Basic Considerations In Speech Therapy

Here are some of the basic of the basic considerations for the SLPs for Speech Therapy

1. Presented By – Piyush Malviya Topic – Basic Considerations In Speech Therapy

2. Contents Target selection Basic framework for therapy Goal attack strategies Organizing group therapies Individual vs. group therapies

3. Target Selection The first step in programming is identification of the communication behaviors to be acquired over the course of the treatment program. These therapy targets are often referred to as long-term goals. Initial information about potential therapy targets should be obtained by reviewing the results of previous diagnostic findings. In addition, it is essential that a clinician consider the client’s cultural and linguistic background when identifying potential therapy targets. Speech and language differences arising from dialect usage or a non-English native language do not constitute a communicative disorder. This sampling is accomplished through the administration of pretreatment baselines. Baselines are clinician-designed measures that provide multiple opportunities for a client to demonstrate a given communicative behavior.

4. A good rule of thumb is to include a minimum of 20 stimuli on each pretreatment baseline. The ratio of correct versus incorrect responses is calculated; the resulting percentage is used to determine whether the behavior should be selected as a therapy target. Many clinicians view a performance level of 75% accuracy or higher as an indication that the communication skill in question is not in need of remediation. Baseline measures that fall below the 75% accuracy level represent potential intervention targets. Ultimately, however, the selection of appropriate therapy targets relies heavily on clinical judgment. Some clinicians believe that behaviors that occur with at least 50% accuracy represent targets with the best potential for improvement. Other clinicians argue strongly that behaviors with much lower baseline rates of accuracy may be the most appropriate choices based on individual client characteristics (e.g., intelligibility level, age, and so on).

5. Often, clients present with several behaviors that qualify as candidates for remediation. For individuals who demonstrate a large number of errors, clinicians may choose a broad programming strategy that attacks as many targets as possible in a given time frame. Alternatively, clinicians may select a deep programming strategy for clients who demonstrate either relatively few or highly atypical errors. In addition, clinicians typically employ one of two basic approaches for choosing among potential targets: developmental/normative or client-specific.

6. The developmental/normative strategies This strategy is based on known normative sequences of communicative behaviors in typically achieving individuals. Therapy targets are taught in the same general order as they emerge developmentally. When two or more potential targets are identified from baseline procedures, the earliest emerging behaviors are selected as the first therapy objectives. For example - A 5-year-old child with an articulation disorder produces the following speech sound errors on baseline procedures: 1. /p/ for /f/ as in p inger for f inger 2. /t/ for /ʃ/ as in t ip for sh ip 3. /d/ for / dʒ / as in d uice for j uice 4. /d/ for /b/ as in d oat for b oat

7. Use of the developmental strategy guides the clinician to select /b/ as the initial therapy target because typically developing children demonstrate mastery of this sound earlier than the others. According to a developmental progression, /f/ is the next logical target, followed by /ʃ/ and / dʒ /. The developmental strategy tends to be most effective for articulation and language intervention with children. This strategy has less application for adults and disorders of voice and fluency. A developmental strategy for target selection should be implemented with careful consideration of at least two factors. The sample population from which the norms were derived may have been too small to permit valid generalization of the findings to other populations.

8. Client specific strategy Using the client-specific strategy, therapy targets are chosen based on an individual’s specific needs rather than according to developmental norms. Relevant factors in the selection of treatment objectives include: (1) the frequency with which a specific communicative behavior occurs in a client’s daily activities; (2) the relative importance of a specific communicative behavior to the client, regardless of how often it occurs; and (3) the client’s potential for mastery of a given communication skill. This last factor addresses the notion of stimulability , which is typically defined as the degree to which a client can approximate the correct production of an error pattern on imitation.

9. Mr. Max Asquith, a 52-year-old computer programmer, demonstrates the following speech and language characteristics on pretreatment baseline procedures: 1. Omission of final consonants such as /s/, /k/, and /θ/ 2. Distortion of vowels in all word positions 3. Misarticulation of consonant blends such as / br /, / pl /, / fl /, / ks /, and / skw / 4. Omission of the copula forms ( is and are ) as in “He sad” for “He is sad” 5. Difficulty with the accurate use of spatial, temporal, and numerical vocabulary 6. Difficulty with subject-verb agreement, especially third-person singular constructions, as in “He drink milk” for “He drinks milk” From the client-specific perspective, initial speech intervention targets could consist of / ks / and / skw / because these blends occur in the client’s name and therefore constitute a high priority for him.

10. Basic framework for therapy Speech therapy is the assessment and treatment of communication problems and speech disorders. It is performed by speech-language pathologists (SLPs), which are often referred to as speech therapists. Speech therapy techniques are used to improve communication. These include articulation therapy, language intervention activities, and others depending on the type of speech or language disorder . Speech therapy may be needed for speech disorders that develop in childhood or speech impairments in adults caused by an injury or illness, such as stroke or brain injury .

11. Long term goals & Short Term Goals It is vital for the SLP to create long-term goals that will result in achievement of the language disorder skills within a year. These goals are not designed in terms of what would be expected in language production at your child's age. Long-term goals are written according to your child's language disorder. If your child has a receptive or expressive language disorder this means that he has the inability to process language correctly during communication with others. The teacher may say "please sit down at your desk," but your child may interpret what she heard as sit down.

12. She may not process "at your desk." She may just sit down on the floor. An example of a long-term goal for a receptive disorder is "Christy will understand and process others' speech, at an age-appropriate level as compared to her peers within this school year." An expressive language disorder is the inability to express language appropriately. A child with this type of disorder is unable to use correct word order. For instance a child may say "swim water" for "I want to go swimming."

13. Also, the child will misuse or not use the rules of proper grammar. A short-term goal may be stated as "Christy will build her vocabulary by identifying picture vocabulary in categories such as animals, school items and clothing in order to increase her expressive language three to four months developmentally, as measured by an age appropriate assessment." Building Christy's vocabulary and learning correct grammar are the short-term objectives or goals, to reach the long-term goals of correcting the expressive language disorder.

14. Treatment Approaches There are a variety of phonetic (i.e., articulation) and phonological (i.e., linguistic rules) approaches to intervention. Williams, McLeod, and McCauley (2010) identified 23 approaches that have been utilized in the treatment of speech sound disorders. Selected examples of classic and more recent remediation approaches are described in the following sections. 1 - Traditional (Van Riper, 1978) This phonetic approach to intervention is also known as the sensory-perceptual or motor- based approach.

15. It relies on sensory training (i.e., auditory discrimination or “ear- training”) either before or concurrently with speech production training to provide the client with an internal standard with which to compare correct versus incorrect productions of sounds. 2 - Motor-Kinesthetic ( Stinchfield -Hawk & Young, 1938) This phonetic approach emphasizes development of correct movement patterns and requires the clinician to manipulate the articulators to facilitate sound production. This method is based on the assumption that it is possible to establish positive kinesthetic and tactile feedback patterns through direct manipulation of the client’s articulators. As a result of the feedback, the client is helped to recognize and then to produce the movements of speech. In this approach, the basic unit of therapy is the isolated sound; only later are words and sentence patterns introduced and established

16. 3 - Distinctive Features (McReynolds & Bennett, 1972) Distinctive feature therapy is a phonological approach based on the theory that speech sounds can be defined in terms of articulatory patterns and acoustic properties. Each phoneme in a language consists of a bundle of binary features, in which the presence or absence of these features is specified (e.g., +voicing/−voicing, +nasal/−nasal, + continuancy /− continuancy ; Jakobson , 1968). Some phonemes, such as /t/ and /d/, differ by only one feature contrast, in this case, voicing. Other phonemes, such as /s/ and /g/, differ by many feature contrasts, including voicing, continuancy , placement, and stridency.

17. 4 - Paired Oppositions—Minimal and Maximal (Weiner, 1981) These phonologically based approaches target phonemic contrasts ( errored versus correct) that signal differences in meaning between two words. No explicit instruction on articulatory placement or sound production is given. Instead, this approach emphasizes the use of the child’s communication success or breakdown to teach target sound productions. 5 - Phonological Processes ( Oller , 1975) This phonological approach to intervention is based on the strategies used by young, typically developing children between 1½ and 4 years of age to simplify the production of an entire class of adult speech sounds ( Hodson & Paden, 1981; Khan & Lewis, 2002).

18. For example, young children frequently omit weakly stressed syllables in multisyllabic words (e.g., ephant /elephant, jamas /pajamas ), reduce consonant clusters (e.g., bue /blue, dek /desk ), assimilate consonants in words (e.g., goggie /doggie, chichen /chicken ), and delete final consonants (e.g., ba /ball, hou /house ).

19. 6 - Cycles Approach One of the better-known phonological process intervention programs is the “cycles” approach developed by Hodson and Paden (1983) that is intended for children with highly unintelligible speech. The clinician identifies phonological patterns that are targeted for a designated amount of time (i.e., cycles lasting 5–16 weeks). A typical session sequence includes: auditory bombardment, (2) production training, (3) stimulability probes, and (4) take-home activities for generalization.

20. 7 - Core Vocabulary (Dodd, Holm, Crosbie, & McIntosh, 2010) This approach focuses on functional outcomes in which consistency, as opposed to accuracy, is targeted. The SLP selects 50 to 70 “functionally powerful” words and targets up to 10 at once. Children learn to produce their best pronunciation of the words consistently, both in isolation and connected speech. It targets the ability to generate consistent plans for words; the ability to create a phonological plan is improved by providing detailed, specific feedback about a limited number of words. This approach relies heavily on systematic practice in a drill-like format.

21. 8 - Metaphon Developed by Howell and Dean (1994), this approach is more accurately labeled a “philosophy” rather than a program; it is designed to provide children with explicit information that will enable them to consciously reflect on the phonemic structure of language. Heavy emphasis is placed on the child’s awareness/understanding of the detailed aspects of speech sounds (separately from word meaning) to facilitate accurate sound production.

22. Goal attack strategies A goal attack strategy refers to the way in which multiple goals are approached or scheduled within an intervention session ( Cirrin & Gillam, 2008). Three strategies have been identified: (a) a vertical goal attack strategy in which one goal at a time is targeted until a predetermined level of accuracy is achieved, (b) a horizontal goal attack strategy in which several goals are targeted within every session, and (c) a cyclic goal attack strategy in which several goals are targeted with a repeating sequence, each for a specified time period independent of accuracy ( Cirrin & Gillam, 2008; Fey, 1986; Tyler et al., 2003).

23. Each goal structuring method has advantages and disadvantages. Vertical structuring allows a practitioner to work on one goal at a time and a child to achieve a high response rate for a single target in each session. The one-​goal strategy may help the child focus attention on the targeted skill. However, vertical structuring may lead to a repetitious and potentially boring intervention. In a horizontal structure, the practitioner presents two or more goals in the same intervention session. The goals may target related behaviors (e.g., use of the be verb as a copula [“The boy is a baseball player”] with a be verb as an auxiliary [“The boy is throwing the ball”] or unrelated behaviors (e.g., a goal targeting syntax and a goal targeting semantics).

24. New goals are added as the child reaches predetermined criteria on each goal. The amount of time to reach criteria will vary from goal to goal. One advantage of horizontal structuring is that the intervention session is not too repetitive, and the child is less likely to be bored. Another advantage of a horizontal strategy is that as a primary goal is achieved in a structured intervention context, the adult can relegate a primary goal to secondary status. The interventionist regularly monitors a student’s use of secondary goals during natural, spontaneous speech. In this way, newly learned communication behaviors are generalized to everyday interactions.

25. A disadvantage of horizontal structuring is that presenting multiple intervention targets may cause confusion for children who are easily distracted or more severely impaired. In a cyclic goal attack strategy, an interventionist moves through a series of targeted goals using a predetermined schedule. For example, in the cyclic approach, Goal 1 is introduced during Week 1 and Goal 2 during Week 2. The interventionist then cycles back to Goal 1 in Week 3 and Goal 2 during Week 4. The cyclic approach has features of both vertical and horizontal attack strategies. When implementing the cyclic attack strategy, a practitioner introduces a different goal each week and then moves from one goal to the next, regardless of the child’s progress, or lack of progress, on a particular goal (Williams, 2000).

26. Over time, as the cycle is repeated, the child develops increased competency on individual goals. Consider the following example of an intervention program that uses the cyclic approach. The interventionist develops three goals for Macauley , a student who has deficits in three areas: (1) third-​person verb errors (e.g., “ He walk to school, ”“ She drive the car ”); (2) limited use of conjunctions, such as so and but (e.g., “ The man wants a new car, but he doesn’t have enough money ”); and (3) poor comprehension of why questions. The interventionist writes a goal for each of the targets:

27. 1. Macauley will produce third-​person regular verbs with 70% accuracy in focused stimulation activities in which third-​person verbs are contrasted with regular present progressive verbs (e.g., “What is the girl doing? She is walking her dog. What does she like to do? She likes to walk her dog? Does she do it every day? Yes, she walks her dog every day.” 2. Macauley will produce four to six sentences using coordinating conjunctions during a retelling of a familiar fairy tale, with access to a written list of coordinating conjunctions. 3. Macauley will produce three different why questions and answer at least three different why questions during a shared book reading interaction using a first-​grade-​level book. The three goals are targeted on a rotating basis, and the interventionist records the child’s accuracy for each session.

28. If a child reaches the criteria for a goal, a new goal is brought into the cycle, or the goal is modified to elicit more independent and complex productions. Goals for which the child does not reach criteria continue to be targeted in the cycle. The child learns some skills in a period of a few weeks, but other skills take longer. The cyclic approach has been shown to be effective in teaching morphosyntax skills to preschoolers (Tyler et al., 2003) and in teaching phonological skills (Williams, 2000). A rationale for the cyclic approach is that goal mastery is developmental, and children require varying levels of exposure to meet criteria (i.e., some targets may be acquired with little stimulation, while others take more time). The disadvantage is that generally professionals need more skill and experience to organize and maintain a cyclic intervention schedule.

29. Organizing therapy sessions Organize your digital materials , so you can easily access them in a session. Create Youtube Playlists  for certain types of videos that you use most often. Organize your no print or PDFs that you like to use digitally on your iPad by folders in your Google drive. Make copies  of all those IEP forms, checklists, Health and Developmental, etc. so you have a copy handy when you need to quickly put together a packet for a family. Have extra copies of homework sheets , graphic organizers you use often, or parent handouts. Make a binder for something you have to reference often like your speech referrals . When everything is in one place, it is easier to put speech referrals or give forms to parents and teachers.

30. Include parent consent forms, a log to list when you screened a student, developmental norms, and whatever else you might need. Put helpful developmental milestones, parent permission slips and anything else I need to store a hard copy of for teachers and parents. Here are some links to organizational forms that have helped me or I stick in my binder for reference: Data Binder Forms  that include parent permission slips for RTI intervention from The Speech Bubble SLP (My district has their own template, so if you don’t have a template, I recommend using these). Articulation & Language Flipbook Screeners that I tuck in the back flap of the binder by The Dabbling Speechie (ME) Dual Language Cheat Sheet Guide to reference when getting a speech referral/assessment for a student that has a primary language other than English by The Dabbling Speechie

31. Speech Sound Development Norms shown in the picture above by Rosie Prehoda (FREE printable on TPT) Speech Sound Development Norms by Mommy Speech Therapy (FREE download) Make a binder or therapy resource box filled with all the materials  you need for a certain skill. You have those students/groups where you have a plan in mind for therapy, but prepping items for them each week is time consuming. So, make an /r/ and / s,z / carryover binder filled with all the resources that I need to treat that sound at the sentence, reading and conversation level. It has books, reading passages, homework sheets, conversation starters, etc.

32. 4. Block out time  in your week that is devoted to preparing materials that will help reduce lesson planning time all year long. If you don’t dedicate and schedule in that time, it will either never get done or you will stress doing it at home after a long day. Only prep those materials you need right now, or will be grab n’ go materials for future sessions. If you are limited on time, don’t prep the WHOLE resource if you only need part of it for the week.

33. Individual Therapy vs. group therapy Individual Speech-Language Therapy Professional speech-language pathologists work with children individually to provide intensive, one-on-one, family-centered therapeutic intervention. In conjunction with parents and caregivers, our speech-language pathologists will develop an individualized therapy plan with short- and long-term goals addressing specific areas of need. Therapy activities center on functional, contextual activities to improve skills, as well as incorporate parent/caregiver training.

34. Group Therapy The use of a group therapy model requires attention to several unique aspects of session design that are not pertinent to individual treatment. Unfortunately, there is a paucity of information on group intervention and even less empirical study of this process in the field of speech-language pathology. However, group therapy is critical to any discussion of session design, because it is a frequently used service delivery mode—in fact, it is becoming the dominant model in many therapeutic settings (such as the public schools). Clinicians implement a group intervention model for a variety of purposes. Some groups are intended to teach new communication skills at introductory levels. Others are designed primarily to provide clients with practice on skills previously established in individual sessions. Still others have socialization, self help, or counseling as their main purpose.

35. Group Size - The size of a group will vary depending on its purpose, the setting, and client age. Groups whose primary purpose is to teach new skills tend to be smaller than those geared for the generalization of previously mastered skills. Group size is also determined by the availability of clients in different service delivery settings. Institutions such as metropolitan hospitals and public schools lend themselves more readily to the formation of larger therapy groups than do private practices or small clinics.

36. Group Composition - The primary client characteristics to be considered in the formation of a group are age, gender, disorder type, and disorder severity. Other factors that may be relevant to some groups include intelligence, socioeconomic status, education level, and personality type. As a general rule, the two most important factors are client age and disorder type. Effective groups tend to be relatively homogeneous with respect to one or both of these variables. Clinicians may choose to organize groups in either a closed or open format. Closed groups frequently operate for predetermined time periods and maintain the same membership throughout. In contrast, open groups have revolving membership and accept new individuals whenever space becomes available.

37. Clinician’s Role. The role of the clinician is to function as group leader. Leadership style can be directive or nondirective. A directive style is typically used with groups composed of young children. In addition, it is more common in the early stages of therapy when a group model is being used to teach new communication behaviors. In this role, the clinician sets the agenda, chooses the materials and activities, provides specific instruction, and gives corrective feedback. A nondirective approach is more commonly used in the carryover stages of therapy and with self-help groups.

38. Procedures - Several procedures can be used in group settings to maintain the active participation of all members throughout the entire session. In one method, the clinician presents a stimulus and pauses before choosing a particular group member to respond. This strategy increases the likelihood that all members will pay attention and prepare answers to every stimulus in anticipation of being called on. In another strategy, clients can take turns modeling target behaviors for other group members to repeat in unison. Finally, clients can be required to listen, watch, and evaluate the performance of a target behavior by fellow group members. Clinicians can use a variety of techniques to facilitate group interaction.

39. The following examples are applicable to any type of communicative disorder: ■■ Reinforce client behaviors and comments that are consistent with treatment goals. ■■ Model the target behaviors or techniques group members are attempting to develop. ■■ Focus attention and group time on members who are making progress toward established goals. ■■ Encourage interaction within the group by asking one member to demonstrate a target behavior for the other members. ■■ Ask open-ended questions that require longer than one- or two-word responses. ■■ Cue a group member to focus on a particular therapy target before she or he begins speaking.

40. ■■ Restructure comments or topics so they have appeal for all members of the group. ■■ Use behaviors of individual members to form generalizations that are applicable to the group as a whole.

41. References Language Disorders in Children Fundamental Concepts of Assessment and Intervention – Joan N. Kaderavaek (2 nd Edition) Treatment resource manual for speech language pathology – Froma p Roth (5 th Edition) Assessment and treatment of articulation & phonological disorders In children M.N. Hegde ( 2 nd Edition)

42. The end