Towards Generalization: Use of Intrinsic targets in Therapy for Speech Sound Disorders

Agenda

  • What are SSDs

  • The Traditional Approach

  • Extrinsic & Intrinsic Targets

  • Benefits of Intrinsic Targets

  • Choosing Intrinsic Targets: Ration and examples

  • Intrinsic Targets and Contextual practice

  • Intrinsic Targets and Transfer training

  • Data Collection

  • Home Practice Activities

  • Recap

Learning Outcomes

  • By the end of this session you will:

    1. Define the traditional approach and examine how to individualize the articulation hierarchy effectively to lead to generalized improvements in speech sound production.

    2. Select targets that are intrinsic to activities to promote generalization. Examine evidence-based strategies and interventions designed to facilitate the generalization of speech sound production goals.

    3. Determine how to measure progress. How to effectively measure intrinsic targets that lead to generalized goals and compare at each level to the hierarchy level to demonstrate the transformative impact on clients' communicative competence.

    4. Consider various approaches, including contextual practice, transfer training, and involving families and caregivers in the therapy process.

Fast Facts: Why do we care:

  • ASHA 2020 report:

    • 89% school based SLPs working with SSDs

    • 41% of caseload aged 3-10 year old is SSD only

    • 24% of caseload of 11-17 year old is SSD only

  • Poor speech sound production skills in kindergarten is associated with lower literacy outcomes (Overby, Trainin, Smit, Bernthal, & Nelson, 2012).

  • Increased likelihood of reading disorders in children with a preschool history of speech sound disorders (Peterson, Pennington, Shriberg, & Boada, 2009).

  • Increased academic difficulties (Anthoney et Al, 2011)

  • Teachers indicated perceiving children with SSD as less intelligent (Overby et al, 2007)

  • Overlapping concerns- social, academic, language (Farquhason, 2019)

What do we know about Treatment for SSD?

  • We know there are Articulation and Phonological differences

  • We know that Articulation is at the phonetic level- production errors (outcome error)

  • We know Phonological errors are at the phonemic level-language based and alters meanings of words

  • How do we know which is which?

How do we treat SSD?

  • Variety of methods- to be discussed and named

  • CJASLPA Quebec study – 98% in schools use traditional-2022

ASHA Definition: Articulation and Phonology

  • Can we consider that it is not just a SEQUENCE but an over lapping process- Not- establish, then generalize, then maintain, but establish TO generalize AND maintain…

  • Factors contributing to Success

    • Severity (PCC, phonological processes, level on intelligibility)

    • Family/Environmental supports

    • Motivation (client and others)

    • -Law et al, 2017- Cochrane review

  • Moving from focusing on HOW to say it to WHAT they want to say

  • awareness and attention

Traditional Approach

  • Created by Charles Van Riper, 1939

  • Provides clearly defined structure for articulation therapy

  • Addresses goals in "developmental progression" (Sauerwein, 2022)

  • Focuses on motor production

  • 70 studies show evidence for this approach (Sauerwein, 2022)

  • Can often lead to "drill" therapy

    • Typical hierarchy is traditional approach

    • PCC (Percent of correct consonants) *trials

Articulation Therapy Steps to Graduation

  • Auditory Discrimination

  • Isolation

  • Syllables

  • Words

  • Phrases

  • Sentences

  • Stories

  • Structured Conversation

  • Unstructured Conversation

  • Generalization

Video

  • Buckaroo

  • Identify what the goal is.

  • Ask HOW many trials were done and what level? Generalize IN the session- intrinsic targets!

  • Improved outcomes

  • Play and fun leads to taping into the episodic memory, making deeper connections for those targets. (Harold, 2013)

  • Flashcards is a F- word

Intrinsic vs Extrinsic targets

  • What is an Extrinsic Target?

    • A target that aims to elicit the production of a specific sound.

    • aka standard targets

    • words in different contexts (except: isolation & syllable levels)

  • What is an Intrinsic Target?

    • A target that aims to elicit the production of a specific sound in a natural or contextual manner, relative to an activity.

Extrinsic Targets: Common Examples

  • INITIAL/SP/WORDS

    • Flashcards approach

    • Articulation cards

    • Word lists

Child Client Example

  • Client Profile: elementary school age

    • Goal: /s/, initial position, word level

    • Materials: /s/ initial articulation cards, and…

Child Client Example

  • Client Profile: elementary school age

    • Goal: /s/-blends, initial position, word level

    • Materials: /s/-blends articulation cards, and…

    • Meet Sam, the pirate.

    • He has a lot of swords.

    • He is a silly guy.

    • He sails the seven seas.

Benefits of Intrinsic Targets

  • Reduced pressure on clients for some productions of targets

  • Increased trials (intensity) per goal in different contexts

  • Efficient, seamless trials

  • Applicable to a variety of intervention approaches

  • Increased opportunities for:

    • Natural, realistic speech productions

  • Observation of Goal Progress

  • Data Collection

  • "The more episodic and story-like your play-based session is, the better. This is because associated events scaffold memories.” Meredith Poore Harold, PhD, CCC-SLP (2013)

Generalization= "Waiting room Speech"

  • "It is important that the student can produce the sound at home, school, and community and not just in the therapy room.” Patricia Rakovic, SLP (2019)

  • What, Why, How to generalize

    • It will encompass a range of approaches, including

      • contextual practice,

      • transfer training,

      • involving families and caregivers in the therapy process.

Evidence: Contextual Practice- building IN generalization

  • Rvachew et all- 2021- The results of this study show that it may not be necessary to over practice or maintain a high degree of performance accuracy during treatment sessions to achieve transfer and retention of speech production learning.

  • Eisenberg, 2004- Structured Communicative Play- proved and accepted for Language- can be applied to speech sound disorders.

  • Hmm? Like NSOME?

  • Selecting Targets that are intrinsic to the activity:

    • In this article- Meredith gives the example of "Sleepy Sue" -NAME the toys with your target.

    • Contextual Practice:

      • Pick an activity for a client to lead- Sue makes SOUP or SALAD

      • Add crazy items to the mix to make it memorable-

Suggestions-Contextual Practice

  • Play with Purpose

  • Procedural Language

  • Routine

  • Replay video

  • Generalizing more than speech

    • (ASHA) 11% to 40% of children with speech sound disorders had concomitant language impairment (Eadie et al., 2015; Shriberg et al., 1999).

    • FUNCTIONAL play-based therapy taps into both language structures and word structure providing benefit to both

    • Routine of a game- "when I go camping, I bring a …..

Learning outcome: promote long term generalized improvement

  • Drill therapy vs Generalization.

  • Traditional approach of setting individualized articulation goals for clients and use of the articulation hierarchy (Vertical Approach).

  • Limitationsof this approach in promoting long-term and generalized improvements in speech sound production.

  • Research supports a complexity approach (Horizontal Approach)

    • targeting later developing sounds leads to system-wide change to earlier developing sounds, but that this does not go the other way- treating earlier will not lead to change in later developing.

  • Self-Monitoring leads to Generalization

    • Teach how to monitor, teach how to know if a sound is correct or not- ask what the goal is- several studies supports self-monitoring as facilitating generalization

    • Challenge point+ ZPD

    • Performance driven changes frequently within a session

    • How self-monitor- encourage tally self and tally awareness (family)

    • Johnson and Johnson 1972 showed monitoring others lead to better generalization- supporting family inclusion and practice.

    • Shriberg (1990) SBRS effectiveness

Structured Practice- moving from stabilized to generalized pp 435 ssd

  • Van Riper's hierarchy moves - syllable to conversation- BUT include several steps- track data on several steps.

  • Varied cuing- from model to spontaneous- track both (all) from beginning target both (all) from the beginning.

Dynamic Targets- moving targets

  • Dynamic movement along the hierarchy

  • Moving up allows for data that indicates if the client is making any gains.

The Hierarchy IS Principals of Motor Learning

  • Acquisition is the learning phase where the motor performance is establishment. Retention and transfer reflect the level of learning where change is observed outside of practice (Generalized). The level of performance during the Aquisition does not predict retention and transfer of the skill (Maas et al., 2008).

  • Work more on Transfer

    • Transfer- through using other EVIDENCE based techniques

    • By embedding targets in therapy so that there is active acquisition AND passive opportunities to demonstrate retention.

    • Maas et al (2008) emphasized three areas to focus on during session- prepractice, principles of practice, and principles of feedback.

      • Prepractice = teaching phase

How do we step?

  • Although the traditional approach is well known, there is little consensus on how to do it, when to move to the next step, and how to cue at each step.

  • Individualized for the client.

  • Often mix in PML- to help AQUIRE and then RETAIN - Brooke Rea

Evidence: Transfer Training Complexity Approach

  • Gierut et al. 1996- found that treating later developing sounds lead to greater system wide change than treatment of earlier developing sounds

  • Susan Rvachew- 2011 more effective to treat early developing sounds that have some stimulability over late that have no stimulability

  • Both these arguments true. What model you work in helps guide how to best focus the generalization

Complexity AND stimulability

  • Judith Gierut, 2007

    • Trickly down effect- seen to shorten time for treatment because of the generalization approach- teach later developing sounds-

  • Rvachew et al- 2011- We know children need to be within the zone of proximal development and have better success when they have some stimulability for a target.

Internal Locus of control

  • Children who are active participant make more gains

  • Understand and are invested in the program

  • They know the WHY

Evidence: Involving Families

  • Aravind: Family involvement leads to 7% increase in goal attainment for every hour of home practice

  • Increased home practice frequency and duration (number of practice minutes per sitting)resulted in better articulation outcomes and less variance in treatment success (Günther & Hautvast, 2010).

  • Binns- Scoping review- 214 studies looked at ICF model and pointed to the importance of Participation based therapy for client success

Suggestions- Involving Families

  • Education- teaching family WHY it's important.

  • We all play

  • Word of the week- small dose home practice

  • Specific instructions- like, really specific

  • Include family- (groan) YES

  • Aim for a number- 1-3 session?

  • Include the family as a member-

  • Make it meaningful.

  • Set a limit. Home work

Data tracking.

  • Measuring Progress. How to effectively measure intrinsic targets that lead to generalized goals and compare at each level to the hierarchy level to demonstrate the transformative impact on clients' communicative competence.

RECAP:

  • Re watch buckaroo video-

  • Now- track the SWL

  • Track the structured intrinsic targets compared to the drill (extrinsic) targets (flash cards)

  • Track spontaneous productions

  • Prepared data sheet

Resources

  • ASHA definition of Treatment

    • https://www.asha.org/practice-portal/clinical-topics/articulation-and-phonology/#collapse_6

  • ASHA Complexity Approach :

    • https://pubs.asha.org/doi/10.1044/2017_LSHSS-17-0082

  • Bernthal, J. E., Bankson, N. W., & Flipsen, P. (2017). Articulation and phonological disorders: Speech sound disorders in children. (8th Ed.). Pearson.

  • Cunningham BJ, Washington KN, Binns A, Rolfe K, Robertson B, Rosenbaum P. Current Methods of Evaluating Speech-Language Outcomes for Preschoolers With Communication Disorders: A Scoping Review Using the ICF-CY. J Speech Lang Hear Res. 2017 Feb 1;60(2):447-464. doi: 10.1044/2016_JSLHR-L-15-0329. PMID: 28219081.

  • Eisenburg, S. (2004) Structured Communicative Play therapy for targetting Langauge in young chhldren. Communication Disorders Quarterly. https://www.montclair.edu/profilepages/media/308/user/2004JCD.Structuredcommunicativeplay_therapy.pdf

  • French- Speech-Language Pathology Intervention Practices for French-Speaking Children with Speech Sound Disorders: Results of a Québec Survey - https://www.cjslpa.ca/files/2022CJSLPAVol46/No3/CJSLPAVol46No320221257.pdf

  • Gierut, J. A. (2007). Phonological complexity and language learnability. American Journal of Speech-Language Pathology.https://doi.org/10.1044/1058-0360(2007/003)

  • Harold, M. P. (2013, September 3). Planning a play-based therapy session. ASHAwire.

  • Informed SLP Complexity: https://www.theinformedslp.com/review/complexity-approach-for-speech-sound-disorders

  • Informed SLP- Speech Sound Disorders treatment https://www.theinformedslp.com/review/everything-you-want-to-know-about-treatment-approaches-for-speech-sound-disorders

  • JOHNSON, J. M., & JOHNSON, G. T. (1972). Modification of consonant speech-sound ar ticulation in young childr en. Jour nal of Applied Behavior Analysis, 5, 233-246.

  • Koch, C. (2023). 20Q: Principles of motor learning and intervention for speech sound disorders. SpeechPathology .com. Article 20589. Available at www.speechpathology.com

  • Kummer, A (2023)- Sound Judgement- Speech Prerequisites, Therapy Techniques and Use of Motor Learning Principals Article 10447. Av ailable at www.speechpathology.com

  • Law, J- Inter Locus of Control https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6464758/

  • Leaf e N, Pagnamenta E, Taggart L, et al: What works, how and in which contexts when supporting parents to implement intensive speech and language therapy at home for children with speech sound disorder? A protocol f or a realist rev iew. BMJ Open 2024;14:e074272. doi: 10.1136/bmjopen-2023-074272

  • Maas.E, Littlejohn, M. (2023) How to Cut the Pie Is No Piece of Cake: Toward a Process Orientated Approach to Assessment and Diagnosis of Speech Sound Disorders. International Journal of Communication Disorders. DOI: 10.1111/1460-6984.12934

  • Maas, E., Robin, D. A., Austermann Hula, S. N., Freedman, S. E., Wulf, G., Ballard, K. J., & Schmidt, R. A. (2008). The principles of motor leaning in treatment of motor speech disorders. American Journal of Speech-Language Pathology , 17, 277-298.

  • Matthews T, Barbeau-Morrison A, Rv achew S. Application of the Challenge Point Framework During Treatment of Speech Sound Disorders. J Speech Lang Hear Res. 2021 Oct 4;64(10):3769-3785. doi: 10.1044/2021_JSLHR-20-00437. Epub 2021 Sep 15. PMID: 34525308.

  • Namasiv ayam, A. K., Shin, H., Nisenbaum, R., Pukonen, M., & v an Lieshout, P. (2023). Predictors of f unctional communication outcomes in children with idiopathic motor speech disorders. Journal of Speech, Language, and Hearing Research, 1–16. https://doi.org/10.1044/2023_jslhr-23-00070

  • Ov erby et al, 2007 https://pubmed.ncbi.nlm.nih.gov/17890513/

  • Rakov ic Speech Language Chat. (2021, December 28). What is van riper approach to articulation therapy?.

  • Rv achew, S., & Nowak, M. (2001). The ef fect of target-selection strategy on phonological learning. Journal of Speech, Language, and Hearing Research. https://doi.org/10.1044/1092-4388(2001/050)

  • Shr iber g and Kwiatakowski (1990)https://waismanphonology.wiscweb.wisc.edu/wp-content/uploads/sites/532/2018/07/1990Shriberg-Kwiatkowskiself-monitoring-and-generalization.pdf

  • Williams, A. L., McLeod, S., McCauley, R. J. (2021). Interventions for speech sound disorders in children (2nd ed.). Paul H. Brookes.