Getting the most “Bang for your Buck” with CAS treatment (with a bonus review of DTTC!)

Treating kids with childhood apraxia of speech (CAS) can be an involved and lengthy process. So what are the optimal conditions for CAS treatment? Maas et al. are on it, giving insight into how we can structure our therapy for kids with CAS. They provided integral stimulation treatment (see below), that differed based on the amount and distribution of practice.

Practice amount (aka cumulative intervention intensity) is the “number of practice trials and sessions provided throughout the treatment period”. Unsurprisingly, more therapy generally led to greater gains for children in this study (ages 4–12, who all had at least 50 words). The more a child practices saying a target word, the more opportunities he has to learn and retain the movement pattern.

Practice distribution refers to how the practice is divided over time, either many trials in a short period (massed practice) or spread out over a longer one (distributed practice). Massed practice led to greater improvement and maintenance of target words for most children in the study. This is consistent with neuroplasticity literature (yay science!). Massed practice might look like working on five targets for four weeks, and then five new targets for four weeks, rather than ten targets for eight weeks straight.

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This study also gives us a great review of integral stimulation treatment (the basis of Dynamic Temporal and Tactile Cueing, or DTTC), which is one of the most evidence-based treatments out there for CAS. As a preview the core aspects of integral stimulation are: (1) tactile cues, (2) slowed rate of speech, (3) gradual fading of cues, and (4) focus on whole-target movement accuracy. Free CEUs and downloadable charts are available to learn how to deliver DTTC, so look into it if you serve these kids!

 

Maas, E., Gildersleeve-Neumann, C., Jakielski, K., Kovacs, N., Stoeckel, R., Vradelis, H., & Welsh, M. (2019). Bang for your buck: A single-case experimental design study of practice amount and distribution in treatment for childhood apraxia of speech. Journal of Speech, Language, and Hearing Research. doi:10.1044/2019_JSLHR-S-18-0212

Half the minutes for the same morphology outcomes? Yes, please

We’ve talked before about dose, or how much of the “active ingredients” of therapy a child is getting. In a new study, researchers wanted to find out if the intensity of the dose within a single session affected outcomes. They tested two groups of preschoolers with developmental language disorder (DLD). For each child, the researchers chose two morphemes—one to treat and one to monitor without treatment. All children got Enhanced Conversational Recast* treatment, which calls for 24 unique recasts (correct clinician repetitions of the child's attempt to use their treated morpheme) while the child attends to the clinician. Half of the children had “sparse” sessions, where recasts were spread out over 30 minutes (0.8 recasts per minute). The other half had “dense” sessions, where recasts were crammed into only 15 minutes (1.6 recasts per minute).

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After six weeks of daily sessions, both groups improved their average accuracy for their treated (but not their untreated) morphemes. The results weren’t significantly different across groups though—it didn’t matter whether children had sparse or dense sessions.

So for Enhanced Conversational Recast treatment, the dose of 24 unique recasts is crucial but the length of the session is not. The authors point out that this means we could split a pair of antsy kiddos seen together for 30 minutes into individual 15-minute sessions and likely see the same progress, as long as the dose number stays the same.

*For more on Enhanced Conversational Recast treatment see reviews here, here, and here

 **Also, read the comments below for a pro tip for implementing this from Dr. Plante!

Plante, E., Mettler, H. M., Tucci, A., & Vance, R. (2019). Maximizing treatment efficiency in developmental language disorder: Positive effects in half the time. American Journal of Speech-Language Pathology. doi:10.1044/2019_AJSLP-18-0285.

Tutorial Throwback (2014): Am I doing this right? Some under-the-hood tips to structuring language therapy

SLPs have to make LOTS of decisions about how to structure our therapy:

How many minutes do you see each student?

How much time should you spend on a single goal?

What type of activities should you use to target a specific goal?

 The list goes on…

The answer to these questions isn’t always clear (even when you consult the available research), so when an article comes along that tackles these issues, we get pretty excited! This 2014 article by Eisenberg reviewed the research to break down what SLPs need to know about treatment dosage, dose form (type of treatment the student receives), and treatment procedures. Note that the author decided to focus on specific aspects of language therapy rather than any particular packaged approach, which helps us think critically about what’s making a difference in children’s success.

Language and education researchers have borrowed the concept of dose from our friends in medicine. While we might not typically talk about language services in terms of dosage, this analogy actually works really well in helping us think about our therapy and its “active ingredients.”  Imagine a kindergarten student with a goal of using progressive forms who is seen weekly for 30 minutes. In this case, dose would be the number of targets given per session (“Spiderman is swinging” and “Minnie is laughing” would be two), and frequency would be the amount of time the dose is given (30-minute weekly sessions).

We know that children with developmental language disorders (DLD) need a higher dosage than their typically-developing peers to learn new words and new grammatical forms, but just how much more? The article provides some numbers for comparison:

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For frequency, it seems that spaced exposure (compared to mass exposure) leads to better learning. So a student receiving a consecutive 60-minute session (mass exposure) may not be benefiting as much as a peer who receives two 30-minute sessions (spaced exposure).

So now we can talk about what the dose (language input) should actually look like. Here are some general guidelines for teaching specific grammatical targets (e.g., passives, bound morphemes). You should:

Vary the surrounding vocabulary

  • Children learn forms better when they’re combined with different vocabulary

  • e.g. The boy was scolded. This cat was licked.

Keep the target consistent across trials

  • Children acquire rules better when exceptions are limited 

  • e.g. She walks. / He runs……….. Instead of: She walks. / I walk.

Speak in grammatical (not telegraphic) sentences

  • There’s no compelling evidence that telegraphic speech improves comprehension

  • Children need grammatical models to produce grammatical forms

  • Children use grammatical knowledge to understand sentences and learn new words

  • e.g. The boy helps his mama…….. Instead of: Help mama.

Finally, for treatment procedures, therapy activities range from least natural (e.g., drills) to most natural (e.g., literacy based interventions or conversation activity). There seems to be a trade-off, with imitation training giving you quicker short-term gains, but activities like recasts being more important for spontaneous productions.

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Lots to think about, right? Now, while this information certainly doesn’t answer all our questions, it’s a good framework that can help SLPs think about why something in therapy may (or may not) be working and making meaningful improvements to our sessions.

Looking for more about dose and treatment intensity? Check out our blog post on that topic from 2018.

Eisenberg, S. (2014). What works in therapy: Further thoughts on improving clinical practice for children with language disorders. Language, Speech, and Hearing Services in Schools. doi:10.1044/2014_LSHSS-14-0021

Who needs extra time in fluency therapy?

A lot of what we know about evidence-based practice is how things work (or don’t) in general, for groups of similar clients, on average. But as we’ve all seen, even the best approaches don’t work for everyone, or don’t work to the same degree, at the same speed, or in exactly the same way in every case. Knowing how to factor individual differences into our assessment and intervention process is a huge research question (or ten thousand small ones), and it’ll take time for our field to get there. This new study is one link in that chain, addressing how self-regulation abilities relate to therapy outcomes and duration for young children who stutter.

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Children who stutter often struggle with self-regulation, in a similar way to kids with ADHD. (We mentioned a study last month that addressed the importance of “effortful control” in predicting stuttering severity.) Basically, self-regulation is the ability to control your reactions (emotions AND behaviors) to changes in your environment. Kids who have a hard time self-regulating will have really big emotions, both positive and negative, and struggle to calm down when they're upset or excited. They'll also have more trouble focusing and shifting attention than other kids. Here, Druker et al. looked at 185 children between 2 and 6 years old, all of whom had been discharged or discontinued from stuttering therapy within the last three months. About half of these kids displayed “elevated” ADHD symptoms (subclinical, so not actually receiving a diagnosis), as determined by a parent-report measure. Refer back to the article for more details on how this was measured.

Now that in itself is worth knowing, but even more useful is this: the children with more ADHD symptoms needed about 24% more time in therapy (here corresponding to about 3 sessions), to meet the criteria for discharge. If you know right off the bat that your new little client struggles with attention and self-regulation (consider adding a questionnaire to your evaluation protocol or intake process so you know this!), you can take that into account in your treatment plan and expectations for progress.

What other implications do we see for practice? The authors suggestjust like the authors from the piece last month—that SLPs directly address self-regulation skills within fluency therapy. We can’t say from the current research how to do that, or how it might affect outcomes, but it’s a logical step to consider.

 

Druker, K., Hennessey, N., Mazzucchelli, T., & Beilby, J. (2019). Elevated attention deficit hyperactivity disorder symptoms in children who stutter. Journal of Fluency Disorders, 59, 80–90.

Random, reading, or rendof: What type of target words maximize treatment gains?

Ah, the age-old question—what words should we use in therapy for kids with speech sound disorders? There are a number of choices, each with some good arguments in its favor:

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This study checked out differences in treatment success for each of these three word types for 24 children ages 3 to 7. Therapy for each kid focused on one, word-initial complex phoneme (/r/, /l/, “th” or “ch”), with five target words (either high-frequency, academic vocab, or nonwords, depending on which group the child was assigned to). The article describes the activities within each 50-minute intervention session, and supplemental treatment materials are available on a lab website (woo!). Each child’s progress was compared with his own performance in a baseline condition.

So, the winner? It’s the best possible news for clinicians, really. All the kids improved their phonological skills, with no significant differences among the words types. The authors point out that in reality, you’ll probably want to incorporate multiple types of words into your sessions. Like starting with nonwords for that “clean slate” effect, then moving to academic vocabulary words after a while to help boost those skills. But either way, the initial familiarity of the words likely won’t make or break your therapy. 

A second research question looked at treatment intensity. By splitting their subject pool in half (which, keep in mind, meant the number of kids per condition was pretty small), they found a large effect of treatment after 19 sessions (accuracy of target sounds in new words), and a medium effect after 11. I doubt anyone here is shocked—shocked!—that more therapy leads to better outcomes, but the size of the difference was actually pretty surprising. As we know, many kids don’t just make slow and steady progress, but need to get to that point where things start to “click.” It’s good to realize that the “clicking” place might be a little further away than we think.

 

Cummings, A., Hallgrimson, J., & Robinson, S. (2018). Speech Intervention Outcomes Associated With Word Lexicality and Intervention Intensity. Language, Speech, and Hearing Services in Schools. Advance online publication. doi: 10.1044/2018_LSHSS-18-0026.