Evidence Based Practices for the Management of School Age Speech and Language Disorders

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Evidence Based Practices for the Management of

School Age Speech and Language Disorders

Susan RvachewSchool of Communication Sciences and Disorders

McGill University



Introduction to Evidence Based Practice

Part I



Evidence Based Practice

• Integrate your own clinical expertise, the values and preferences of the child and the child’s family, and the best research evidence to make decisions about the services that you provide to a given child.

• American Speech-Language-Hearing Association. (2004). Evidence-Based Practice in Communication Disorders: An Introduction [Technical report].



Facilitated Communication:A case study of the consequences of failing to apply EBP

• 1980: Crossly & Mcdonald develop FC for use with children with CP

• 1990: Blicklen publishes “Communication Unbound: Autism and Praxis” in the Harvard Educational Review

• 1990 to 1993: wide dissemination through published case reports and media reports

• 1991: Autism Society of America provides advocacy materials

• 1993 to 1996: series of research studies published that consistently invalidated the approach

• 1994: Myers publishes paper describing court cases in which FC was allowed in the court room to support allegations of child abuse

• 1996: ASHA publishes position paper stating that FC had no established validity



Application of EBP

• Theoretical coherence

• Basic research

• Direct evidence (clinical trials)

• Appropriateness of context

• Professional experience



Part II. Vocabulary Learning

1. Theory2. Basic Research3. Applied Research4. Application



Pe

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Vocabulary

Phonology

Higher Language

Literacy

Skills

and

Academic

Success







Amount and Frequency Effects

• Overall amount of parent speech accounts for a substantial amount of variation in vocabulary growth.

• The relative frequency of exposure to specific words is related to the order of acquisition of those words.

• Huttenlocher et al (1991)



Complexity of Input (Snow)

Density of sophisticated words

Embedding sophisticated words in helpful or instructive interactions

INPUT

AT AGE FIVE YEARS

Predicted 50% of variance in

Receptive Vocabulary

OUTPUT

AT AGE SEVEN YEARSWow! What a big

truck!

Wow! What a large

vehicle!

Look at this truck on the road. That’s

a large vehicle!



Variations in InputHart & Risley (1995)

0

500

1000

1500

2000

2500

Professional WorkingClass

Welfare

Wo

rds

per

Ho

ur

48 M words

28 M words

12 M words



How many repetitions are enough?

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Pre-Test Post-Test

SLI - 3

SLI - 10

NL - 3

NL - 10

1.5 words

2.5 words

0 words

2.5 words



Variations in InputHart & Risley (1995)

0

500

1000

1500

2000

2500

Professional WorkingClass

Welfare

Wo

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per

Ho

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48 M words

28 M words

12 M words







Explanation: DefinitionOut behind the big red barn at the edge of the walnut grove is a most magnificent pond shaded by an old oak tree. I'll tell you right now, before it's too late. It belongs to McFeeglebee.

A grove is a small group of trees (without underbrush).

And McFeeglebee absolutely forbids fishing in that pond. He's put up five signs to prove it. "Before I'll allow any little boys to fish in there," he says, "I'd rather remove it."

Forbid means that he won’t let anyone fish in his pond.



Explanation: Synonym

Everyone warned him. "A pool is not the sea. You can't fish for free, it's stealing. Besides, there's all sorts of surprises in McFeeglebee's pond. Nobody knows just what is in there besides fish and old shoes and the things people lose. You'll catch something dangerous so you'd better beware. Fish in that pond? I wouldn't dare!"

But little Georgie P. Johnson just wiggled his nose and pretended not to hear, as if he had molasses stuck in his ear. Of fishing he was very fond, why should he fear McFeeglebee's pond?

Sea is another name for ocean.



Explanation: Picture Support

All of a sudden with a bob and a jerk, the fishing line woke him. Grabbing the pole and holding on tight he used every muscle to fight what was without doubt the biggest of trout.

He pulled ten minutes before seeing that what he had caught was not a trout, but a huge grisly catfish. How could he have been so wrong? Its whiskers alone were a foot long!

You see here, this is the catfish. It’s a fish but it has whiskers like a cat.



Penno et al. Study Design

Class A Class B

randomization randomization

Group 2 Group 1 Group 2

Story 1, explanations


Story 1, no explanations


Group 1







Results Overall by Ability Group



Results: Explanations vs Retellings



Repetitions by Ability Group



Penno et al. Conclusions

• A combined approach to vocabulary instruction, providing both incidental learning from the story context and contextually relevant direct instruction, is more beneficial than either in isolation.

• Listening to stories did not overcome the ‘Matthew effect’.

• The intervention effects generalized to words that were not explained.



Biemiller & Boote Intervention

• Definitions provided by teacher prior to first reading.

• Definitions provided ‘in-flight’ during repeated readings.

• Definitions provided by students if possible and by teacher if necessary on repeated readings.

• 4 to 6 new definitions provided per reading• 2 story comprehension questions to the

class after each reading.



Design: Biemiller & Boote (2006; Study 1)

112 children in kindergarten, Grade 1, and Grade 2 classrooms

Week 1: Two books each read twice.

Explanations provided for half the target words.

Pretests

Week 2: One book read four times.

Explanations provided for half the target words.

Post-tests



Biemiller & Booth: Study 1 Results

0

5

10

15

20

25

30

Two Readings Four Readings

Ga

in In

Pe

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Wo

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De

fin

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Instructed

Uninstructed



Biemiller & Boote: Study 2

• Teacher definitions provided for all words.

• Target words increased to 7- 9 for each reading.

• 4 readings for all books

• Reviews of vocabulary taught on previous days were added each day.

• An additional review of vocabulary in new contexts was added on the fifth day.



Study 2 Results

• Large gains in vocabulary knowledge were observed at post-test (35% on average)

• Gains were largest in grade 1 (42%)• Gains for instructed words were much larger

than in the previous year (35% vs 22%)• Continued gains of about 6% were observed in

the 4 weeks following the immediate post-test• Word meanings transferred to new contexts



Biemiller and Boote Conclusions

• The 41% gain in vocabulary knowledge that was observed between pretest and follow-up suggests that it is feasible to teach children 400 new words per year.

• This means teaching 1000 new words or about 25 words per week.







Part III. Narrative Skills




Oral Narratives

Literacy

Skills

and

Academic

Success

Written Narratives



Oral NarrativesAcademic

Success

Cognitive Skills

Social Skills

Linguistic Skills

Executive Function

Exposure

Scaffolding

Instruction







5-yr-old story (typical language)

• What do you see happening here?

• The dog is digging a bone so nobody can’t find it and then the dog leaves it. And then the squirrel comes and digs and he gets it.



5-yr-old story (SLI)

• So tell me, what happens here?• A puppy bring him bone.• And then what?• Him walk away.• He walks away.• Then that digging it.• Who is? What’s that?• I don’t know.• It’s a squirrel.• Squirrel digging. Then he find the bone.



Fey et al. (2004)

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9.00

10.00

TL SLI NLI LNIQ

Na

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ua

lity

grade 2

grade 4



Norbury & Bishop (2003)







NBLI: Lesson Activities

• Story Retell Task• SLP reads story containing 10 exemplars of target

grammatical form• SLP rereads the story component by component• Child retells the story component by component

• Sentence Imitation• 10 sentences pairs: target form vs contrast

• Story Generation Task• Child generates a story about a picture of a scene• SLP illustrates the child’s story for retelling by child



Teaching Procedures

• Modeling sentences with the target forms

• Modeling narrative components: • setting, problem, resolution, complication,

ending

• Recasting phonological, sematic, and grammatical errors

• Verbal prompts to include missing components during story retell activities



Let’s make up a story about this

picture. First, let’s talk about who’s going to be in our story and where our

story is going to take place.

The boy in the river. Here a tube and here another tube. This girl, her

pointing at him. Another girl looking at him. Here a bridge…and a waterfall.



That’s right. The boy is tubing in the river. There are some big

rapids! Two girls are watching him.

Oh no! What do you think might happen in our

story?The boy fall in

the river!



The boy falls in the river.

Can he swim?

No, him don’t know how.



He doesn’t know how! That would be

scary! That’s a good ‘problem’ for

our story. A boy falls in the river but he can’t swim. How

will the boy get back to shore?

Him hafta yell “Help, help!” And she’ll save him.



The boy was tubing in the

river. He fell in the water but he doesn’t know

how to swim. He yells ‘Help, help!’ and the girl saves

him. This is a great story. Let’s start over and tell this

story again.



NBLI: Study Design

10 7 year old children with specific language impairment

Pretests

First Two Weeks (6 Sessions):

1 intermediate goal; 3 specific goals; 6 stories

Second Two Weeks (6 Sessions):


Third Two Weeks (6 Sessions):


Post-tests



NBLI: Results

• 8/10 children exceeded the threshold for clinically significant improvement in Narrative Quality

• Little or no improvement for:• Number of different words• Developmental Sentence Score• Nonsense Word Repetition



NBLI: Conclusions

• Children with SLI may have insufficient attentional resources to learn implicit grammatical targets in the context of an activity that provides explicit instruction in the production of narrative targets.



Recent Modifications of NBLI

• Intervention implemented in small groups (2-3 children)• 12 sessions in 5 weeks• Stories modified to simplify vocabulary• Stories modified to target multiple grammar goals• Story grammar markers (‘story keys’) used to make story

grammar elements explicit• During novel story generation task, each group member

is responsible for a different story element• Sentences for imitation modified to ensure

meaningfulness when taken out of the story context• Future research will evaluate the NBLI when

implemented alone or in combination with FFW







Part IV. Phonology




Development of Speech Accuracy



VL

TT

TB

LP

GL


σ

O R

C V



VL

TT

TB

LP

GL


σ

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C V



VL

TT

TB

LP

GL


σ

O R

C V



Part IV. Phonology




Adult Produced /ɹ/ (left)Child Produced /ɹ/ Distortion (right)



Perception Task

• Stimuli• 25 self-produced words (incorrect)• 25 self-produced words (corrected)• 25 other-produced words (incorrect)• 25 other-produced words (corrected)

• Task• Judge if the word was said ‘right’ or ‘wrong’• Judge if self-produced or other-produced



Right/Wrong Judgments (younger group)

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self+ other+ self- other-

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Jud

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Right/Wrong Judgments (older group)

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self+ other+ self- other-

Per

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Jud

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Production of /ɹ/



Undifferentiated lingual gesture



Part IV. Phonology




SAILS demonstration

[ɹæt]

[wæt]

[jæt]

Speech Assessment and Interactive Learning System.

See www.avaaz.com for more information .



Rvachew (1994): Study Design

Recruited 27 4 year olds with SSD who were unstimulable for /ʃ/

Random assignment

SAILS

/ʃ/ vs errors

SAILS

Cat vs Pete

SAILS

/ʃ/ vs /m/

Concurrent speech therapy for /ʃ/ using a behaviorist approach

Isolation, syllables, words, phrases, sentences

Assessment of perception and production of /ʃ/ 6 weeks later



Rvachew (1994): Production Outcomes

-2.5

-2

-1.5

-1

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0

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1

1.5

2

2.5

shoe vs. Xshoe shoe vs. moo cat vs. Pete

Su

mm

ed Z

Sco

res



Rvachew et al., 2004: Study Design

EXPERIMENTAL

Pretreatment Assessment

Speech Therapy

Literacy Enjoyment

EXPERIMENTAL

Post-treatment Assessment

Follow-up Assessment

EXPERIMENTAL

Post-treatment Assessment

Follow-up Assessment

CONTROL

Pretreatment Assessment

Speech Therapy

Perception Training



Control Condition



Rvachew et al (2004): GFTA errors

Pretreatment Post-treatment Follow-up

10

20

30

40

19% resolved

50% resolved

controlexperimental



Spectrographic Feedback

• Explain to the child that the goal is to lower the starting frequency of the third formant.

• Ask the child to say words that start with /ɹ/. • Help the the child find F3 in the spectrogram.• Challenge the child to lower the F3 starting

frequency in increments of about 100 Hz.• Provide phonetic placement and articulatory

instructions if necessary.



Part IV. Phonology




Part V. Phonological Awareness




Phonological awareness

• The knowledge that spoken words can be segmented into abstract phonological units.

Phonological Word

σ σ σ

O R O R O R

Foot

N N N C

ð ə k l ɑ z ɪ t



Example PA Tasks

• Say “vulbz” without the /b/ • [vʌlz]

• What sound comes after [ɪ] in the nonsense word “nigz” • [g]



Parameters of Task Complexity

matching blending oddity elision

rime

onset

coda

cluster

cognitive load

phon

olog

ical

com

plex

ity

difficulty



VL

TT

TB

LP

GL


σ

O R

C V



mʌmi

dædi



mʌmi

dædi

bɑdo

dɑ

bɛ

mæ

nænæ

no

ke

kʊki

wɑdʌ

wɑ



mʌmi

dædi

bɑdo

nænæ

kʊki

wɑdʌ

dɑ

bɛ

mæ

no

ke

wɑ



mʌmi

mæ

nænæ

no

dædi

bɑdo

kʊki

wɑdʌ

dɑ

bɛ ke

wɑ



mæt

wɑn

mæn

dɑg

bɛd

no

kek mʌmi

dædi

bɑdo

nænæ

kʊki

wɑdʌ

mæd

dɑl

bæt

bæd

dɛd







SpeechPerception

Phonological Awareness

Emergent Literacy

.39

.15

.48.21

.51 .93.48

.38

.96

Articulation

Vocabulary



Speech Perception, Vocabulary and Phonological Awareness

30

40

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60

70

80

90

100

60 70 80 90 100 110 120 130 140


Sp

eech

Per

cep

tio

n

Cluster 1 PA = 22

Cluster 2 PA = 19

Cluster 3 PA = 11

Cluster 4 PA = 9




30

40

50

60

70

80

90

100

60 70 80 90 100 110 120 130 140


Sp

eech

Per

cep

tio

n

Cluster 1 PA = 22




30

40

50

60

70

80

90

100

60 70 80 90 100 110 120 130 140


Sp

eech

Per

cep

tio

n

Cluster 1 PA = 22

Cluster 2 PA = 19




30

40

50

60

70

80

90

100

60 70 80 90 100 110 120 130 140


Sp

eech

Per

cep

tio

n

Cluster 1 PA = 22

Cluster 2 PA = 19

Cluster 3 PA = 11




30

40

50

60

70

80

90

100

60 70 80 90 100 110 120 130 140


Sp

eech

Per

cep

tio

n

Cluster 1 PA = 22

Cluster 2 PA = 19

Cluster 3 PA = 11

Cluster 4 PA = 9



PA and SSD/SLI

0

+ 1

- 1

Normal

Normalized SpeechNo LI SSD

No LI SSDNormalized Language

SSDLI



70

80

100

Typical Resolved SLI Persistent SLI SSD

90

110







Sound Foundations

• Targets• Initial /s/, /m/, /p/, /l/, /t/, and /æ/• Final /s/, /m/, /p/, /l/, and /t/• /ʃ/, /g/, and /ɛ/ were omitted from this study but are

normally part of this program

• Procedures• Worksheets for sound matching• Posters for identifying target words• Card games such as Snap• Dominoes-like game• Recorded jingles with alliteration



Byrne et al: Study DesignRecruited 128 children from 4 preschool programs

Random assignment

Intervention

n = 12 groups

Control

n = 12 groups

Post-treatment assessment about 12 weeks later

Follow-up assessment at end of kindergarten

Follow-up assessment at end of grade 1

Follow-up assessment at end of grade 2

Follow-up assessment in grade 5



Post-treatment Generalization

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4

6

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10

12

Pretest Posttest

Co

rre

ct

Re

sp

on

se

s

Experimental (Initial)

Experimental (Final)

Control (Initial)

Control (Final)



Follow-up Assessments

• Nonword decoding significantly better in the experimental group through grade 5

• No significant differences for real word reading, spelling, or reading comprehension

• 16% of experimental group and 28% of control group scored below 75 on one or more reading tests in grade 5



Word Building: Study Design24 children with poor reading skills at the end of first grade

Randomization

Word Building Intervention

20 sessions, 4 months

Provided with materials from America Reads

Pretest PA, decoding, word reading, passage comprehension

Post-test PA, decoding, word reading, passage comprehension



Word Building Procedures

s a t




s a p




t a p




t o p




t o ps




t o p



Sentence Reading Activity

• Silly Sentences• Can a sick kid kick a stick?

• Tutor provides scaffolding to help the child decode the words in the sentence.

• Playful discussion about the meaning of the sentence.



Word Building Results

Word Attack

80

82

84

86

88

90

92

94

96

98

100

Pretest Post-test

Sta

nd

ard

Sc

ore

Experimental

Control

Word Identification

80

82

84

86

88

90

92

94

96

98

100

Pretest Post-test

Sta

nd

ard

Sc

ore

Experimental

Control

Comprehension

80

82

84

86

88

90

92

94

96

98

100

Pretest Post-testS

tan

da

rd S

co

re

Experimental

Control



Phoneme Discrimination: Study Design

30 children, aged 8- to 10-years

“whole-class” assignment

Phoneme Discrimination Intervention

30 min, 3/wk, 4 weeks

No Intervention

4 weeks

Pretest: alliteration, rhyme, spoonerisms, and nonword reading

Post-test: alliteration, rhyme, spoonerisms, and nonword reading



‘Phenomena’: Procedure



‘Phenomena’: Results



Phoneme Discrimination: Study Design

60 9-year-old children

Randomization

FastForWord

Pretest: phonological awareness, language, and reading

Post-test: phonological awareness, language, and reading

Earobics LiPS



Interventions

• FastForWord• Computer intervention targeting a variety of

auditory, memory, and language skills

• Earobics• Computer intervention targeting a variety of

auditory and phonological awareness skills

• LiPS (Lindamood)• Small group intervention targeting auditory

processing and phonemic awareness at the articulatory level



Improvements x Program

FFW EAROBICS LiPS

PA - + ++

LANGUAGE - - -

READING - - -



Conclusions

• Programs that are narrowly focused on phonological awareness with little or no application to decoding are relatively ineffective in remediation reading deficits.







Part VI. Limits of the Evidence

1. Program goals2. Administrative constraints3. Access to the evidence4. SLP effects



Program Goals:Raise the Average OR Close the Gap



Program Goal:Provide Services OR Label the Child

• Responsiveness to Intervention• 123 children received a 45 hour intensive

instruction program• Two years later only 8 of these children met

the criteria for special education



Administrative Constraints:Six hours of therapy is not enough!

Treatment

N = 71

Watchful Waiting

N = 88

Still eligible for treatment receipt

62% 77%

Odds Ratio for Improvement > .25 s.d.

Auditory Comprehension 1.4

Expressive Language 1.1

Phonology 2.7



Accessing the Evidence



Therapist Effects

Best therapist

Worst therapist



What makes the difference?• In psychotherapy:

• Outcomes were NOT related to:• Level of training• Type of training• Theoretical orientation• Gender

• Outcomes WERE related to:• Duration of therapy:

• LESS therapy BETTER outcomes

• Hypothesis:• Some therapists encourage dependency in their clients



Barriers to the Application of EPB

Documents

Evidence Based Practices for the Management of School Age Speech and Language Disorders