1. Efficacy of the SATPAC Approach for remediating persistent /s/ errors Stephen Sacks, M.A., CCC-SLP SATPAC Speech, Fresno, CA & Peter Flipsen Jr., Ph.D., S-LP(C), CCC-SLP Pacific University, Forest Grove, OR

2. Disclosure-Stephen Sacks Financial: Owner and Developer of SATPAC Speech and receives royalty payments. Receives royalty payments from Marshalla Speech & Language. Consultant for the Bureau of Education & Research and receives honorarium compensation. Nonfinancial: Board Member of the Oral Motor Institute

4. Disclosure – Peter Flipsen Jr. No financial or non-financial conflicts to report

5. Outline What are persistent speech errors? Current approaches to treatment The SATPAC Approach Study design and results Discussion Questions

6. Persistent Speech Errors Frequently encountered on school caseloads Mild distortions of /s, z, r, l/. Hard to justify more than limited treatment. Minimal impact on intelligibility? Usually little impact on academics? Have proven difficult to correct with traditional methods Ingrained bad habits?

7. Management Options? Traditional therapy but more Tx time? Unlikely; no more time available Ignore? Probably not a good idea. Negative peer reactions See Crowe Hall (1991), Madison & Gerlitz (1991), & Silverman & Paulus (1989). Reduced adult expectations See Overby et al. (2007) & Lass et al. (1988) Possible increased risk of emotional and behavioral problems See Beitchman et al. (1986)

8. Management Options? Modify the therapy sequence? Concurrent task sequencing (Skelton, 2004). Relatively unstudied so far. Modify feedback? Electropalatography? Still somewhat expensive and requires considerable training Spectrograms? Ultrasound? Speech Buddies? All relatively unstudied.

9. The SATPAC Approach Systematic Articulation Training Program Accessing Computers. www.satpac.com Combines the use of: 1. Non-words based on facilitating contexts (with transition to real words) Helps get around ingrained bad habits, and Takes advantage of coarticulation 2. Computer generated stimulus lists Progressively move through ever more challenging contexts, and Avoid other error sounds that may interfere or are not in the student’s repertoire. 3. Practice at normal (or near-normal) speaking rate Avoids odd prosody, and Promotes normal motor planning, and Promotes generalization from an early stage

10. Multimodality Approach to /s/ Remediation

11. Use of /t/ Sound (and other unusual things) /s/ is not mentioned Mouth is open which is not normal for /t/ (but only temporarily)

12. Use of an Auditory Visual Model to Contrast Correct/Incorrect “EET” Production

15. Use an Applicator Stick for Visual Tactile Feedback (EE-point)

17. Tongue Tip Pointing for Visual, Tactile-Kinesthetic Feedback

18. page 33

19. Tongue Pops for Visual, Tactile-Kinesthetic Feedback

21. EE Point Tip for Visual, Tactile-Kinesthetic Feedback

23. Tongue, Lips and Jaw Differentiation

25. EET for Auditory, Tactile-Kinesthetic Feedback

27. KF Second Session

29. EETS for Auditory, Tactile-Kinesthetic Feedback

30. The French /t/ page35

33. Systematic Articulation Training Program Accessing Computers

34. SATPAC Procedure Checklist- Establishment Phase

35. Practice Phase-Criteria for Completion  80%+ accuracy on the first 4 lists @ 140 BPM  80%+ accuracy on List 5 at a normal conversational rate with no slowing down on the target sound

36. Practice Phase-Lists 1 and 2 Practice Phase Lists 1 and 2

37. Practice Phase-Lists 3 and 4 Practice Phase Lists 3 and 4

38. Practice Phase-List 5 Practice Phase List 5 Contrastive Stress

39. Generalization/Transfer Phase

40. TALLY COUNTER

41. Generalization/Transfer Phase Phrases

42. Generalization/Transfer Phase Short Sentences

43. Generalization/Transfer Phase Sentences

44. Generalization/Transfer Phase Short Contrasts

45. Generalization/Transfer Phase Contrasts

48. Current Study Sacks, Flipsen, & Neils-Strunjas (in press) revealed significant improvement in persistent /s/ with the SATPAC approach when administered by the first author (who is also the program designer). Attempting to replicate using other clinicians trained in the approach. Between groups alternating treatments design Measure baseline performance, treat group 1 while group 2 waits. Then measure performance on both and treat group 2 while group 1 waits Measure both groups again and re-measure after an additional 12 weeks to check for maintenance.

49. Participants 13 children recruited from two public schools. 7 males; 6 females – initial age 6;11 to 8;8 (Mean = 7;11) No previous speech or language treatment rec’d. 8/13 monolingual English speakers; 5/13 bilingual but English dominant. All presented with either dentalized or interdental versions of /s,z/ Dentalized = sounds distorted Interdental = may or may not sound distorted but looks atypical

50. Progress Measures Measured production accuracy of /s/ in: 1. CPAC /s/ probe (words and sentences; Secord & Shine), and 2. conversational speech Allowed for measurement of performance in the structured context of therapy and to monitor generalization.

51. CPAC /s/ Probe

52. Treatment Plan Participants randomly assigned to two groups Group 1 (n=7) included 5M; 2 F; ranged in age from 6;11 to 8;8 Group 2 (n=6) included 2M; 4 F; ranged in age from 7;5 to 8;3 No significant age difference Individual treatment sessions by 2 clinicians who were trained on the approach Focus only on /s/ Each clinician saw about half the children in each group 12 weeks of treatment; 1 X 15 minute session per week = 180 minutes of total treatment. 180 total minutes of therapy.

53. Observations about Treatment Variation between SLPs One SLP administered the program more faithfully than the other and consequently showed significantly better results (7/8 90%+ in conversation vs. 2/5 90%+ when study was completed). All completed Tx but 3 (2 from Group 1) moved at the end of the school year and were no longer available at follow-up. Net result: missing any follow-up data for 1 participant.

54. Group Results (CPAC probe)

55. Group Results (Conversational Speech)

56. Individual Results Not all participants achieved the same results 6/12 (3 from each group) followed an “ideal” pattern. Saw change on both measures immediately after therapy and it was maintained at follow-up.

57. Individual Results “Delayed” generalization? 1/12 showed immediate change after treatment on CPAC probe but no generalization to conversation until follow-up. 1/12 showed gradual change over time on CPAC probe but no change in conversation until 24 weeks post- treatment.

58. Individual Results At least one participant showed gradual improvement to acceptable levels by initial follow-up but regressed at 24 week follow-up

59. Individual Results 3/12 participants showed little or no change in one or both measures.

60. Overall Results and Conclusions Group results show obvious effects for both the CPAC probe and conversational speech. Individual results showed obvious signs of improvement for 8/12 participants to acceptable levels of performance on both measures. Doesn’t work for everyone. With a relatively short treatment period (12 weeks) and relatively brief sessions (15 minutes per week), the SATPAC Approach appeared to be effective at correcting persistent /s/ errors.

61. Future Directions Need to determine efficacy with other errors (/r/, /l/). Need to evaluate whether each component is absolutely necessary. E.g., are the specific “establishment” procedures necessary or can any technique to establish good /s/ work? E.g., how crucial are the nonsense stimuli? Need to determine why some don’t respond to the therapy.

62. Questions?