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Commentary on "Treatment Decisions for Children With Speech–Sound Disorders": Revisiting the Past in EBP

Contact author: Ann A. Tyler, PhD, University of Nevada, Reno, Speech Pathology and Audiology, Mail Stop 152, Reno, NV 89557. E-mail: anntyler{at}med.unr.edu

	ABSTRACT

TOP ABSTRACT VALIDATING TREATMENT DECISIONS... VALIDATING APPROACHES FOR LONG... EFFICIENCY IN SERVICE DELIVERY CONCLUSION REFERENCES

 

PURPOSE: This commentary, written in response to Alan Kamhi's paper, "Treatment Decisions for Children with Speech–Sound Disorders," further considers the "what" or goal selection process of decision making with the aim of efficiency—getting the most change in the shortest time.

METHOD: My comments reflect a focus on the client values piece of the evidence-based practice (EBP) triad through validating treatment decisions for individual clients using generalization data. Such data are ideal for demonstrating change according to specific benchmarks and suggesting that treatment was responsible for this change. Consideration is also given to deficit profiles and their implications for long-term outcomes when validating the effects of treatment.

CONCLUSION: Although the abundance of evidence suggests that a variety of treatment approaches are effective for children with speech–sound disorders, less is known about which are most efficient as compared to one another or for which specific children. Practitioners, however, are embracing EBP when they select a treatment by matching the research evidence with a client's profile, collect systematic data, and use those data to demonstrate that change is attributable to treatment.

KEY WORDS: EBP, treatment, generalization, speech–sound disorders

Kamhi's approach to making treatment decisions evidence-based not only emphasizes the integration of high-quality research with clinical expertise and client values, but also stresses the importance of experimentally validating a chosen treatment approach with a particular client. In his final statement regarding change in individual client behaviors as an overriding variable in decision making for children with speech–sound disorders (SSD), Kamhi leaves practitioners with a tall order: They must be responsible for demonstrating that change in individual clients resulted primarily from the treatment provided. This has a familiar ring in the current age of assessment and accountability. Although practitioners have always been responsible for showing that their "treatment works," they are increasingly being held accountable for systematically documenting change according to specific benchmarks. This commentary is organized to first provide my perspective on how practitioners might accomplish this. Second, I consider the expressive speech deficit with respect to concomitant deficits and their implications for long-term outcomes when selecting an approach and validating its effects.

	VALIDATING TREATMENT DECISIONS WITH DOCUMENTED CHANGE

TOP ABSTRACT VALIDATING TREATMENT DECISIONS... VALIDATING APPROACHES FOR LONG... EFFICIENCY IN SERVICE DELIVERY CONCLUSION REFERENCES

 
The theoretical perspectives on treatment for SSD that Kamhi discusses often conflate goal selection and treatment procedures. For example, the complexity perspective involves goals that are selected according to complex linguistic features but often uses bottom-up techniques. Regardless of how one disentangles treatment approaches from goal selection, the practitioner must decide where to begin with each individual client, considering all elements of evidence-based practice (EBP). Practitioners must be astute consumers within the array of EBP sources and reviews, such as meta-analyses, with an eye toward the quality of the evidence. Due to time limitations, they must develop working groups within their clinical settings or obtain continuing education that will provide an evaluation of review databases (e.g., Cochrane Collaboration). It is important to know, for example, what the inclusionary and exclusionary criteria were for selecting studies to review. Even when a practitioner is wedded to a particular approach because it has been proven effective, the generalizability of efficacy study findings is limited to only those clients with profiles of linguistic strengths and weaknesses, severity levels, and demographic characteristics that are similar to those of the study participants. In determining how well the evidence matches the needs of a specific client, practitioners must also consider efficiency. We have limited empirical evidence about which intervention approaches are most efficient in comparison to one another, or for which subgroups of children with SSD.

Lacking efficiency evidence, practitioners can strive to demonstrate efficiency through generalization with individual clients. Kamhi cites Gierut's (2001, 2005) complexity approach as being most emblematic of efficiency, but I would argue that any approach striving for generalization is aimed at efficiency. Yet, generalization was not incorporated in annual speech-language goals in the more than 200 individualized education plans (IEPs) that were reviewed (Panagos, 2002). If generalization is an overreaching goal, how do approaches differ in this regard? Each has inherently different assumptions regarding generalization. Developmentally based approaches typically expect generalization to untreated sounds within the sound class from which targets are trained, and ideally to conversational speech. For example, if selected clusters /sm, st/ are targeted, other untrained clusters that share features of the targeted clusters may be expected to change as well (e.g., /sn, sp/). Language-communication-based approaches expect generalization to conversational contexts for as many of the linguistic targets that receive a focus. Complexity-based approaches expect generalization to untreated sounds across several sound classes (in words), often representing implicationally "simpler" aspects of the system. For example, if final fricatives are targeted, change might be expected in final stops.

How then would we validate clinical decisions for individual clients using generalization data? Practitioners must plan to measure individual success through generalization; therefore, it is imperative that they identify generalization goals based on their targets and select measurement tools before initiating treatment. Measurement, in the form of probes for untrained as well as trained aspects of the linguistic system, should be performed at scheduled intervals, such as 6, 8, or 12 weeks. In addition, an untreated control pattern could be measured to document lack of change. Practitioners can set aside a group of single words, containing the target and related sounds, as probe words that will not be used in training. The key is to show that aspects of the system that were targeted and those related to these structures changed, whereas those that were not targeted, and were unrelated to target behaviors, did not change. If, for example, the practitioner can demonstrate that targeting final /f, s/ was accompanied by change in untargeted fricatives, as well as certain grammatical morphemes, but not liquids, then that is strong evidence for efficacy of the treatment approach with that particular client. This systematic approach is ideal for demonstrating quarterly change, for example, in school district programs.

	VALIDATING APPROACHES FOR LONG-TERM OUTCOMES

TOP ABSTRACT VALIDATING TREATMENT DECISIONS... VALIDATING APPROACHES FOR LONG... EFFICIENCY IN SERVICE DELIVERY CONCLUSION REFERENCES

 
The type of generalization a practitioner could plan for and expect to achieve with a particular client is probably, in part, a function of the client's profile and should involve consideration of concomitant deficits to the primary SSD. With respect to long-term outcomes of speech normalization and preparedness for academic success, a concomitant language deficit or early literacy deficit indicates a greater risk for academic difficulties and may be reflective of subgroups. Our literature has long recognized that the population of children with SSD is heterogeneous, and there are likely subgroups (Arndt, Shelton, Johnson, & Furr, 1977; Powell, Elbert, Miccio, Strike-Roussous, Brasseur, 1998). Such subgroups have more recently been identified according to etiology (Shriberg, 2004) and according to profiles of deficits displayed on large test batteries (Bishop, 2002; Botting & Conti-Ramsden, 2004; Conti-Ramsden, Crutchley, & Botting, 1997; Dodd, 1995; van Daal, Verhoeven, & van Balkom, 2004). From this deficit perspective, we find that subgroups have been identified largely in populations of British school-age children with speech-language impairment (SLI) attending language units. These include children with speech-only difficulties (some motor-based); groups with language-only difficulties (either semantic or pragmatic); and the largest groups, in one study representing almost half of the more than 200 participants, with phonological and language deficits (Botting & Conti-Ramsden, 2004; Lewis, Freebairn et al., 2004). In preschool children, the coexistence of SSD and language impairment is estimated at 30% to 60%. Shriberg's extensive research program in childhood SSD has led to five general etiological classifications: speech delay–genetic, speech delay–otitis media with effusion, speech delay–developmental psychosocial involvement, speech delay–motor involvement, and speech errors. The largest proportion of the population is represented by the speech delay–genetic group (60%), wherein the proposed neurodevelopmental processes affected are cognitive–linguistic (Shriberg et al., 2005). If the largest SSD group manifests genetically determined cognitive–linguistic differences, it is also likely that such differences may manifest as concomitant speech, language, and/or reading impairments.

Thus, practitioners might consider whether their treatment goals need to be language and speech (communication) based, speech based, or literacy based to align with an individual client's profile of speech only or concomitant speech, language, and/or reading deficits. Of course, necessary for this decision is a comprehensive battery of tests, particularly those that involve nonword repetition and phonological awareness skill, as well as expressive phonology and morphosyntactic measures, preferably from conversational samples. With the resultant profile of a client's strengths and weaknesses, practitioners can select the what to target with the aim of greater efficiency and demonstrate that change occurred due to treatment. Presumably different combinations of deficits or subgroups would require slightly different interventions.

As an example, a child with concomitant speech–sound and language impairment would be a candidate for a language-speech-based approach that involved alternated cycling of both speech and language targets (Tyler, Lewis, Haskill, & Tolbert, 2003). There is an expectation of generalization within and across domains with this dual focus approach. For example, with a focus on tense and agreement markers, it would be appropriate to assess speech for the generalization of accurate sound production to final singletons and clusters (Tyler, Lewis, Haskill, & Tolbert, 2002). It is likely that a focus on past tense –ed, which results in clusters such as /kt, st/ (e.g., kicked, kissed), facilitates generalization to accurate final /k/ or /s/ production. In contrast, a child with a speech-only profile and motor involvement would be a candidate for an approach that focuses on speech targets such as the bottom-up perspective. A child with a concomitant SSD and early literacy deficits may need a phonological awareness-based approach wherein generalization to speech production could be expected (Gillon, 2000, 2005). Gillon has shown that a focus on phoneme identification and letter knowledge tasks also results in gains in speech intelligibility for children as young as 3 to 4 years of age. In the above examples, consideration is given to whether or not it is possible to work on other domains and facilitate change in speech as well as monitoring for expected change related to the direct speech targets.

	EFFICIENCY IN SERVICE DELIVERY

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Although the how, or the specific intervention approach, may be less important than the goals chosen for children with SSD, Kamhi acknowledges that service delivery factors may play an important role in efficiency. I would include service delivery factors in the how and argue that these are critically important with respect to rate of change and long-term outcomes. Unfortunately, these are variables about which we have very little data and need more systematic investigation. In particular, the intensity of treatment may be a primary factor in greater efficiency. Not surprisingly, more individual sessions lead to greater functional gains in preschoolers with both speech and language impairments, and younger children make the greatest gains (Jacoby, Lee, Kummer, Levin, & Creaghead, 2002). In addition, intensive treatment blocks, for example, 4–6 weeks of daily intervention sessions, have been associated with significantly greater change as compared to more traditional once or twice a week, 30-min session models (Gillam et al., 2005; Torgeson et al., 2001).

If we choose to implement intense treatment blocks, it might be hypothesized that they could be tailored according to a client's profile and shift focus among domains if there are multiple deficits. Intensive treatment for children with concomitant speech–sound and language or reading disorders might take the form of cycling blocks focused on speech, language, or literacy with no-intervention blocks interspersed. Generalization across domains can be anticipated and monitored according to the type of intervention provided. Such generalization is more complex to monitor; however, the point remains that we want to demonstrate that change in an individual's communication behaviors was due to our treatment.

	CONCLUSION

TOP ABSTRACT VALIDATING TREATMENT DECISIONS... VALIDATING APPROACHES FOR LONG... EFFICIENCY IN SERVICE DELIVERY CONCLUSION REFERENCES

 
Just as much of EBP is not new, what I have discussed above is not new. The search for etiological/causal factors, and the implication of heterogeneity in the speech-disordered population, fueled research in the 1960s to 1970s. Generalization has been the topic of much of the treatment efficacy research in SSD dating back to the 1960s (Elbert, Shelton, & Arndt, 1967; McReynolds, 1972). Also in the 1960s, intensive treatment blocks were shown to lead to higher dismissal rates (Van Hattum, 1969). In this era of EBP, it is simply time to consolidate what we do know from rigorous scientific evidence, our experience, and our clients and marshal this knowledge to provide services that result in the greatest change in the shortest time frame. It means that practitioners must investigate the how of service delivery systems and document the what of treatment decisions for individual clients. It means that they must serve in the role of systems change agents to advocate different service delivery models. It means that they must be knowledgeable of all approaches and eclectic in choosing what to target based on good scientific evidence and thorough description of a client's profile. Finally, it means that practitioners must demonstrate accountability by showing that treatment made a difference, gains resulted primarily from their treatment, and, if not, the treatment was modified accordingly.

Received March 22, 2006
Accepted June 26, 2006

	REFERENCES

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