general education curriculum. (For a preschool child, how the disability affects his/her participation in appropriate activities.) Student Name: Susie Jones IEP Date: Background Information Referral Information/Parent Concerns Strengths Needs How disability affects participation in appropriate activities/curriculum


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Consideration of Special Factors Page 3 Student Name: Susie Jones IEP DATE:

Is the student limited English proficient? Yes No If the answer to this question is “yes”, please explain the language needs of the student as these needs relate to the student’s IEP.

Are there any special communication needs? Yes No If the answer to this question is “yes”, what direct instruction will be provided in the student’s mode of communication?

Does the student require Braille? Yes No If the answer to this question is “yes”, what Braille services will be provided?

Does the student’s behavior impede his or her learning or that of others? Yes No If yes, what strategies are required to appropriately address this behavior, including positive behavioral interventions and supports?

Assessment State and/or District-wide (Circle the form(s) of assessment that student will take.) 1. Student will be taking the assessment without accommodations. 2. Student will be taking the assessment with the accommodations identified on Page 6. 3. Student will be taking an alternate assessment (The alternate assessment is for students working in the alternate achievement standards) The student meets criteria for significant cognitive disability (cognitive abilities are 2 standard deviations below the mean, goals and objectives focus on alternate content standards, and requires extensive and direct instruction) Alternate assessments to be administered._________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ 4. Student not required to take district or statewide assessment at this grade level.


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Educational Goals and Objectives/Benchmarks Page 4 ___

Student Name: Date: Title of personnel responsible to carry out annual goal: Susie Jones Speech Therapist

Procedure

Code Progress Measurable Annual Goal#__1__ Date Code Susie will produce the /k/ sound spontaneously in all positions of words on 9 out of 10 trials with auditory and visual cues across 2 sessions.

Objective/Benchmark (Only required for students who take alternate assessments aligned to alternate achievement standards)



Procedure Codes

(Complete at IEP meeting)

1 Teacher-made tests 7 Work Samples 2 Observations 8 Portfolios 3 Weekly tests 9 Oral Tests 4 Unit tests 10 Data Response 5 Student Conferences 6 Other: _____________________________________

Progress Codes P = Progress being made I = Insufficient Progress to meet goal X = Not Addressed this Reporting Period M = Met goal

Reporting Frequency to Parents

Quarterly Reports X Trimester

Other- describe frequency______________________

Reporting Method to Parents

Conferences Report Card

X Copy of Goal Page Other

______________________________ ______________________________

See modifications checklist for specific goal modifications.


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Procedure

Code Progress Measurable Annual Goal#__2__ Date Code Susie will produce the /g/ sound spontaneously in all positions of words on 9 out of 10 trials with auditory and visual cues across 2 sessions.




Procedure Codes (Complete at IEP meeting)









______________________________ ______________________________



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Procedure

Code Progress Measurable Annual Goal#__3__ Date Code Susie will spontaneously produce the /s/ sound in /s/ blends on 9 out of 10 trials when naming picture cards across two consecutive sessions.




Procedure Codes

(Complete at IEP meeting)









______________________________ ______________________________



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Student Name: Susie Jones IEP Date: Modifications and Supplemental Aids/Services or Supports for Student and/or School Personnel Page 6 Describe accommodations/program modifications and frequency of these modifications/program modifications to be used in general and special education, including supplemental aids/services or supports for school personnel, that will be provided to the student.

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x 1. Small group instruction x

2. Guided to unguided instruction

3. Taped texts

4. Highlighted texts

5. Taping lectures

6. Note taking assistance

7. Extended time for assignment completion

8. Shortened assignments

9. Assignment notebooks

10. Peer tutoring

11. Study guides

x 12. Repeated review/drill x

13. Preferential seating

14. Frequent breaks

15. Concrete/positive reinforcers

16. Special instructional/adaptive equipment

17. Increased verbal response time

18. Directions given in a variety of ways (Specify)

19. Alternative materials (Specify)

20. Adjustments for speech intelligibility/fluency

21. Alternative setting

22. Oral tests

23. Short answer tests

24. Extended time for test completion

25. Taped tests

26. Multiple test sessions

27. Other:

28. Other:

29. Other:

Supports For School Personnel

30. Consultant service (Specify)

31. Specialized material (Specify)

32. Other:


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Related Services To Be Provided Page 7 Student Name: Susie Jones IEP Date:

Title of Personnel Amount of Services, and Location Responsible

A. Occupational Therapy

B. Physical Therapy

C. Psychological Services

D. Counseling Services

E. Social Work Services

F. Audiological Services

G. Recreation Therapy

H. School Nurse Services

X I. Speech/Language Therapy

Any Therapist 40 minutes per week at Head Start

J. Transportation (Specify when, how often, where, distance, costs, etc.)

Significant physical disability/health condition Program located other than home school Student’s disability significantly impacts their ability to independently and safely access special education program

K. Other

L. Assistive Technology

M. Orientation and Mobility

N. Medical Services (Diagnostic Services only)

O. Interpreting Services

P. Parental Counseling/Training

Physical Education

Regular Not Required Adaptive Physical Education (Short-Term Objectives attached) Hearing Aid Maintenance If yes, Title of Personnel Responsible for Monitoring ________________________ Monitoring Frequency ________________________

Yes Not Applicable Monitoring Process ___________________________


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Preschool Least Restrictive Environment (Ages 3, 4, and 5) Page 8B Student Name: Susie Jones IEP Date: Continuum of Alternative Placements

0305 Home 0315 Early Childhood Setting 0325 Part-Time Early Childhood/Part-Time Early Childhood Special Education Setting

0335 Early Childhood Special Education Setting 0345 Separate School 0355 Residential Facility

Special Education to be provided: (Specify description of services, amount of services, and location of services) Speech/Language Therapy – Two times per week for 20 minutes for a total of 40 minutes per week in the Speech Therapy room at Head Start Comments:

Does child attend a regular education program? Yes No (District-run preschool, Head Start, Kindergarten) If yes, please provide a description: Susie attends Talking Tots Head Start. Justification for Placement--An explanation of the extent, if any, to which the child will not participate with non-disabled children in regular classes, and non-academic activities. (Please use accept/reject format for each alternative placement considered.) Home – Rejected. Susie attends Talking Tots Head Start. Early Childhood Setting – Rejected. Susie needs to reduce the noise and distractions of the regular classroom in order to concentrate on her individual speech needs. Part-Time Early Childhood/Part-Time Early Childhood Special Education Setting – Accepted. Susie can interact with her peer models and still receive pullout services to address her individual needs.

The team addressed the potential harmful effects of the special education placement.

Reintegration Plan Is the student moving from a more to less restrictive environment? Yes No If yes, what strategies are required to appropriately address reintegration? ________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________


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Extended School Year Page 9 Student Name: Susie Jones IEP Date:

Extended School Year Services: needed not needed to be determined by (Date) ______/______/______

Goal(s) # *Type of Service Beginning Date mm/dd/yy

Ending Date mm/dd/yy

Minutes Per Week Based on **

* Instruction, related services (specify), other (list) ** Regression/Recoupment, Emerging Skills, or Maintenance of Critical Life Skills

Parent/Guardian Consent For Extended School Year Program only “Consent” means that the parent(s)/guardian(s) have been fully informed of all information relevant to the activity for which consent is sought, in the native language, or other mode of communication; the parent(s)/guardian(s) understand and agree in writing to the carrying out of the activity for which consent is sought, and the consent describes that activity and lists any records which will be released and to whom; and the granting of consent by the parent(s)/guardian(s) is voluntary and may be revoked in writing at any time. ____________________________________ ____________________________ Parent/Guardian Signature Date

Parent/Guardian Consent Required For Initial Placement Only “Consent” means that the parent(s)/guardian(s) have been fully informed of all information relevant to the activity for which consent is sought, in the native language, or other mode of communication; the parent(s)/guardian(s) understand and agree in writing to the carrying out of the activity for which consent is sought, and the consent describes that activity and lists any records which will be released and to whom; and the granting of consent by the parent(s)/guardian(s) is voluntary and may be revoked in writing at any time. __________________________________ ________________________ Parent/Guardian Signature Date

Clarifying Comments:


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Sidebar 22.4Sample Speech-Language Pathology Treatment Plan


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• Treatment in a university speech-language clinic– Student clinician and supervisor together• Determine the child’s needs• Select goals and objectives• Document progress at the end of the academic

semester or quarter


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Implementation


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SAMPLE SPEECH/LANGUAGE LESSON PLAN:

Days & Times: Tuesdays @

11:00AM – 11:30AM

Student(s): Mary Paulson

Date: 11/11/2012

Lesson Plan:

Mary will produce the /k/ sound imitatively in the final position of words while playing a memory matching game with final /k/ picture cards. Auditory models and visual cues will be provided. The criterion is 9 out of 10 correct productions.

Final /k/ words + + - + - + - + + + 7/10

Sidebar 22.5 IEP Lesson Plan


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Sidebar 22.6 Phonological Remediation Plan


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The Role of Caregivers and Home Practice

• “Speech sessions are a lot like a piano lesson.”– The child learns new skills in the sessions– Parents stay informed about their child’s progress– Regular home practice is essential– The family should not be overloaded – just a few

minutes of home practice a day is sufficient


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22V1 Excerpts from a Cycles treatment session with a 3-year-old child


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Generalization

• Carrying the normalized speech productions over into daily life

• Increase the length and complexity of conversational speech

• Move the conversations out of the treatment room into other environments

• Inobtrusive feedback strategy in the classroom and at home


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Criteria for Dismissal from Treatment

• The child has reached the end goal, normalized conversational speech

• The child has reached his/her potential for improvement

• The child and/or parents have not participated in the treatment effort

• The parents refuse further services


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Troubleshooting• A 3-year old boy is scheduled for his first treatment session. He keeps jumping up from

his chair and is generally extremely uncooperative. How can the SLP direct his attention to the treatment activities?

• A 4-year old boy is terrified of headphones and refuses to wear them for the listening activity list. What can be done to help him overcome his fear?

• A third-grade girl working on /r/ appears unmotivated to participate in the sessions and to complete her home practice.

• A first-grader complains to the SLP that his mom corrects his speech “all the time” and that it has gotten so annoying that he sometimes doesn’t feel like talking at all anymore.

• A parent informs the school SLP that the child is now seen by a private SLP for an hour per week in addition to the SLP services at school. How will this affect treatment delivery in both settings?

• A Kindergartener with a severe SSD does not initiate contributions in the classroom and spends most recesses by herself. According to the parent, this child has had so many frustrating experiences with unsuccessful communication attempts that she retreated into a shell.


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Connections

• This chapter focuses on treatment design and implementation

• Chapter 1 provides theoretical and historical background for the treatment approaches described in this chapter

• Chapter 18 focuses specifically on treatment options for motor speech disorders

• Chapter 21 discusses evidence of efficacy• Not all approaches work equally well for all children

with SSD; Chapter 15 discusses disorder subtypes


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Concluding Remarks

• Future research is needed to– Investigate treatment efficacy more fully– Discover why all intervention techniques produce some

positive results and which elements in each approach are most effective and efficient

• To serve a child with SSD best, the SLP should– understand the needs of the child– Tailor treatment – Use phoneme-based approaches for mild disorders– Use pattern-based approaches for severe disorders

Documents

Chapter 22 Treatment Design and Implementation