interventions within broader contexts: part i speech and concomitant impairments

Interventions within Broader Contexts: Part I

Speech and Concomitant Impairments

Overview of 12 Interventions within a Broader Context• Psycholinguistic intervention• Metaphonological intervention• CBI• Perceptual intervention• Nonlinear phonological intervention• Dynamic systems (whole language)• Morphosyntactic intervention• Naturalistic speech intelligibility training• Parents and Children Together (PACT)• Enhanced Milieu Teaching with Phonological Emphasis• PROMPT• Family-focused interventions

Levels of Evidence (LOE)

Level Description Approach

1a Well-designed meta-analysis of >1 randomized controlled trial

MPA

1b Well-designed randomized controlled study MPA; CBI; Perc; DS; MS; NSIT; FF

2a Well-designed controlled study without randomization

MPA; Perc; NPI; MS; NSIT; PACT; EMT/PE; PROMPT; FF

2b Well-designed quasi-experimental study PLI; MPA; NPI; DS; MS; PROMPT

3 Well-designed nonexperimental studies, i.e., correlational and case studies

PSI; MPI; NPI; DS; NSIT; PACT; EMT/PE; PROMPT

4 Expert committee report, consensus conference, clinical experience of respected authorities

PSI; EMT/PE

3 Stages of Research

Stages of Research LOE Number of Studies

Exploratory Studies 3 25

Efficacy Studies 2b

2a

21

21

Effectiveness Studies 1b 19

LOE: Promising Interventions with Probable Efficacy

Stages of Research LOE Number of Studies

Exploratory Studies 3 25

Efficacy Studies 2b

2a

21

21

Effectiveness Studies 1b 19

Characteristics of InterventionsComparative Factors

Specifications

Age 3;0-6;0 • NSIT primarily for toddlers/preschoolers; MPA/PSI for school-age

Population Concomitant speech/language; speech/literacy impairments• cleft lip/palate (EMT/PE)• Down syndrome; ASD; stuttering (NSIT)

Intervention Agents SLP• Supplemental assistants: (parents/caregivers; paraprofessionals; teachers)

Key Components Varies, but can include perception, language (vocab, morphology, syntax, phono awareness, literacy)

Characteristics of Interventions: con’tComparative Factors

Specifications

Broad Goals Increase speech intelligibility and communicative competence• speech + language• speech + phonological awareness and literacy

Target Selection Primarily developmental; mismatch between perception and production or morphophonology and production

Level of Focus Speech output (perception and production of phoneme within words or conversation)

Session Type Individual and/or small group (30-60 min 2x/wk)

Technology Interactions between child and others; SCIP; PFSS; SAILS

ICF-CY Codes Primarily b320: Functions of productions of speech sounds(Others include: b330; b2304; b176; b16710; Activities and Participation emphasis: d140; d330; d350)

Psycholinguistic Intervention (Stackhouse & Pascoe)

Developmental level

Targeted stage of production

Targeted outcomes

Emerging

Developing

Elaboratng

Key components

Tech and/or materials

Specific diagnoses

Planning

Program

Execution

Spch Prod

Spch Perc

Phono awareness

Other oral Language

Literacy

X XSpeech input (e.g., auditory discrim), lexical representations (e.g., semantic, phonological, motor), speech output (e.g., programming and production of speech)

All resources can be used in a psycholinguistic way; new or specific materials not required

Speech and literacy difficulties

X X X X X X X

3 Components of PLA

1. Speech Processing Profile (series of questions; Fig 9.2)

2. Box-and-Arrow Model of Speech Processing

3. Developmental Phase Model

Simple Speech Processing Model

Box-and-Arrow Model: Speech Processing Routes

Developmental Phase Model: 5 Phases

1. Prelexical Phase (pre-words birth – 1 year)

2. Whole Word Phase (first 50 words – up to age 2)

3. Systematic Simplification Phase (consistent simplifications; 2;6-4;0)

4. Assembly Phase (mastering of connected speech; 3-4;0)

5. Metaphonological Phase (phonological awareness; age 5)

PLA Task Design

• 4 components of task designTASK = Materials + Procedure + Feedback +/- Technique

(e.g., instructions) (e.g., signs/symbols)

• 3 levels of task design:1. Design intervention tasks

2. Understand why altering any one of the 4 components, even minimally, can change the psycholinguistic nature of the tasks and therefore the demands made on the child

3. Use this knowledge to manipulate tasks at the time of delivering them to meet the needs of the child (i.e., how to make task easier or more challenging for child)

PLI: Review Case Study

• Describe the characteristics of child

• How is speech assessed?

• Describe intervention and results

Psycholinguistic Intervention: Review Questions

Metaphonological Intervention (Hesketh)

Developmental Level

Targeted stage of production

Targeted outcomes

Emerging

Develop

in

Elabor

at

Key components

Tech and/or materials

Specific diagnoses

Planni

ng

Progra

m

Executi

on

Spc

h Prod

Spch Perc

Phono aware

ness

Other

oral Language

Literac

y

X X Emphasis on phonological awareness including rhyming, syllable clapping, alliteration, blending, and segmenting activities followed by production of contrasting sounds and minimally paired words

Can include some computer-based resources (e.g., PFSS or SAILS), but not required; written letters linked to picture; standard clinical materials

SSD + PA X X X

Relationship among PA, Speech, and Literacy• PA (particularly phoneme awareness)

important in early literacy acquisition• Children with SSD have poorer PA skills• Therefore, children with SSD are at risk for

literacy difficulties• Some children with pure SSD have good

PA skills• Teaching phoneme awareness

improves phoneme awareness + literacy

• No evidence that PA should be taught separately or as a precursor to speech dev

Unique features of theMetaphonological approach

o aims to increase children’s awareness of word forms and how their own differ from the adult target, to facilitate speech change and literacy acquisition.

o MAKES CHILDREN THINK about the structure of words in ways directly related to their speech patterns

o encourages children to be agents in their own learning; helps them understand the need for change and how to achieve it

o facilitates and capitalises on literacy development

o it is integrated with speech production practice and can be adapted to any phonological goal.

MPA Activities

• Sound matching• Mispronunciation identification• Categorization from internal

representations (silent rehearsal)

MPI: Review Case Study

• Describe the characteristics of child

• How was his speech assessed?

• Describe intervention and results

Metaphonological Intervention: Review Questions

Speech Perception Intervention (Rvachew)

Developmental level

Targeted stage of

production

Targeted outcomes

Emerging

Developing

Elaborating

Key components

Tech and/or materials

Specific diagnoses

Planning

Programming

Execution

Spch Prod

Spch Perc

Phono aware

ness

Other oral

Language

Literacy

X Phonemic perception training

SAILS computer program

SSD X X X

SAILS: Speech Assessment and Interactive Learning System

• SAILS involves a two-alternative, forced-choice identification procedure involving real words– Natural recordings of words, half articulated

correctly by various child or adult speakers with typical speech and half misarticulated by various child speakers with SSD

• Visual feedback is provided for correct responses

Unique features ofspeech perception approaches

• Clarification: Phonemic perception intervention is a procedure, not an approach.

• Compatible (and tested with) linguistic and motoric approaches to the promotion of speech intelligibility.

• SAILS presents the child with highly variable natural stimuli that include actual rather than simulated misarticulations of target words produced by multiple talkers.

SPI: Review Case Study

• Describe the characteristics of each child

• How were their speech skills assessed?

• Describe intervention and results

Speech Perception Intervention: Review Questions

Nonlinear Phonological Intervention (Bernhardt)

Developmental level Targeted stage of production

Targeted outcomes

Emerging

Developin

Elaborat

Key components

Tech and/or materials

Specific diagnoses

Planning

Program

Execution

Spch Prod

Spch Perc

Phono awareness

Other oral Language

Literacy

X X Constraint-based nonlinear approach targeting prosodic structures and segments by considering individual phonological units and interactions between phonological units

Audio and video recording; creative materials, including costumes and props can be included to dramatize certain speech elements

Range of etiologies

X X X X X

Nonlinear Phonology

• Description of hierarchial representation of phonological forms from prosodic phrase to individual distinctive features

• Tiers within phonological hierarchy– Features– Segment– Larger prosodic units (syllables and feet)

Unique features of Nonlinear phonological intervention

Q: How much fun is there in nonlinear /fənɑlədʒi/?

A: The [fən] starts at the feature and ends at the prosodic phrase

Focus on multiple levels will enhance Tx outcomes....

Hola from Canadaand the GSFs.....

4 Basic Types of NL Intervention Goals

FORMS

DOMAIN New Form Existing Form in New Structures or Combinations

Prosodic Structure New word lengthsNew stress patternsNew word shapes

New word positionNew sequences

Segments and Features

New individual features (e.g.,

[+continuancy]

New simultaneous feature combinations

NPI: Review Case Study

• Describe the characteristics of the child

• How was the child’s speech skills assessed?

• Describe intervention and results

Non-linear Phonological Intervention: Review Questions

Enhanced Milieu Teaching/Phonological Emphasis (Scherer and Kaiser)

Developmental level

Targeted stage of production

Targeted outcomes

Emerging

Developin

Elaborat

Key components

Tech and/or materials

Specific diagnoses

Planning

Program

Execution

Spch Prod

Spch Perc

Phono awareness

Other oral Langu

age

Literacy

X X • Vocabulary and speech sound production simultaneously

•Phonological recasting

Materials/ toys of interest to child; occasional limited use of low resistance blowing toys (e.g., bubbles)

SSD; CLP

X X

Unique features of the Enhanced Milieu Teaching-Phonological Emphasis approach

• Supports phonological change simultaneously with language for children under 3 years of age

• Components– Target words chosen based on phonologic and

vocabulary criteria– Phonetic awareness to promote consonant

production & oral airflow– Responsive interaction and environmental

arrangement to promote engagement in play and communicative activities

– Prompting strategies provide opportunities to model, expand, request responses, and recast speech sound targets

EMT-PE Review Questions

1. EMT-PE facilitates which two communicative components?

a. Verb tenses and speech sounds

b. Vocabulary and speech sounds

c. Communicative functions and speech sounds

d. Semantic relations and speech sounds

2. Generalization of goals into routine communicative interaction is enhanced through

a. Target word selection

b. Clinician use of speech recasting

c. Parent training

d. Transcribing data

3. EMP-PE fosters speech development in children with CLPa. Expansion of consonant inventories

b. Prevention of habituation of compensatory artic errors

c. Reduction of phonological processes

d. a and b

e. All of the above

PROMPT: Prompts for Restructuring Oral Muscular Phonetic Targets (Hayden)

Developmental level

Targeted stage of production

Targeted outcomes

Emerging

Developin

Elaborat

Key components

Tech and/or materials

Specific diagnoses

Planning

Program

Execution

Spch Prod

Spch Perc

Phono awareness

Other oral Langu

age

Literacy

X X X • addresses motor phonemes (via auditory-tactual input) and lexicon within broader linguistic context

No specific materials required (toys, books, academic resources); also some PROMPT intervention materials, including computer software, stimulus cards, and web site resources (SmarTalk)

SSD; CAS

X X X X X

Unique features of thePROMPT approach• Uses Global Domain Analysis, Speech Analysis Observation and Motor

Speech Hierarchy to create, assess and devise a Communication Focus for treatment goals & objectives.

• Works across all domains (physical-sensory, cognitive-linguistic, social-emotional) and embeds motor speech actions at the appropriate level to establish functional communication.

• Uses very specific types of tactual input devised to support and activate different levels of the motor system; varies according to child profile.

• Always uses a motor-phoneme warm-up (mass practice), and implements distributed, variable practice in functional, game-like activities. Always gives clear feedback and directions e.g. “yes”, “no”, “correct”, “incorrect”.

• Co-articulation is always worked on. Beginning at the basic syllable level e.g. “be”, “bo”, “ba” , the changes (acoustically) that result from different motor movements and timing are considered

• Always includes turn-taking, choice making in age appropriate activities, routines, games.

• Parents are an essential part of the team and work with clinician to develop appropriate home program.

• Can be used with clients with cognitive impairments.• PROMPT is a motor skill; requiring extensive clinician training and practice.