Therapeutic Methods: Selecting Therapy Targets and Baseline Data

Therapeutic Methods

Selecting Therapy Targets and Baseline Data

Selena Browning, M.S. CCC-SLP with adaptations from Dr. Tanya Dantuma, Biola University

Course Objectives

Demonstrate knowledge to describe and define the 5 steps to selecting meaningful therapy targets and methods of gathering baseline data.
Demonstrate application of therapy target selection and baseline data collection to write meaningful goals, through completion of LAB 2.

Rapport Building: Feelings Check-In

The Zones of Regulation:
- Blue Zone: Sad, Bored, Tired, Sick
- Green Zone: Happy, Focused, Calm, Proud, Peaceful, Serene, Nurturing, Faithful, Secure, Important, Thankful, Appreciated, Confident, Discerning, Valuable, Proud, Respected, Successful, Worthwhile, Aware, Optimistic, Surprised, Content, Relaxed, Pensive, Responsive, Thoughtful, Intimate, Loving, Trusting, Powerful
- Yellow Zone: Worried, Silly, Frustrated, Excited, Irritated, Hateful, Critical, Skeptical, Bewildered, Discouraged, Insignificant, Inadequate, Scared, Confused, Rejected, Helpless, Embarrassed, Submissive, Insecure, Anxious, Overwhelmed, Daring, Excited, Fascinating, Sensuous, Stimulating, Energetic, Amused, Joyful, Cheerful, Creative, Playful, Hopeful
- Red Zone: Overjoyed/Elated, Panicked, Angry, Terrified, Jealous, Mad, Sad, Shy, Inferior, Stupid, Remorseful, Distant, Isolated, Apathetic, Sleepy, Bored, Lonely, Depressed, Ashamed, Guilty, Hurt, Frustrated, Sarcastic, Angry, Hostile, Selfish, Jealous, Tired

The Therapeutic Process

Pre-Tx Tasks:
- Gather Data
- Choose Tx Targets
- Write Goals
- Determine Baseline
Session Planning and Implementation:
- Determine Teaching Methods
- Develop Scaffolding Strategies
- Develop Generalization Plan
- Create Tx Activities
Session Documentation:
- Data Collection
- Document SOAP Note
- Write Progress Note

Selecting Therapy Targets

What communication needs does my patient/client have?
Which of these needs will be addressed in therapy during this episode of care?
- Needs: All areas of deficit
- Targets: Communication areas we will address in therapy.
It is important to remember we do not necessarily target EVERY area of need.

General Guidelines for Selecting Therapy Targets

Select targets after thorough assessment.
Select functional targets.
Targets should be culturally appropriate.
Targets should be linguistically appropriate.
Select targets that can make an immediate improvement to the client’s abilities.
Select targets that can serve to be building blocks to more advanced targets.
Use Evidence-Based Practice (EBP) to select targets.

Steps for Selecting Therapy Targets

Obtain a thorough assessment/assessment update.
Develop a list of areas of need.
Choose a strategy.
Gather information from the family.
Consult the literature.

Step 1: Assessment Review/Update

Answer the following questions:
1. What can my client do? What are my client’s communication strengths?
  - Reported abilities
  - Response to intervention or dynamic assessment
2. What are my client’s needs?
  - Developmental needs/delays
  - Functional needs
  - Cognitive needs

Step 2: Develop a List of Areas of Need

Guidelines:
1. Consider all areas of need identified in your thorough assessment.
2. Be specific:
  - Examples:
    - Expressive Language
    - Morphology
    - Pragmatics
    - Semantics
    - Past Tense -ED
    - 3rd person /s/
    - Subject pronouns
    - Limited verbs
    - Word finding
    - Reciprocity
    - Non-verbal

Step 3: Choose a Strategy

Normative/Developmental Strategy
- Comparative to the rest of the population.
- Choose a target based on what comes next in the developmental progression of typical children.
- Most often used with pediatrics who are developing typically in all areas except speech and language.
Client-Specific Strategy

Selecting Targets: Normative Strategy Case Example 1

Cora is a 4-year-old referred due to difficulty being understood.
Evaluation reveals a speech sound disorder with errors in /b/ and /r/.
Areas of need: /b/ and /r/
Using a normative strategy:
- Which would you address first?
- /b/ develops by 2 years, /r/ develops by 5 years.

Selecting Targets: Normative Strategy Case Example 2

Thomas is a 4.5-year-old referred because “he’s not really talking.”
Evaluation reveals a language delay with an MLU of 1.5.
Strengths include present progressive verbs.
Other morphemes were omitted.
Areas of need: early prepositions, third person singular /s/, plural /s/, regular and irregular past tense, possessive /s/, copula and auxiliary verbs, articles.
Using a normative strategy, which would you address first? Why?
Hint: Refer to Brown’s morphological development chart.

Developmental/Normative Resources

Shipley & McAfee, Assessment in Speech-Language Pathology: A Resource Manual, 6th Edition
ASHA website
Brown’s Morphological Development
Caroline Bowen, website resources

Selecting Targets: Normative Strategy Considerations

Appropriate for children developing typically in all areas except language and speech.
NOT appropriate for children with other developmental, physical, or health impairments. Why?
NOT appropriate for adults. Why?

Step 3: Choose a Strategy (cont.)

Normative/Developmental Strategy
Client-Specific Strategy
- Considers targets specific to the client’s goals or interests.
- How important is the area of need to the client?
- How often does it present a problem for the client?
- How much does this need impact communication?
- What would allow the client to communicate more effectively?
- Is the client stimulable?

Selecting Targets: Client-Specific Case Example 1

Cora Smith, 4 years old, referred due to difficulty being understood.
Lives with parents Ryan and Lauren; has an older brother Ricky.
Evaluation reveals speech sound disorder with errors with /b/ and /r/.
Areas of need: /b/; /r/
Given a client-specific strategy for selecting targets, which would you address first?

Selecting Targets: Client-Specific Case Example 2

MaryAnn, 63 years old, self-referred following a CVA and diagnosis of Broca’s Aphasia.
Family reports difficulty “knowing what MaryAnn needs/wants at home.”
Enjoys being with family, especially grandchildren but does not enjoy other social activities.
Areas of need: Limited verb use, telegraphic utterances (syntax), word-finding nouns, difficulty following 2-step directions.
Given a client-specific strategy for selecting targets, which would you address first? Why?

Step 4: Gather Information from the Family

Family-Based Intervention (Remember the 7 characteristics!)
This step is critical if you are choosing a client-specific strategy for selecting targets.

Step 5: Consult the Literature

Is there strong evidence for selecting the target/addressing the selected need in the episode of care?
Refer to normative charts.
Developmental vs. Non-developmental approach (Tambyraja & Dunkle, 2014).
Bottom-Up vs. Top-Down approach (Bellis & Anzalone, 2008).
Tools for clinical decision making (Yorkston & Beukelman, 2004).

Selecting Therapy Targets: Additional Considerations

How many treatment targets should we address in an episode of care?
- Answer: It depends!
  - What is the setting of intervention?
  - What is the length and intensity of service?
  - What is achievable for your client?
We do not necessarily target EVERY area of need.

LAB 2: Part 1

Complete the 5 steps for selecting therapy targets for your client.
Work through the 5 steps of target selection for your client with your partner.
- Step 1: Choose 3 Treatment Targets (25 points)
  - Complete each step: (Show your work by completing each step in writing.)
  - Provide clinical justification for your target: Tell why you chose each target.

Gathering a Baseline

What is a baseline?
- Answer: The patient’s or client’s ability to achieve a selected therapy target in the absence of treatment. What can my client do right now?
When is a baseline collected?
- Prior to treatment: This is your starting point
- At the start of an episode of care (i.e., at Biola, every semester)
- During the course of treatment (to measure progress toward your goal)

Methods for Gathering a Baseline

Administer a Baseline Probe
- A structured, short “evaluation” of a specific, selected therapy target.
- It may incorporate a level of support to facilitate goal writing.
Analyze a speech/language sample
- A transcribed sample of 75-100 utterances with objective analysis of a specific, selected therapy target.
Use data documented in the evaluation or progress report
- If a probe/dynamic assessment was used in the report, the data may be used directly as a baseline for a specific, selected therapy target.

Developing Baseline Probes

Select Tx Targets
Prepare stimulus items
Prepare data sheet and cueing hierarchy
Prepare probe instructions
Present stimulus items and cues as needed
Analyze your objective data
Example: Labeling Verbs
*10 verb picture cards
*Semantic, Phonemic, Orthographic
*Ask “What’s he doing?”
*Present and apply cues in hierarchy order
*Calculate % accuracy

Baseline Probe Practice!

Choose your case/target
- Cora:
  - Initial /b/
  - Initial /r/
- Thomas
  - in/on
  - Regular plural /s/
- MaryAnn
  - Following 2-step directions
  - Labeling nouns (functional objects)
Administer the probe to a group member. Save your data sheets!

Speech/Language Sample Analysis

Select Tx Targets
Prepare method of elicitation of target
Collect (record) the language sample
Determine obligatory context vs. use
Analyze your objective data
- Example: Plural /s/
  - “Loaded” picture scene, delayed modeling
  - Record and transcribe
  - Use $[[divided by]]$ context Calculate % accuracy
Terminology:
- Transcribe: write down verbatim exactly what your client said.
- Obligatory Context: the opportunities the client had to produce the target
- Use: The times the client actually produced the target.

Calculating Baseline from a Sample

Target: Plural /s/
Obligatory Context: 27
Accurate Use: 2
${2 \over 27} = 8.3\%$

Calculating Baseline from a sample (cont.)

Calculate % accuracy
Report frequency
- # of disfluencies produced.
- # of conversation turns on a topic
- # variety of vocabulary (ex. Nouns, verbs, etc.)
- # of anomic events (difficulty word finding)
- # of instances of vocally abusive behaviors.
MLU → mean length of utterance

Data from Evaluation/Report

Select Tx Targets
Review evaluation for use of probe or dynamic Dx
Transfer the data
- Sometimes Baseline Data is reported in the initial assessment.
- If the diagnostician used clinical probes as part of the assessment, those can be used as the baseline measure.
Standardized test scores do not usually make appropriate measures of baseline.

Write a Baseline Statement

Administer a Baseline Probe
Analyze a language sample
Use data documented in the evaluation/report

Examples:
- Based on a baseline probe, MaryAnn can label functional verbs with 10% accuracy independently, increasing to 40% given a phonemic prompt.
- Based on a language sample analysis…
  - …Thomas uses regular plural /s/ with 8.3% accuracy in spontaneous speech.
  - …Kelly engaged in a 3+ turn conversation on 1 occasion.
- Per clinical probe administered as part of the initial assessment, Cora produces initial /r/ with 0% accuracy given verbal and visual cues.

LAB 2: Part 2

Determine Baseline Data for your Client
- Step 2: Determine baseline for each target. (25 points)
  - Describe how you will determine baseline for each target.
  - Write a baseline statement for each target based on hypothetical data.
    - Baseline Statement Formula
      - Based on [method of collecting baseline], [Client Name] can [complete selected therapy target] with [objective measurement], [independently/given level of support/cue provided]