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Targeted early intervention for 2 yr olds with cleft-type speech patterns: Findings implications from an MSc project

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Targeted early intervention for 2 yr olds with cleft-type speech patterns: Findings implications from an MSc project

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    1. Targeted early intervention for 2 yr olds with cleft-type speech patterns: Findings & implications from an MSc project Samantha Calladine Specialist SLT

    2. Background & rationale MSc – opportunity to undertake a small research project Early therapy intervention – babble workshop (Cooper, 2008), input modelling Local SLT provision – need to provide evidence-based recommendations Very good studies on speech development + nature & characteristics of atypical speech output: Facilitate early identification Justify the aims & rationale for early intervention Few studies describing / evaluating methods of intervention: Recommendations based on theory & experience not empirical research

    3. Background In Trent, ~50% of 2 yr olds present with CTCs (Calladine, 2008) Nationally, 31% of children present with CTCs at 5 yrs (Britton, 2009) (based on 2 yrs data) Goal: optimal speech by 5 yrs (Lead SLT Forum, 2009) Atypical patterns (CTCs) reliably identified at 18 mths (Bowden et al., 1997; Barrett & Extence, 2010) Targeted early intervention from 18 mths / 2 yrs To help us achieve optimal speech by 5 yrs ?

    4. Literature review: Nature & characteristics of atypical speech output Pre palate repair, atypical phonetic patterns manifesting in babble are directly related to abnormal anatomy (Russell & Harding, 2001): Fewer oral plosives, predominance of non-orals & nasals, etc. (O’Gara & Logemann, 1988; Russell & Grunwell, 1993; Chapman, 1991; Chapman et al., 2001) Atypical patterns transfer to emerging canonical babbling Psycholinguistic perspective (Stackhouse & Wells, 1997): Primary motor execution deficit Secondary deficits in motor programming / MP / motor planning ?

    5. Literature review: Nature & characteristics of atypical speech output After palate repair (normalised anatomy & function), typically expect phonetic normalisation: ? in size of inventory, especially oral consonants Fewer glottals & pharyngeals (Grunwell, 1988; Chapman & Hardin, 1992; Russell & Grunwell, 1993; Chapman et al., 2001; Jones et al., 2003) Psycholinguistic perspective: Deficit in motor execution resolved Normalised motor programming /MP / motor planning

    6. Literature review: Nature & characteristics of atypical speech output But, atypical patterns don’t always resolve (Russell & Grunwell, 1993; Russell & Harding, 2001): Persisting abnormal anatomy / function (VPI, fistulae) ? ability to make sounds continues to be affected Psycholinguistic perspective: Persisting deficit in motor execution Secondary deficits in motor programming / MP / motor planning Normalised anatomy / function ? ‘phonologisation’ – use of sounds is affected Psycholinguistic perspective: Deficit in motor execution resolved Persisting secondary deficits in motor programming / MP / motor planning Tertiary deficit in phonological representation (PR) ?

    7. Literature review: Aims & methods of early intervention Routine early intervention (Phippen, 2006) Up to 12 mths: general information and advice to all parents From 6 mths: some provide specific advice with demonstration Prevent phonologisation of atypical patterns In the U.S., direct speech intervention from 8 months (Golding-Kushner, 2001; Hardin-Jones & Chapman, 2008) Targeted early intervention From 18 mths / 2 yrs: input modelling therapy approaches for children with CTCs (Dive, 2001) Stimulate favourable speech patterns & prevent development of compensatory patterns De-stabilise phonologised atypical patterns Make early hypotheses about adequacy of VP function Promote successful parent-child interaction (Russell & Harding, 2001; Russell & Albery, 2005)

    8. Literature review: Aims & methods of early intervention Most intervention research reports outcomes on children 3 yrs + e.g. Pamplona et al. (2004) Some emerging data on younger children Naturalistic, language-based intervention (Scherer & Kaiser, 2007) Milieu: behavioural principles to prompt and support, e.g. expansion – includes modelling but low frequency (Scherer, 1999) Focused stimulation: emphasis on high frequency modelling and responsive interaction – use environment – emphasis on word-initial sounds “by adding an ‘h’ after the sound” (Scherer et al., 2008, p30) Use environment / everyday activities / conversational partner Parent- vs. SLT-implemented To expand vocabulary & sound inventories Rationale: ? vocabulary => ? opportunities for sound production => improve speech (Girolametto et al., 1996)

    9. Literature review: Aims & methods of early intervention Scherer (1999) Prospective SLT-implemented milieu – 2x50 min sessions per wk; 5-9 sessions – x 2 phases 3 x 2yr olds All children: ? phonetic inventories (but related to resolution of typical phonol processes?) Limitations: case studies; limited phonetic analysis & no phonological analysis Scherer et al. (2008) Prospective Parent-implemented focused stimulation - 3 mth period 10 experimental + 10 non-cleft controls – 14 to 36 mths of age Parent training was successful (? modelling of target words, ? expansion, ? use of commands) Both groups: signif ? phonetic inventories Experimental group: signif ? PCC & signif ? glottal stops Limitations: non-cleft controls; limited phonetic & phonological analyses, limited qualitative analysis

    10. Literature review: Aims & methods of early intervention Hardin-Jones & Chapman (2008) Retrospective Sound modelling + tactile placement cues & milieu & oral motor 10 referred + thpy; 10 referred no thpy (controls); 10 not referred; 10 non-cleft Onset = 9 to 21 mths of age 1x60-75min session per wk; 1 had 2x30 min per wk – total? Thpy vs. no thpy: no diff. at 17 mths; signif. diff.% glides correct at 27 mths All no thpy chn still needed it Limitations: retrospective; different intervention methods Scherer & Kaiser (2007) Review of early intervention practices In 20 yrs, only 9 studies report treatment data Current studies don’t meet evidence-based practice standards Recommend differentiation of treatment goals & methods btwn 30 & 36 months: “Reluctant”: parent-implemented lang. intervention “Unintelligible”: greater focus on sp. sound stimulation

    11. Multi-sensory input modelling therapy Harding-Bell & Bryan (2001); Harding-Bell (2004; 2007) Aims: To stimulate speech output through silent rehearsal and reflection without emphasis on output Increase awareness of sounds without any pressure to perform Principles: Stimuli modelled with high frequency of repetition Input-only; stimulate all senses (auditory, visual, tactile) Non-confrontational / non-corrective Parents taught how to model Based on psycholinguistic theories of speech processing Concept: stimulating input will stimulate output (McGurk & MacDonald, 1977) Developmental theories of imitation (Meltzoff, 2002) Similarities with Hodsen’s (1991) auditory bombardment approach

    14. Using MSIMT in Trent Targeted approach: 2yr olds with CTCs Variability: Number & frequency of sessions Specialist vs. non-specialist SLT +/- videotherapy Expressive language targeted simultaneously – key vocab, strategies to ? opportunities for communication Input stimuli: isolation ? real words Real words: linguistic route rather than non-linguistic MP correction rather than MP creation

    15. MSc study: Aims Investigation into the use of MSIMT incorporating specific shaping feedback To establish some evidence-base To inform (and standardise) service delivery Research questions: Is this method of therapy effective? Standard vs. non-standard Is effectiveness influenced by word familiarity? More effective with unfamiliar real words because under-specified PRs and MPs (Sutherland & Gillon, 2007) More easily by-passed to facilitate non-linguistic processing?

    16. Method Prospective, multiple case study design 4 participants: Maisie – Max – Louisa – Sameeah Mean age = 22 (range = 21 – 24) Participant diversity: Cleft types Surgery histories Soft palate repairs: 10 – 09+110 – 16 – 15 Palate presentations; (2 x unrepaired hard palates; 2 x fistula) Hearing histories (but all had hearing loss) Speech characteristics Sameeah: Urdu speaking environment

    17. Method and procedure 3 month intervention phase: 2 participants: standard (3 x mthly sessions) 2 participants: non-standard (6 x fortnightly + videotherapy) Home visits / child-sized table & chair Individualised targets: 1-2 target sounds: anatomical and physiological factors Small number of target words: familiarity, stimulability, imageability, adaptability, likeability, age Same sequence of input: Sounds ? unfamiliar real words ? familiar real words

    18. Procedure Input principles: Innovative stimuli – concrete, tangible associations High frequency of repetition 4 activities (5-10 minutes each) All features made salient Stimulating toys, colourful pictures, rewarding concepts How to deal with spontaneous output – Hilary Gardner’s (2006) Talking About Speech Specific articulatory and phonetic feedback To confirm acceptable output, e.g. ‘you used your lips’ Encourage repair of unacceptable output, e.g. ‘I use my teeth’ Home practice programme (+ resource box)

    19. Outcome measures Before & after intervention Compared within & between participants Speech output = primary outcome measure Treated and untreated intervention words & whole sample PACS Toys (Grunwell & Harding, 1995) Phonetic & phonological analyses / qualitative & quantitative methods Language = control measure PLS-3 (UK) Researcher observations and information from parent diaries

    20. Outcome measures Phonetic analyses: Number / type / distribution of sounds (inc. target sound) in inventory PACS Toys Phonetic Inventory x3 (all word positions) Phonological analyses: Types of realisations / realisation changes in words (inc. intervention words) PACS Toys Extended Phoneme Realisation Chart Score consonant realisations Compare post-scores with pre-scores Determine type of change (favourable/neutral/unfavourable) Psycholinguistic interpretation Creation / execution of correct vs. incorrect MP / PR

    21. Outcome measures

    22. Results For all participants: Target sounds were used more frequently and extensively after intervention

    23. Results For all participants: Target sounds were used more correctly and frequently after intervention

    24. Results

    25. Videotherapy Themes from video diaries: 1 activity vs. whole DVD; typically 10 viewings Generally enjoyed but both had ‘less interested’ days Liked to see siblings on DVD Enjoyed watching with other family members Engaged in output whilst watching

    26. Observations & discussion All participants: Engaged in spontaneous output: isolation & words Repaired unacceptable output Maisie / Louisa / Max: incorrect output Input stimulated existing (incorrect) PRs/MPs (linguistic) Even if PRs/MPs were under-specified, they weren’t avoided Unfamiliar words did not have desired effect Sameeah: correct output for unfamiliar words Unfamiliar = unknown (non-English language environment) Absent PRs/MPs Input stimulated new (correct) PRs/MPs (non-linguistic)

    27. Discussion & recommendations Unfamiliar word = may have been heard but not spoken – likely to have MP (& PR) ‘ready for use’ Unknown word = hasn’t been heard or spoken – no MP (or PR) available Both routes were effective: Linguistic / existing (MP correction) Non-linguistic / new (MP creation) But, best to stimulate the non-linguistic route Input stimuli: Sounds Meaningful words Unknown real words / nonsense words assigned meaning, e.g. character names Known real words: unfamiliar ? familiar

    28. Implications for clinical practice & service delivery Targeted early intervention package of care for 2-3 yr olds: Principles of MSIMT + output therapy 6-10 session cycles / fortnightly sessions 1-2 target sounds per cycle Isolation ? unknown real words or meaningful nonsense words ? known real words (? phrases) Videotherapy Help resolve CTCs before they become established ‘Teach’ young children about speech Engage parents / carers early Help us make early hypotheses about VP function Help prepare children for transition to output therapy / VF at ~3 yrs Achieve optimal speech by 5 years

    29. Implications for clinical practice & service delivery Resource kit to support package of care: Equipment (videotherapy / home visits) Toys Activity ideas / picture resources / handouts for parents (on CD) New training package: ‘Intervention in the early years’ Further research: Recruitment of controls New, larger study – randomised control trial?? Twin- or multi-centre Control participants ? procedural biases; ? variables (e.g. age at palate repair, 1 model) Incorporate meaningful nonsense / unknown real word stage Longer intervention period / longer follow-up

    30. Acknowledgements Yorkshire & Humber Strategic Health Authority – MSc sponsor Nottinghamshire University Hospitals NHS Trust (Trent Region Cleft Lip and Palate Service) – research sponsor Leeds Teaching Hospitals NHS Trust (Yorkshire Region Cleft Lip and Palate Service) – secondary sponsor The University of Sheffield (Professor Joy Stackhouse – academic supervisor)

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