A. Lynn Williams, Ph.D. East Tennessee State University Updates in Treating Updates in Treating Speech Disorders Speech Disorders in Children in Children Workshop Objectives Workshop Objectives • Make it ACAP ACAP Assessment Assessment PVM and SPACS Analyses Target selection Target selection New perspectives on old procedures New approach: Distance Metric Intervention Intervention Contrastive Approaches Software support (SCIP) Time Time Management Management Time Management Time Management ASHA (2000) identified “organizing and time management” as one of nine skills that graduate students in SLP/A need to learn in addition to their “technical knowledge” of the field (Long, 2001) Time Management Time Management 1. Collect speech sample 2. Transcribe sample 3. Analyze sample 4. Interpret results 5. Select appropriate treatment targets 6. Select appropriate treatment model 7. Develop list of training exemplars 8. Retrieve pictured stimuli for training exemplars 9. Copy, cut, and paste treatment pictures onto index cards 10. File pictured stimuli and data sheets in client folder (and hope they don’t fall out as you run to session!) Time: Time: • Less time • More time required on the front end for SLPs – Less training and linguistic expertise required to complete analyses and develop treatment materials – Availability of commercial materials required on the front end for SLPs – More training and linguistic expertise to complete analyses and develop treatment materials – Currently no commercial materials available for newer treatment models Longer periods of time in treatment for clients (5-6 years; Hodson, 1998) Shorter periods of time in treatment for clients (2-3 years or less; Williams, 2000) v s Traditional Approaches Traditional Approaches Phonological Approaches Phonological Approaches 1
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A. Lynn Williams, Ph.D.East Tennessee State
University
Updates in TreatingUpdates in TreatingSpeech DisordersSpeech Disorders
in Childrenin Children
Workshop ObjectivesWorkshop Objectives• Make it ACAPACAP
AssessmentAssessmentPVM and SPACS Analyses
Target selectionTarget selectionNew perspectives on old proceduresNew approach: Distance Metric
InterventionInterventionContrastive ApproachesSoftware support (SCIP)
Time Time ManagementManagement
Time ManagementTime ManagementASHA (2000) identified
“organizing andtime management”as one of nine skills that
graduate students in SLP/Aneed to learn
in addition to their“technical knowledge”
of the field(Long, 2001)
Time ManagementTime Management1. Collect speech sample2. Transcribe sample3. Analyze sample4. Interpret results5. Select appropriate treatment targets6. Select appropriate treatment model7. Develop list of training exemplars8. Retrieve pictured stimuli for training exemplars9. Copy, cut, and paste treatment pictures onto index cards
10. File pictured stimuli and data sheetsin client folder(and hope they don’t fall out as you run to session!)
Time:Time:• Less time • More time
required on the front end for SLPs– Less training and linguistic
expertise required to complete analyses and develop treatment materials
– Availability of commercial materials
required on the front end for SLPs– More training and linguistic
expertise to complete analyses and develop treatment materials
– Currently no commercial materials available for newer treatment models
Longer periods of time in treatmentfor clients (5-6 years; Hodson, 1998)
Shorter periods of timein treatment for clients
(2-3 years or less; Williams, 2000)
vvss
Traditional ApproachesTraditional Approaches Phonological ApproachesPhonological Approaches
1
Time:Time:
required on the front end for SLPs
• Shorter periodsin treatment for clients(2-3 years or less; Williams, 2000)
Phonological ApproachesPhonological Approaches
• Less time
ItIt’’s Also About Times Also About Timefor Our Clientsfor Our Clients
• Critical age hypotheses for remediating unintelligible speech:– Unintelligible speech must be resolved
by age 5;6 in order to significantly reduce academic problems associated with speech disorders(Bishop & Adams, 1990).
ItIt’’s Also About Times Also About Timefor Our Clientsfor Our Clients
• Critical age hypotheses for remediating unintelligible speech:– Unintelligible speech during
early school years may affectliteracy development.
ItIt’’s Also About Times Also About Timefor Our Clientsfor Our Clients
• Critical age hypotheses for remediating unintelligible speech:Given that many children do not come to SLP for treatment until age 4 (Castrogiovanni, 1999), there is a significant need for efficient and effective therapies to remediate the speech disorder within a short time period (e.g., 18 months)
ItIt’’s Also About Times Also About Timefor Our Clientsfor Our Clients
• Traditional analyses, and some newer approaches, are based on the description of individual sounds in relation to the adult sound system– Provides a more fragmented description of child’s speech
disorder– Sound-to-sound comparison
• System-based analyses, such as SPACS, map child’s system to the adult’s system– Provides a holistic description of child’s sound system in
relation to the ambient sound system– System-to-system comparison
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Sound Based orSound Based orSystemSystem--Based?Based?
Characteristics of a Characteristics of a Phonological DisabilityPhonological Disability
• Child’s system is smallerthan the adult system
• One-to-manycorrespondence betweenchild:adult systems
• Relationship between the phonetic properties of adult target and child’s production
Systemic PhonologicalSystemic PhonologicalAnalysis of Child Speech Analysis of Child Speech (SPACS)(SPACS)
• Child’s ENTIRE system is examined as a unique, independent system (“own language”)
• Views child as ACTIVE and CREATIVE learner of the sound system
• Compares SYSTEM to SYSTEM (child:adult)• Maps child:adult system in terms of
phoneme collapses (one-to-many correspondence)
• Child-based rather than adult-based
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Systemic PhonologicalSystemic PhonologicalAnalysis of Child Speech Analysis of Child Speech (SPACS)(SPACS)
• Describes idiosyncratic errors not captured by common phonological processes
• Provides a holistic assessment of child’s speech• Phoneme collapses (phonological rules) are seen
as compensatory strategies that child uses to accommodate a limited sound system to the larger adult sound system– these compensatory strategies are organized
according to particular aspects of adult system in terms of PLACE, MANNER, VOICE
• There is “order” in the “disorder”
GFTAGFTA--22Data SetData Set
(Adam)(Adam)
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5
6
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8
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SPACS Phoneme CollapseSPACS Phoneme Collapsegb stopsdð w glidesf jv w l liquidss fricatives rz fl clusters
g ʃ slʧ affricates swʤ 1:7 phoneme collapsegldrfrgr clusterstrkwst
1:18 phoneme collapse
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12
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TargetTargetSelectionSelection
Selecting Targets for InterventionSelecting Targets for Intervention
• Target selection is the between assessment and intervention
- Earlier or laterdeveloping sounds?- Absent or inconsistentsounds?
- Stimulable or non-stimulable sounds?- Targets from the same or different
classes?- Clusters or singletons?
Influence of Phonological ComplexityInfluence of Phonological Complexityin Management Decisionsin Management Decisions
• Shift in traditional methods of target selection– Traditionally, select sounds that were assumed to be
easiereasier to produce and followed a developmental sequence
– Early, stimulable, and inconsistent sounds
• Currently, new methods of target selection examine the role phonological complexityphonological complexity has on learnability– Specifically, select sounds that are more complex
(later, non(later, non--stimulable, and absent sounds)stimulable, and absent sounds)– Shift from “sound learning” to “system shifting”
Traditional Traditional vsvs PhonologicalPhonologicalApproaches to Target SelectionApproaches to Target Selection
TraditionalTraditional PhonologicalPhonological•• Based on Based on phonemicphonemic
•• Ease of the production:Ease of the production:-- early developing soundsearly developing sounds-- stimulablestimulable soundssounds-- inconsistent soundsinconsistent sounds
•• Based on Based on motoricmotoricaspects of sound aspects of sound learninglearning-- greater individual sound greater individual sound learninglearning
•• Based on Based on learnabilitylearnability-- greater systemgreater system--wide wide changeschanges
ComplexityComplexity A Third Optionfor Target Selection
• The distance metric represents a different perspective to target selection that doesn’t rely on the dichotomous characterization of targets as early ~ late; stimulable ~ non-stimulable; known ~ unknown, etc.
A Third Optionfor Target Selection
• Rather, it is based on the function a particular sound has within a given child’s system– Using phoneme collapses that represent
compensatory strategies developed by the child to accommodate a limited phonetic inventory, we can use a distance metric to select those targets that will result in the greatest amount of change in the least amount of time
• Select up to 4 different target sounds from one rule set based on two parameters:– Maximal Distinction:
select targets that are maximally different from child’s error in termsof PVM
– Maximal Classification:select targets from each of the following:
(a) different manner classes (b) different places of production (c) different voicing
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Target Selection Using Distance Metric
dkʧfsʃstsktrkrkl
1:11 phoneme collapse
Maximal Distinction
clusters
fricatives
affricate
stops Maxi
malClass
ifi
cation
t
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Targets Selected for AdamTargets Selected for Adamgb stopsdðfvs fricativesz
g ʃʧ affricatesʤgldrfrgr clusterstrkwst
1:18 phoneme collapse
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Distance MetricDistance MetricBy selecting targets that are more distinct
from the child’s error(maximal distinction)
and are representativeof the sound classes
collapsed across a phoneme collapse (maximal classification),
the target sounds are more salientand therefore predictedto be more learnable.
Distance MetricDistance Metric• Systemic/functional characteristics of target
sounds are specific to each child’s own unique system
• Assumes that the importance of target sounds is broader than the characteristics of the sound itself.
• The function of a sound is dependent on the role it plays in a particular child’s unique sound system and therefore it will vary from child to child.
With the distance metric,targets are the salient
“corner puzzle pieces”that help the child
put together the big pictureof the adult sound system
Target Selection:Target Selection:The BIG PictureThe BIG Picture
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Practice Selecting Treatment Targetsw w glideglidel l liquidliquidff
h s h s fricativesfricativesʃʃswsw clustersclustersslsl
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Practice Selecting Treatment Targetsb b d d stopsstopsgg
ØØ ð ð v v fricativesfricativeszzʤʤ affricateaffricate
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Estimates of changes in “Big 10” errors
Three-fourths5%19%//
Three-fourths5%23%//
Three-fourths4%18%Vocalic /r/
Two-thirds8%22%/r/
Age of acquisition <6/v/
About half6%10%//
Very little8%10%/ʧ/Less than half7%11%//
Less than half10%18%/z/
Less than half10%17%/s/
How much change?% of children in error at age of typical acquisition
Percentage of children in error at age 6
Phoneme
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History of Residual Errors
• From percentage of changes after age 6, it’s clear that improvement only occurs for some phonemes (/r, ɝ, , /
• More than half of the children still in error at age 6 are not going to improve on /s, z, ʃ, ʧ, /– In fact, they will get to practice their error for another
year or two if use developmental norms• In particular, self-correction of /s/ is unlikely;
especially if it is a lateralized distortion
Residual Errors• Need to predict which children with one or more
residual errors will correct them without intervention and which ones will not
• Research suggests that children 5-6 years old who are not stimulable for an accurate production will need intervention; those who are stimulable may self-correct.
• Therefore, may want to do short-term intervention with first graders who are not stimulable in order to make them stimulable and then monitor for change– “jump-start” the process and prevent later intervention
Choosing Challenging Targets for Intervention
• How can we get kids to jump to the norms? How can we achieve 2-3 year gains in 1 year?
• Are we applying our resources in the best possible way?
• Nelson, Camarata, & colleagues suggest we need to consider the level of challenge of task
High and Low Challenge Targets
Low Challenge TargetsCould run risks:
• hold child below optimal learning rates
• child less interested
• child’s ability is greater than their assessment performance
High Challenge TargetsCould frustration discourage the
child?
• YET with rich supports and supportive contexts, child can get RAPID change
• child is positively engaged
• Series of studies by Nelson & colleagues reported that higher challenges were picked up quicker
Goal Attack Strategy (Fey, 1986)
•• How many goals How many goals do you target in do you target in one one txtx session?session?
•• Do you use a Do you use a horizontal, vertical, horizontal, vertical, or cyclical or cyclical strategy?strategy?
Phonological?Phonological?• Traditional approaches focus
on individual sound learning– Emphasis is on placement and
sound production accuracy
• Phonological approaches focus on system-wide change– Emphasis is on generalization and system
shifting
Homonymous or NonHomonymous or Non--homonymous?homonymous?• Homonymous approaches directly
confront child’s rule by contrasting his/her error with the new target sound(s) to be learned.
• Non-homonymous approaches indirectly address child’s rule with assumption that greater contrastive distinction of word pairs facilitates learning.
- Minimal Pairs and Multiple Oppositions
- Maximal Oppositions and Empty Set
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Minimal Pairs: contrasts the childchild’’s errors error with the target target soundsound
Designing Treatment for AdamDesigning Treatment for Adam
error ~ target
example: g ~ d / #____
go ~ doegate ~ dategown ~ down
Guy ~ dyegame ~ dame
Designing Treatment for AdamDesigning Treatment for AdamMaximal Oppositions: Contrasts a “known”, independent, and maximally different sound with the target sound
correct ~ target
Example: m ~ d / #
moo ~ dewmore ~ doormate ~ dateMay ~ dayme ~ Dee
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Empty Set: Contrasts two target sounds that are unknown, independent, and maximally different from each other
Designing Treatment for AdamDesigning Treatment for Adam
Target 1 ~ Target 2
Example: r ~ d / # ____
row ~ doeray ~ dayrye ~ dyeran ~ Danram ~ dam
Designing Treatment for AdamDesigning Treatment for AdamMultiple Oppositions: Contrasts child’s error with several target sounds from across an entire rule set.
error ~ targets
df
g t∫ # _____st
dew dill deerFu fill fear
goo chew gill chill gear cheerstew still steer
daze Danefaze feign
gaze chaise gain chainstays stain
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Multiple OppositionsMultiple OppositionsAssumes learning is facilitated by the size and nature of linguistic “chunks” presented to the child (learning of the whole is greater than the sum of its parts)
Assumes learning is a dynamic interaction between child’s unique sound system and intervention
Predicts learning will be generalized across a rule set (i.e., learning will generalize to obstruents and clusters collapsed to [g] in the 1:17 phoneme collapse) and result in system-wide restructuring.
• Generalization Criteria– 90% accuracy on target in untrained probe items– If this is met, 50% accuracy on target in
conversation
Phase 2: Contrasts + Naturalistic Activity
• Imitation– Comparison word first, then target word– Slower models, physical prompts, focus (antecedent
event)– Shadowing, set-ups (during)– Feedback (consequent event)– Gradually fade supports; switch order of presentation
• Naturalistic Play Activities– Sound-loaded communication-centered activities– Dense responses (generally at least 20 responses in 5-8
min)
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Phase 3: Contrasts within Communicative Contexts
• The focused practice and the play are intertwined
• Play games with the contrasts– Away from the computer (Go Fish,
Memory/Concentration, Teacher, What’s Missing?)
– At the computer (Teacher, 20 Questions, $10,000 Pyramid, Hide-a-Pix)
Phase 4: Conversational Recasts
• Develop sound-loaded communicative scenarios– Naturalistic Speech Intelligibility Training
(NSIT)– Immediate recasts (“hotspots”)
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Working in Small Groups
• Grouping children together does not require that they areworking on the same goals
• Each child has a turn with their treatment profile
• Tallies can be kept to see which child, or team, has the most points to encourage healthy competition among the children or between groups of children to motivate them
• Each child, or team, takes turns being the “teacher” and “student”
• Use peers to monitor accuracy, give feedback, and provide assistance
• Each child, or team, can “phone a friend” if they need help
Nick and Savannah Video
Savannah (g ~d, ʧ, s, fl)
Nick (j ~ z, ʃ, sl)
Removing the Removing the Barriers Through Barriers Through
TechnologyTechnology
We could develop a software program?
What If What If ……??
– with an extensive database of illustrated words?
– that could be used with any of the contrastive approaches?
?
??
??
– at the click of a mouse?
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Sound Contrasts in PhonologySound Contrasts in Phonology
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Group InterventionGroup InterventionUsing SCIPUsing SCIP
Multiple oppositions
Gliding668305;9LJ
Multiple oppositions
Gliding1485205;7TD
Minimal pairsGliding669285;11SR
Contrastive Treatment Approach
Targeted Error
Pattern
PercentileStandard Score
Raw ScoreAgeParticipants
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Summary of Group TreatmentSummary of Group TreatmentUsing SCIPUsing SCIP
• All children exhibited improvement on their target sounds– The 2 children who received training on w ~ l, r
using MO exhibited moderate to significant improvement in treatment performance
– These children also exhibited generalization of the target sounds to untrained words
Summary of Group TreatmentSummary of Group TreatmentUsing SCIPUsing SCIP
• These results indicate that SCIP was effective in children achieving improvement in treatment and generalization during a brief treatment period of only 10 sessions that were 30 minutes in length within a group setting
Working with SCIPaway from the computer
• Hide the cards in big boxof rice or beans
• Put chip/token on each picture as child produces it
• Play “Go Fish”, “Teacher, Concentration”, and “What’s Missing?”with the cards
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What is What is Evidence?Evidence?
Evidence-Based Practice
• Purpose of EBP in clinical intervention is to promote effective protocols while delaying the adoption of unproven protocols, and preventing the adoption of ineffective interventions (McCauley, 2004)
Integrating EBP• Each of the 4 intervention approaches
represents highly credible evidence to support the effectiveness of each treatment approach
• Therefore, users of SCIP will be implementing phonological treatment models that have high levels of evidence that support their effectiveness
– Levels I and II of the EBP framework criteria used to evaluate the quality and credibility of evidence
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Practice Based Evidence• SLPs can document their practice based
evidence and answer their own clinical questions about the effectiveness of their interventions with the clients they serve.
– Data collection and graphing features of SCIP provide SLPs theirown database to evaluate the effectiveness of their treatment
– Data can be used to evaluate specific treatment approaches, document clinician accountability, and compare differences in performance across clinical sites.
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Using SCIPas a Practice Based Evidence Tool
– Data-tracking options can be used to examine treatment performance with regard to differences in progression through intervention in terms of time spent at imitative and spontaneous levels of production and differences in performance related to specific vowel contexts
– Comparisons can be made across clients and clinical sites with regard to overall performance, number of contrastive word pairs used in treatment, number of treatment sessions, and total treatment time in minutes
• What is thetime investment
for the SLP?• What arethe benefits
for the client?• Is one approach best?
Wrap Up:InterventionIntervention
Let’s Revolutionize Therapy!• Hodson (1998) indicated that only
about 10% of SLPs were incorporating phonological principles in their practice
• We can bridge the gap between research and practice with access to newer models of intervention
• And … decrease the time that children are on our caseloads
A. Lynn Williams, Ph.D.Professor
Department of Communicative DisordersEast Tennessee State University