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.

And more...

Baylis and Shriberg found that 14 of 17 children (82.4%) with 22q11.2 deletion syndrome (aka DiGeorge syndrome and velocardiofacial syndrome) had comorbid motor speech disorders. Speech motor delay and childhood dysarthria were more common than CAS. These initial prevalence estimates add to a growing body of evidence that helps us better understand the profile of 22q syndrome.

Glover et al. found that young children (preschool through 3rd grade) had more negative attitudes toward stuttering than their parents. By 5th grade, those attitudes improved and were similar to attitudes of parents.

Hammarström et al. found that an intense treatment (4 sessions per week for 6 weeks) was effective for a 4 year old, Swedish-speaking child with a severe speech sound disorder. Treatment incorporated multiple approaches—integral stimulation, nonlinear phonology, and a core vocabulary approach. After therapy, the child produced more target words, word shapes, and consonants correctly.

Kraft et al. replicated an earlier study to find that effortful control (an aspect of temperament) was the most important factor predicting stuttering severity in children. They recommend addressing self-regulation as part of the holistic treatment of stuttering.

Lancaster and Camarata set out to explain the heterogeneity of language skills in kids with DLD. At this time, it’s looking like a spectrum model (think autism!) fits best, versus labeling kids by subtypes or chalking up the differences to unique, individual profiles; but lots more data is needed. For now, the evidence suggests we should assess and treat kids with DLD based on level of severity *and* individual needs—which is probably what you’re doing already. 

Lane et al. profiled the communication skills of children with Sotos Syndrome using a parent-report measure. They found that most of the children had a language impairment (with issues in both structure and pragmatics), with a relative strength in verbal vs. nonverbal communication and a weakness in using context. These children are likely to need support in peer relationships, too. 

Sutherland et al. found that a standardized language test (the CELF-4) can be reliably administered via telehealth to children with autism. The specific children they tested were between 9 and 12 years old and mostly mainstreamed.

 

Baylis, A. L., & Shriberg, L. D. (2018). Estimates of the prevalence of speech and motor speech disorders in youth with 22q11.2 deletion syndrome. American Journal of Speech-Language Pathology. doi:10.1044/2018_AJSLP-18-0037

Glover, H. L., St Louis, K. O., & Weidner, M. E. (2018). Comparing stuttering attitudes of preschool through 5th grade children and their parents in a predominately rural Appalachian sample. Journal of Fluency Disorders. Advance online publication. doi:10.1016/j.jfludis.2018.11.001

Hammarström, I. L., Svensson, R., & Myrberg, K. (2018). A shift of treatment approach in speech language pathology services for children with speech sound disorders – a single case study of an intense intervention based on non-linear phonology and motor-learning principles. Clinical Linguistics & Phonetics. Advance online publication. doi:10.1080/02699206.2018.1552990 

Kraft, S. J., Lowther, E., & Beilby, J. (2018). The Role of Effortful Control in Stuttering Severity in Children: Replication Study. American Journal of Speech-Language Pathology. Advance online publication. doi: 10.1044/2018_AJSLP-17-0097

Lancaster, H. S., & Camarata, S. (2018). Reconceptualizing developmental language disorder as a spectrum disorder: Issues and evidence. International Journal of Language and Communication Disorders. Advance online publication. doi:10.1111/1460-6984.12433

Lane, C., Van Herwegen, J., & Freeth, M. (2018). Parent-Reported Communication Abilities of Children with Sotos Syndrome: Evidence from the Children’s Communication Checklist-2. Journal of Autism and Developmental Disorders. Advance online publication. doi:10.1007/s10803-018-3842-0

Sutherland, R., Trembath, D., Hodge, M. A., Rose, V., & Roberts, J. (2018). Telehealth and autism: Are telehealth language assessments reliable and feasible for children with autism? International Journal of Language & Communication Disorders. Advance online publication. doi:10.1111/1460-6984.12440

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.

Throwback (2009): Individual or group sessions: How much does service delivery type matter?

In the schools, service delivery may differ (along with a myriad of other variables) in terms of session type—individual or group—and service provider—direct services by a speech–language pathologist (SLP) or services provided by a trained speech–language pathology assistant (SLPA) (or a combination of these). We know therapy leads to improved language skills in children with DLD, but how do we choose among the service delivery models out there? And how much does it matter? For example, can group therapy provided by an SLPA be just as effective as individual sessions provided by an SLP, all else being equal? The answers to these questions have implications for our treatment recommendations. Surprisingly (or maybe not so surprising), this question hasn’t received a whole lot of attention in the research world…

The authors of this study provided an intervention targeting receptive and expressive language to school-age children in elementary schools in Scotland. All students had language disorder, with no concomitant hearing loss, articulation disorder, or fluency disorder.  Students were randomly assigned to either an intent-to-treat control condition or one of four treatment conditions (all of which consisted of 30-minute sessions 3 times a week for a 15-week period):

  1. individual sessions administered by an SLP,

  2. group sessions administered by an SLP,

  3. individual sessions administered by an SLPA, and

  4. group administered by an SLPA

Receptive and expressive language (measured using the UK version of the CELF) were measured pre-treatment, post-treatment, and during a 12-month follow-up (to look at how well skills were maintained). Post-treatment and follow-up testing were conducted by other SLPs to avoid bias.

The results showed no significant differences between the treatment conditions. There were, however, differences in which outcomes improved: expressive, but not receptive, language gains were made between pre- and post-treatment. For the follow-up, across conditions, language gains were not maintained.

A strength of this study was its use of an RCT design with assessor blinding to promote replicability and minimize bias. Many of the intervention choices—length of sessions, number of sessions per week, and “active ingredients” of the intervention–were informed by previous research (all important things to consider!). In fact, one of the cool finds from this article is the structured intervention as detailed in McCartney (2007)—a therapy manual available free of charge

Of course, one of the limitations in applying this study’s results is that all services took place in the UK context. It’s very likely that there are differences in child and professional variables between the UK and the US (e.g. training standards for SLPAs). The authors also suggest caution in extending these results to children who differ from the study sample (e.g. those with speech sound disorders).

So what’s the take-away? This study provides some evidence that group sessions and sessions provided by SLPAs can yield similar results to individual sessions provided by SLPs, that children with receptive and expressive difficulties (compared to expressive alone) may require more intensive therapy, and providing continued support is likely important for maintaining language skills.

 

Boyle, J.M., McCartney, E., O’Hare, A., Forbes, J. (2009). Direct versus indirect and individual versus group modes of language therapy for children with primary language impairment: principal outcomes from a randomized controlled trial and economic evaluation. International Journal of Language and Communication Disorders, 44(6), 826–846.

Going beyond best practice with at-risk readers

I think we can all agree that there’s a lot of research out there aimed at improving literacy outcomes for at-risk readers, and that the use of evidence-based practices is crucial to literacy success. But what about those students who still struggle to read, despite our use of evidence-based practices?  How do we get to those students?

The authors of this study looked at the evidence, identified the most effective current practices, and designed a new theory-driven intervention package to improve reading outcomes for those at-risk poor readers. They compared their Direct Mapping and Set-for-Variability Intervention (DMSfV for short) to a Current or Best Practices (CBP) approach with a big group of first graders with low word-reading scores. Interventions were delivered in small groups outside of the classroom for 30 minutes, 3 times a week for 10 weeks.

The CBP approach included typical phonics strategies (like blending and segmenting phonemes), along with teaching sight words and doing shared book reading.

The DMSfV included three components:

  1. Direct mapping: Teaching grapheme–phoneme correspondences, and then, critically, applying them by linking to texts, e.g., learning /sh/ and then reading a book with lots of /sh/ words
  2. Vowel digraphs: Teaching the various ways to pronounce vowel sequences and the rules associated with them, like how when vowels are paired together, the first one is usually long and the other is silent, as in “boat”
  3. Set-for-variability strategies: Teaching the students strategies to read “exception” words (those with spelling-sound inconsistencies), and how vowels and vowel digraphs can be pronounced differently (“ou” in touch versus soul)

A key goal of the DMSfV* intervention was to teach the skills necessary to read words even when they broke standard phonic rules.

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So, which intervention was more effective?

Immediately after the intervention, the DMSfV group performed significantly better on word reading and spelling measures. Five months later, they performed significantly better on word reading and sentence comprehension tasks. Despite this success, though, half of the children still remained relatively weak word readers and needed ongoing support—there’s no magic solution here. The takeaway? It seems that some struggling students will benefit from stepping outside of the box of current practices, even when those practices are generally effective. There is more than one evidence-based way to teach reading, and some students will benefit differently from different approaches.

If this study calls out to you, check out the full article (and don’t miss the Appendix!). The authors have included a lot of detail about the intervention procedures and materials, including the specific story books used and the frequency of specific phonemes/vowel digraphs in each story. If you’re working on vowels with a student, this list might be valuable!

*“Dims fuv”? We like our acronyms pronounceable!

Savage, R., Georgiou, G., Parrila, R., & Maiorino, K. (2018). Preventative reading interventions teaching direct mapping of graphemes in texts and Set-for-Variability aid at-risk learners. Scientific Studies of Reading, 22, 225–247. doi:10.1080/10888438.2018.1427753.

Can older children with language disorders improve vocabulary in just 30 minutes a week? (Yes!)

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Targeting vocabulary skills with older children with language disorders seems like a no-brainer. However, according to Wright et al., “We know of no studies specifically aiming to improve receptive vocabulary in secondary-aged children with identified [developmental language disorder (DLD)].” Yikes. To address this evidence gap, the researchers set out to see whether 25 secondary age (i.e., 9- to 16-year-old) children with language disorders (18 with DLD, 7 with autism) could learn to understand and use new words.

Children received 7 weeks of one-on-one intervention, with one 30-minute session and one 5-minute review session each week. SLPs taught the children 10 nouns and 10 verbs (words like “customer” and “avoid”) through explicit instruction and games, and SLP assistants assessed them on their knowledge and use of the words using a variety of tasks, as well as children’s own ratings of how well they knew the words. The researchers provide a fabulous description of the treatment sessions in the methods and a list of words, scoring examples, and treatment tasks in the appendix.

Results showed that children improved their knowledge of taught words (measured by identifying whether the word is a word, answering multiple choice definition questions, using the word in a sentence, and giving the word’s definition) compared to untaught control words. Children also self-reported greater knowledge of the taught words. As expected, children showed better learning for nouns than verbs. Overall, children learned an average of 4 words out of 10 in a relatively short time. Best of all, the treatment was conducted by the participants’ usual SLPs under normal circumstances (absences and all), which suggests that it can be effectively implemented in everyday clinical practice.

**If this topic is up your alley, check out this review from 2017, too!

 

Wright, L., Pring, T., & Ebbels, S. (2017). Effectiveness of vocabulary intervention for older children with (developmental) language disorder. International Journal of Language and Communication Disorders. Advance online publication. doi: 10.1111/1460-6984.12361.

Throwback (2007): Teaching print concepts to young children with language disorder—No response required!

We know that children with language disorder often experience difficulty acquiring early literacy skills. One key skill is knowledge of print concepts, which include understanding things like:

  • Where the front of the book is
  • The fact that we read a book from left to right
  • Where you can find the title of the book

Explicit strategies that encourage young children to respond to print-related questions and verbal prompts during book reading can enhance print awareness (Ezell & Justice, 2000), and strategies like dialogic reading (Whitehurst et al., 1988), which allow children to answer questions and participate at their individual language levels, have a positive impact on language skills. But, are these strategies effective for young children with language disorder? What happens when our young clients don’t have the language skills needed to respond to print-related questions? Do they still benefit?

In this study, the authors wanted to determine whether comments and references about print that do not require a verbal response (“non-evocative”) could improve print concepts in 4- and 5-year-olds with language disorder. Specifically, the researchers used commenting (e.g., "This is the beginning of the story."), finger tracking of print, and pointing to print. These techniques were embedded within two 10-minute book reading sessions per week over 10 weeks. The sessions targeted 20 print concepts as well as language concepts from each participant’s IEP.

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Each of the participants demonstrated gains in their understanding of print concepts after only four 10-min shared book reading sessions using those no-response-required print referencing procedures. And even better, each child continued to learn and maintain their understanding of the targeted print concepts with different books even after the intervention ended!

These findings provide important lessons for SLPs (and parents!) of preschools with language disorders. First, it’s not necessary to use fancy questioning or cueing strategies to enhance knowledge about print when reading with these kids. Simple comments focused on early print concepts that carry no linguistic demands can be just as effective at enhancing their early literacy skills. The findings also suggest that it doesn’t require a lot of time or effort—focused, explicit, but brief book reading activities a couple of times a week can have a big impact.

NOTE: The article includes a list of each of the 14 books that were included in the study, as well as a list of each of the targeted language concepts and print concepts. In addition to these “free” materials, the criterion-referenced screening tool that the authors developed, the Concepts of Print Assessment (CAP), is also available as a reference.

 

Lovelace, S., & Stewart, S. R. (2007). Increasing print awareness in preschoolers with language impairment using non-evocative print referencing. Language, Speech, and Hearing Services in Schools, 38(1), 16–30.

Word learning and exemplar variability in preschoolers with language disorder

Do you have young children with developmental language disorder (DLD) on your caseload? Eighteen 4- and 5-year olds with DLD in a recent study learned new words with this treatment—and, even better, retained their word learning after three weeks.

The preschoolers with DLD were assigned to one of two groups. Both groups were exposed to real objects that represented the target vocabulary words, one- or two-syllable nouns, such as “hinge” and “tassel.” The only difference between the groups was the variability of the objects that the preschoolers were exposed to. For example, the no-variability group was taught the target word “hinge” with three very similar hinges. Alternatively, the other group was exposed to hinges that varied in size, color, and/or texture.

Training consisted of just 18 presentations of each target word—six presentations of each of the eight target words in three sessions within a three-week period—during fun activities such as building a robot and a pirate treasure hunt. The six presentations included the following:

  • a sentence from the activity directions
  • a statement
  • an imperative command
  • a question
  • a natural fifth and sixth presentation, based on the context of the activity
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While both groups showed word learning gains during testing, the group exposed to a variety of objects during training performed significantly better during retention tasks three weeks later.

Check out the “Learning Activity” section of the article for examples of the models that you can implement during therapy along with examples of objects to represent the words you are teaching. Also, do note that there were individual learning differences—some children learned more target words than others.

 

Aguilar, J. M., Plante, E., & Sandoval, M. (2017). Exemplar variability facilitates retention of word learning by children with specific language impairment. Language, Speech, and Hearing Services in Schools. Advance online publication: doi:10.1044/2017_LSHSS-17-0031.

Teaching text structures to boost comprehension: What makes for a good intervention?

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If your work brings you into contact with the Common Core standards, you probably know that they majorly up the ante for students to read and interact with expository (so, informational, not narrative) text, starting as early as kindergarten. A popular strategy to help students understand these texts is to teach the structures: cause-and-effect, compare/contrast, problem/solution, etc. The idea is that knowing the underlying organization of the information helps us create a working model of it in our minds, leading to better understanding and recall.

This article is a meta-analysis of expository text structure intervention research, meant to figure out, overall, if teaching text structures looks like a helpful approach for comprehension (for students with and without a learning disorder), and what characteristics of interventions give the biggest bang for their buck. They looked at 21 peer-reviewed studies from 1970 on that: a) used a targeted text structure intervention, b) provided data for students with LD, and c) looked at some measure of comprehension as an outcome.

Big Picture: Teaching text structures had a large, positive impact on reading comprehension.

The Finer Points: What made for a particularly good intervention?

  • Scaffolding of instruction, either by students gradually taking more ownership over the use of strategies, or gradually increasing the complexity of the passages
  • Focusing on just one or two structures, especially the ones that are easiest to recognize, like cause-and-effect and compare/contrast (but watch out: which structures work best might vary by content area…)
  • Intervention delivered by adults who understand text structures well themselves, as well as the treatment strategies. Seems like a no-brainer, but interventions that were led by researchers rather than less-specifically trained teachers were more successful.
  • The younger the student, the larger the improvement, as measured by standardized reading tests. So, think early elementary school. Students with learning disabilities showed the biggest benefits.
  • Treatments of 11–20 hours were more successful than either shorter or longer ones.

It’s important to note that some of these specific findings are preliminary, or need to be taken with caution, just because of the fairly limited pool of evidence they are coming from. Even keeping that in mind, teaching expository text structures is definitely good practice for a range of learners. The authors specifically recommend that we:

  • Explicitly describe text structures and teach associated signal words
  • Model uses of the strategy
  • Consider using graphic organizers
  • Turn over responsibility for the strategy to students over time

Pyle, N., Vasquez, A.C., Lignugaris/Kraft, B., Gillam, S., Reutzel, D.R., Olszewski, A… Pyle, D. (2017). Effects of Expository Text Structure Interventions on Comprehension: A Meta-Analysis. Reading Research Quarterly, 52(4), 469–501.