EBP Paediatric Speech Group 2008 Key findings & their clinical application Bronwyn Carrigg – Sydney Children’s Hospital

Background Information: Intervention options for children with Speech Sound Disorder (SSD) include decisions about; How to select targets/goals How to target the selected targets Intervention structure Some contradictory intervention findings…

Why are there contradictory findings? Few studies compare different intervention approaches. Most compare Rx with no Rx. Children with SSD are a heterogenous group (ie severity, error type, different underlying deficits) Core Vocabulary - an intervention approach designed for a well defined clinical population – ie the subgroup of children with inconsistent SSD

Dodd’s SSD Classification System 1. Articulation Impairment 12.5% 2. Delayed Phonological Skills 57.5% 3. Consistent Deviant Speech Disorder 20.6% 4. Inconsistent Speech Disorder 9.4% 5. Childhood Apraxia of Speech *(CAS) * CAS variably included in Dodd’s classification system (Crosbie et al 2005, Broomfield & Dodd, 2004) Shriberg also proposes a model of 5 subtypes of SSD.

Dodd’s Classification System (cont’d) Articulation impairment – ‘inability to produce a perceptually acceptable version of particular phonemes, either in isolation or in any phonetic context…..errors are due to a peripheral problem where the wrong motor programme for the production of specific sounds has been learned' eg lateral lisp, [w] for /r/. (all quotes Crosbie et al 2005 p. 472) Delayed phonological skills: 'speech characterized by the use of regular error patterns that occur in normal development but at a chronological age when the patterns should not be evident.

Consistent deviant disorder: 'systematic use of atypical (non-development) phonological patterns (e.g., deleting all syllable initial consonants.‘ Inconsistent across words within same linguistic context. Inconsistent speech disorder: 'Speech characterized by variable production of the same lexical items or phonological features not only from context to context, but also within the same context. ….a deficit in phonological planning.' *Childhood apraxia of speech: This diagnostic subgroup has been variably included in Dodd's publications (not in Crosbie et al, 2005 but in Broomfield and Dodd (2004).

Clinical Question: In children with inconsistent speech sound disorder, does a Core Vocabulary approach, or a phonological contrast approach (Metaphon/minimal pairs), or a PROMPT approach result in consistent speech production. (6 papers)

Core Vocabulary Approach: Grew out of clinical research study evaluating phonological contrast treatment (Dodd & Iacono 89) 1/7 children made no gains. Child differed, - errors were inconsistent across same lexical items, no CAS tomato - /mugug/, /tunawor/ TV - /pikeg/, /teeting/ Core Vocabulary treatment for 2 months until consistency of errors established. Then phonological contrast approach used successfully

Components of Core Vocabulary Approach Targets the consistency of whole word production, not surface error patterns or sound features Aim is for child to say word same way each time, not to be error free Min. 50 functional, powerful words chosen. Not chosen on basis of word shape or segments. Each week 10 words randomly chosen from this list as target words

Core Vocabulary (cont’d) Child’s best production is then established in that session using cues, eg sound & syllable seg, imitation, cued articulation, letter/symbols Child required to say words same way in tasks throughout week. Imitation avoided in therapy stage as imitation provides a phonological plan. Aim is for children to practise generating their own phonological plan.

Phonological Contrast Therapy Targets a cognitive-linguistic deficit Aims to reorganise child’s linguistic system Uses meaningful contrasts (key-tea) Results in new hypothesis & systems for child Range of approaches eg minimal pairs maximal pairs empty set multiple oppositions metaphon

PROMPT (Prompts for Restructuring Oral Muscular Phonetic Targets) Clinician provides active tactual-kinaesthetic- proprioceptive sensory input to child’s articulators to facilitate speech production That is multimodal information provided to child about the sound, sight and feel of desired speech movements 4 types of prompts: 1) parameter, 2) syllable, 3) complex, 4) surface (see Hayden 2006 for summary) Ref for this slide – Hayden 2006

Clinical Question: In children with inconsistent speech sound disorder, does a Core Vocabulary approach, or a phonological contrast approach (Metaphon/minimal pairs), or a PROMPT approach result in consistent speech production. (6 papers)

Clinical Bottom Line: Children meeting the diagnostic criteria for inconsistent SSD benefit most from a core vocabulary approach until errors become consistent, followed by a phonological contrast approach. Children with consistent deviant SSD benefit most from phonological contrast therapy. PROMPT was a less effective approach than core vocabulary or phonological contrast, for both groups

Clinical Bottom Line (cont’d) Differential diagnoses of the type of SSD is necessary in order to select the most appropriate intervention approach. There is a low level of evidence that in bilingual children with inconsistent SSD, a core vocabulary approach implemented in english resulted in improved error consistency in both languages.

Resources DEAP – Diagnostic Evaluation of Articulation & Phonology (Dodd et al 2002). Has articulation, phonology, inconsistency, oromotor ‘subtests’. Core Vocabulary CD available to order $ McAuley & Fey new book covers therapy interventions. Contains DVD of 20 approaches. Due out soon.

Plans for 2009 Next meeting: Thurs 5 th Feb 2009 CDTRC, Cumberland Campus Topics for 2009: Early indicators/risk factors for SSD in late talkers Research on interdental & lateral lisps Review latest core vocab article just out

New members very welcome! If you’d like to join and can complete a minimum of 2 CAPs per year, please contact:

References: Bradford, A. & Dodd, B. (1997). A treatment case study of inconsistent speech disorder. Australian approach Communication Quarterly, Autumn, 24–28. Crosbie, S, Holm, A & Dodd, B (2005). Intervention for children with severe speech disorder: A comparison of two approaches. International Journal of Language communication Disorders Oct – Dec ) No 4 pp 467 – 491 Crosbie, S., Pine, C., Holm, A., Dodd, B. (2006). Treating Jarrod: A core vocabulary approach. Advances in Speech- Language Pathology, September 2006; 8(3): Dodd, B. (2007). Evidence-based practice and speech- language pathology: Strengths, weaknesses, opportunities and threats.. Folia Phoniatrica et Logopaedica, 59,

Dodd, B., Bradford, A., A comparison of three therapy methods for children with different types of developmental phonological disorder (2000). International Journal of Communication Disorders, 35:2, Hayden, D (2006) The PROMPT model: Use and application for children with mixed phonological-motor impairment. Advances in Speech-Language Pathology, Sept 8(3) Holm, A. & Dodd, B. (2001) Comparison of Cross-Language Generalisation Following Speech Therapy. Folio Phoniatrica et Logopaedica; May/June 2001: 53, 3; ProQuest Health and Medical Complete pg Holm, A., & Dodd, B. (1999). An intervention case study of a Bilingual Child with phonological Disorder. Child Language and Teaching Therapy (15) MacIntosh, B., & Dodd, B (2008) Evaluation of Core Vocabulary intervention for treatment of inconsistent phonological disorder: Three treatment case studies Child Language Teaching and Therapy, Vol. 24, No. 3,

A big thank you this year to: Dr Elise Baker – Co Leader EBP, Sydney Uni Active members from; Parramatta CHC, Liverpool Health Service, Caringbah CHC, Sutherland CHC, Menai CHC, Peakhurst CHC, Hunter New England AHS, Campbelltown Hospital, Hills CHC, Hospital, Wollondilly CHC, Hornsby-Kuringai SPT, Mt Druitt CHC, Sydney Children’s Hospital & CHC, Learning Links Northern Suburbs, Sydney University