Chapter 22 Treatment Design and Implementation

1. Chapter 22Treatment Design and Implementation Carol Ellis and Barbara Hodson

2. 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

3. 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

4. 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

5. 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 • Stimulabilityinformation regarding possible targets (Hodson, 2007)

6. 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

7. 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

8. 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

9. 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)

10. Phonology-Oriented Approaches • Distinctive Features • Natural Phonology (Stampe, 1969): phonological processes • Cycles (Hodson, 2007; 2011) • Aligned with Gestural Phonological Theory (Browman & Goldstein, 1992)

11. 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

12. Whole Language • Whole language (Hoffman, Norris, &Monjure, 1990) • Based on a story-telling task • Questions remain about the effectiveness in severely affected children

13. Metaphonological Awareness Integrated phonological awareness (Gillon, 2000) Metaphon Can integrate metaphonological awareness components (e.g., rhyming, syllable segmentation) into other approaches

14. Nonlinear/Multilinear Approaches Metrical phonology (Liberman, 1975; Liberman & Prince, 1977) Optimality Theory (McCarthy & Prince, 1995)

15. Additional Theoretical Applications Complexity (Gierut, 2007) Dynamic Systems (Rvachew & Bernhardt, 2010)

16. Sidebar 22.1 Target Stimulable Sounds or Non-StimulableSounds 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).

17. 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.

18. 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

19. 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

20. 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

21. Sidebar 22.3 Sample IEP

31. Sidebar 22.4 Sample Speech-Language Pathology Treatment Plan

32. 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

33. Implementation

34. Sidebar 22.5 IEP Lesson Plan

35. Sidebar 22.6 Phonological Remediation Plan

36. 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

37. 22V1 Excerpts from a Cycles treatment session with a 3-year-old child

38. 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

39. 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

40. 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.

41. 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

42. 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