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2/8/2011
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Challenging current models of intensity of intervention
Kara Anderson, M.A.Ellen Kester, Ph.D.Scott Prath, M.A.
Region 13 ESC Bilingual SLP Leadership MeetingFebruary 14, 2011
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The Origins of Our Pilot The Origins of Our Pilot StudyStudy
We have large, diverse caseloads that grow throughout the school year.
Questions: Is there a more efficient way to serve our Is there a more efficient way to serve our students and not sacrifice quality?
What are other academic areas doing to improve services?
Can academic models work within the framework of speech pathology?
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Our Discussion TodayOur Discussion Today
Identify successful intervention techniques and service delivery models.
Discuss research on improving clinical servicesReview results of a clinic camp that tests these Review results of a clinic camp that tests these ideas for speech‐language intervention
Apply these successes to the school setting Provide therapy plans for implementing changes to how you provide intensity of services
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Professional ConstraintsProfessional Constraints
Location of ServiceFormat of Service (group vs. Individual)Dosage (Frequency, Intensity of Services) Insurance InsuranceFederal Mandates
• IDEA
• Least Restrictive Environment
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h f f i i flWhat aspects of our profession influence intervention practices?
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Improved Language OutcomesImproved Language Outcomes
Gillam and Loeb, (2010) reported that four components of language intervention were associated with successful language outcomes• Intensity• Intensity
• Active Attention
• Feedback
• Rewards
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Increased VocabularyIncreased Vocabulary
Repetition of Vocabulary words requires exposure of at least 15 times (Pui Fong, 2010 )
Longer interventionsTeaching words through definitions and in Teaching words through definitions and in context (Stahl & Fairbanks, 1986)
More word encounters Active processing (Baumann et.al, 2003 and A. Graves, 1986)
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EvidenceEvidence‐‐based Intervention based Intervention Techniques Techniques
Literacy‐based intervention ImitationModelingCloze proceduresCloze proceduresBinary choiceExpansionRecastScaffolding
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h d id i f h fWhy do we provide services for the amount of time that we currently do?
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Mixed Results Mixed Results
Studies on the following topics found mixed results
Dosage (frequency)Parent implemented vs clinician administeredParent implemented vs. clinician administeredClassroom base vs. Pull‐outSchool vs. Clinic
• (Schooling et. al., 2010)
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• 30/60 minutes twice a week
• direct service on average 2‐4 kids per group
• Who ever decided on 30 minutes/week ?• Who ever decided on 30 minutes/week ?
?
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Alternative Delivery ModelsAlternative Delivery Models
• Limited research on group intervention Adults with aphasia
Hearing impairments
Stuttering
Very little address speech & language
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Alternative Delivery ModelsAlternative Delivery Models
Recent Studies found intensity as a consistent factor that contributed to increased language outcomes • Gillam et al (2008) Loeb et al (2009) Tomblin • Gillam et.al (2008) , Loeb et. al. (2009), Tomblin, (2007), Gillam and Loeb (2010)
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Define “Intensity”Define “Intensity”
“The number of hours of intervention over a specific time period.” (Lovaas)
“The ratio of adult to children” (Graff et. al.)“The quality and quantity of services in a given The quality and quantity of services in a given period of time.”(Barnett & Escobar)
“The number of specific teaching episodes per unit of time.” (Guralnick)
From Ukrainetz et. al. 2008
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How Much is Necessary?How Much is Necessary?
How often should we use therapeutic techniques in a session?
Which techniques work best for working on specific goals?specific goals?• (Ukrainitz, et.al. 2008)
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Research on intensityResearch on intensity‐‐overover‐‐time time is contradictory is contradictory
Intervention of more than 8 weeks was more Intervention of more than 8 weeks was more effective than less than 8 weeks (From Ukrainitz et.al, 2008; Law et. al, 2004)
Contradicted by:Contradicted by:
Intensive 6 week service delivery model showed 5x the gains as a traditional 2‐year
d l d lservice delivery model ( Gillam & Loeb, 2010)• Number of delivery hours being equal
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Study on IntensityStudy on Intensity
Could we do a study of intensity that applies to a public school population?
How does the Bilinguistics pilot study look different from the Gillam et al (2010) than the different from the Gillam et.al. (2010) than the study?
How would we create a larger scale study in the public school setting?p g
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ld l h f d i i fCould we alter the frequency and intensity of speech therapy and get equal or greater results?
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Applying a Pilot Study of Applying a Pilot Study of Intensity to our Field.Intensity to our Field.
IndividualMonolingual English
Group Bilingual population
Gillam Study Bilinguistics Study
1:40/day for 6 weeks Literacy‐based, computer program and academic program
2:00/day for 2 weeks Literacy‐based program Children with speech, language, hearing,
Only enrolled children with language impairments
social and cognitive disorders enrolled in program
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Study OverviewStudy Overview
The current study will examine the efficacy of a short‐term intensive group intervention program for both English and Spanish‐speaking children ages 3‐8 with all classes of speaking children ages 3‐8 with all classes of disorders.
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MethodsMethods
Participants‐6 children per group 2 groups of 3‐5 year old bilinguals
2 groups of 3‐5 year old English speakers
1 groups of 6‐8 year old bilinguals
1 group 6‐8 year old English speakers1 group 6 8 year old English speakers
Time
Two weeks sessions, 4 days a week
Intensity 2 hours a day
Disorders All disorders (Autism, speech and language impairment, Down Syndrome)
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Day 1Day 1
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Day 8Day 8
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ResultsResults
Complete data sets on 13 students (4 Spn, 9 Eng)Standardized testingNarrative language sampleNarrative language sample
• Phonological errors
• Word/utterance errors
• Type‐token ratio
MLU• MLU
• Story grammar components
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MLU in WordsMLU in Words
6
7
English Mean Length of Utterance
6
Spanish Mean Length of Utterance
0
1
2
3
4
5
IS CL RG BE IG JF NC AC IR
Pre‐MLUW
Post‐MLUW
0
1
2
3
4
5
Pre‐MLUW
Post‐MLUW
IS CL RG BE IG JF NC AC IRAG AA JR KV
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Total Number of WordsTotal Number of Words
250
300
350
400
English Total Number of Words
250
300
350
400
450
Spanish Total Number of Words
Pre TNW
0
50
100
150
200
IS CL RG BE IG JF NC AC IR
Pre TNW
Post TNW
0
50
100
150
200
AG AA JR KV
Pre TNW
Post TNW
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Number of Different WordsNumber of Different Words
50
60
70
80
90
100
Spanish Number of Different Words
Pre NDW60
80
100
120
140
English Number of Different Words
Pre NDW
0
10
20
30
40
AG AA JR KV
Post NDW
0
20
40
IS CL RG BE IG JF NC AC IR
Post NDW
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Number of Word ErrorsNumber of Word Errors
25
30
35
40
45
50
English Word Errors
15
20
25
30
Spanish Word Errors
PreWord Errors
0
5
10
15
20
IS CL RG BE IG JF NC AC IR
PreWord Errors
PostWord Errors
0
5
10
15
AG AA JR KV
PreWord Errors
PostWord Errors
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ImplicationsImplications
Short‐term intensive intervention is beneficial for speech and language development
Children can benefit from intensive group interventionintervention
This could have implication for service delivery in the schools
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d h k d fHow can I adapt therapy to take advantage of changes in intensity?
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30/60 minutes / week240 minutes in 9 weeks6 sessions across four weeks6 sessions across four weeks
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Therapy PlanningTherapy Planning‐‐Caseload 50 Caseload 50 across 2 schoolsacross 2 schools
Intensity• Students will receive 8 hours of therapy every six weeks
Forming groupsg g p• Groups classified by disorder or age?
Alternating schedule• 3 groups of 16 students (1,2,3)
• Each group will have an rotating schedule (a b c d e)• Each group will have an rotating schedule (a, b, c, d,e)
• Group are rotated through two week cycles along with alternating daily schedule
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Therapy PlanningTherapy Planning‐‐Caseload 50 Caseload 50 across 2 schoolsacross 2 schools
Monday Tuesday Wednesday Thursday ARD day
8:00‐9:00 Group a Group e Group d Group c
1 Rotation of a two week session
9:05‐10:05 Group b Group a Group e Group d
10:10‐11:10 Group c Group b Group q Group e
11:10‐11:40 lunch lunch lunch lunch
11:40‐1240 Group d Group c Group b Group a
12:40‐1:40 Group e Group d Group c Group b12:40 1:40 Group e Group d Group c Group b
1:45‐2:45 Flexible hour
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Schematic of a Therapy SessionSchematic of a Therapy Session
• Introduction – greeting
• Pre‐Reading
• Reading
• Post readingPost reading
• Direct Therapy
• Closing
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Sample SessionsSample Sessions
PPCDSchool Age
www.bilinguistics.com
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Future StudiesFuture Studies
What is next?• What would happen across a semester
• Is the next step in the study.
What are the results between disorder What are the results between disorder classes• We saw gains in all but bigger gains in some
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BrainstormingBrainstorming
In groups• List different possibilities for service delivery models
• Brainstorm roadblocks or reasons it would be difficult to implement such a programp p g
• Identify potential solutions to those road blocks
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Dickson, K., Marshall, M., Boyle, J., McCartney, E., O’Hare, A., Forbes, J. (2009). Cost analysis of direct versus indirect andd d l d f l b d h d l h f h l h ld hindividual versus group modes of manual‐based speech and language therapy for primary school‐age children with primary
language impairment. International Journal of Language & Communication Disorders, 44, 3, 369‐381. Edgar, D. L., Rosa‐Lugo, L. I. (2007). The critical shortage of speech‐language pathologists in the public school setting:
Features of the work environment that affect recruitment and retention. Language, Speech, and Hearing Services in Schools, 38, 31‐46.
Gillam, R. B., Love, D. F., Hoffman, L. M., Bohman, T., Champlin, C. A., Thibodeau, L., Widen, J., Brandel, J., Friel‐Patti, S. F. (2008). The efficacy of Fast ForWord Language Intervention in school‐age children with language impairment, A randomized controlled trial. Journal of Speech, Language, and Hearing Research, 51, 97‐119.
Schooling, T., Venediktov, R., Leech, H., EB Evidence‐Based Systematic Review: Effects of Service Delivery on the Speech and Language Skills of Children From Birth to 5 Years of Age ASHA October 2010and Language Skills of Children From Birth to 5 Years of Age ASHA October 2010
Loeb, D. F., Gillam, R. B., Hoffman, L., Brandel, J., Maruis, J. (2009). The effects of fast forword language on the phonemic awareness and reading skills of school‐age children with language impairments and poor reading skills. American Journal of Speech‐Language Pathology, 18, 376‐387.
Peters‐Johnson, C. (1996). Action: School Services. Language, Speech, and Hearing Services in Schools, 27, 185‐187. Tomblin, J. B., Records, N. L., Buckwalter, P., Zhang, X., Smith, S., & O’Brien, M. (1997). Prevalence of specific language
impairment in kindergarten children. Journal of Speech, Language, and Hearing Research, 40, 1245‐1260. Schooling, T., Venediktov, R., Leech, H.,(2910) EB Evidence‐Based Systematic Review: Effects of Service Delivery on the
Speech and Language Skills of Children From Birth to 5 Years of Age ASHA October 2010 Stahl, S.A. & Fairbanks, M.M. (1986). The effects of vocabulary instruction: A model‐based meta‐analysis. Review of 9 y y
Educational Research, 56(1), 72‐110.Ukrainetz et. al. 2009 Ukrainetz, T., Proctor‐Williams, K., Baumann, J., Allen, M., Hoffman, L., Justice, L (2008). How Much is Enough? The
Intensity Evidence in Language Intervention. Presentation at the American Speech Language Association Annual Convention, Chicago
Pui Fong, Kan(2010). Vocabulary Development and Function in Bilinguals: Comparison Across the Life span. Presentation at the American Speech Language Association Annual Convention, Philadelphia
