From the Desk of Ann Kummer
My first job as an speech-language pathologist (SLP) was working in the public schools. At that time, I was seeing each child twice a week for half an hour in a group. In addition, I was giving each child speech homework after every session. Despite my efforts, I found that I could get a child to produce a misarticulated sound correctly in therapy, but it took forever to get the child to produce the sound spontaneously and consistently in connected speech. I had the same frustration in working with kids who had issues with syntax. What I have come to realize over my years of practice is that carryover is dependent on the frequency and intensity of correct practice and correct productions. This is consistent with motor memory principles where a high degree of repetition of a motor sequence results in the ability to produce the movement with automaticity rather than conscious thought.
In recent years, the term “dose” has been used in regard to speech therapy. The traditional medical definition of “dose” is the amount of medicine taken or radiation given at one time. In our field, dose can be defined as the number of teaching episodes in one therapy session (or even as the number of correct responses achieved). Of course, we can’t predict the required dose for each individual child in order to achieve carry-over, but we can assume that an increase in dose, in both speech therapy and with practice at home, will result in faster progress.
Because this is such an important concept, I am particularly excited about this 20Q article. In this article, Dr. Farquharson and her doctoral student, Anne Reed, discuss research on why dosage matters in speech sound therapy, the type of frequency that is most effective, and the factors that influence what’s possible in school-based sessions. They will also discuss the results of a recent investigation regarding these factors.
Here is a little information about both authors:
Kelly Farquharson, PhD, CCC-SLP, is an associate professor and director of the Children Literacy and Speech Sound Lab at Florida State University. Her research interests include school-age children with phonological and language disorders; the effect of those disorders on the acquisition of literacy skills; and the cognitive, environmental, and academic factors that contribute to phonological and language disorders. Prior to pursuing a research degree, she was a school-based SLP in Pennsylvania.
Anne Reed is a doctoral student with valuable experience working in public schools as well as with students with dyslexia. Her research interests include speech sound disorder therapy dosage and intensity on progress, type of reading instruction and its impact on future special education referrals, and state stakeholder (e.g., DOE, legislators) awareness of new speech sound development data and the subsequent impact on SPED eligibility. Anne is currently working on a study coaching paraeducators in shared book reading techniques.
This is an important article for not just school-based SLPs, but for all SLPs who want to achieve carryover of skills quickly.
Now…read on, learn, and enjoy!
Ann W. Kummer, PhD, CCC-SLP, FASHA, 2017 ASHA Honors
Browse the complete collection of 20Q with Ann Kummer CEU articles at www.speechpathology.com/20Q
20Q: Dynamics of School-Based Speech and Language Therapy Variables
After this course, readers will be able to:
- List and define therapy variables that affect the dynamic of speech and language therapy sessions.
- Describe how therapy quality, and IEP goals, may impact the outcomes seen in children with speech and language impairments.
- Describe how the role of SLPs' job satisfaction and caseload size are related to therapy outcomes and practice patterns.
- Identify service-delivery models and how therapy variables may change as a result of them.
1. What are speech and language therapy variables?
There are many moving parts that contribute to positive speech and language therapy outcomes. Often, the focus is solely on the child or client, without a broader examination of the context in which the therapy is taking place. However, this contextual examination is crucial for implementation science - what are the facilitators and barriers for clinicians in implementing best practices? How do the dynamics of speech and language therapy sessions differentially contribute to child outcomes? We hope to raise awareness of these dynamics - particularly within school-based settings. We will include information regarding SLP-level variables like job satisfaction and caseload size as well as therapy-level variables like session frequency, duration, and dosage. We also consider service delivery options that clinicians may use to maximize the impact of speech and language therapy variables. We end with ideas for advocacy.
2. Are SLPs satisfied with their jobs?
ASHA’s survey of work satisfaction in 2018 reported 86% of Audiologists and SLPs were satisfied or very satisfied with their current job. The top three reasons respondents said they have stayed at their current job were interesting work, good relationships with co-workers, and a convenient location. Surveys targeting School-Based SLPs have measured job satisfaction based on factors such as salary/benefits, caseload size, workload, administrative support, collaboration, resources, and workspace (Amir et. al., 2021).
3. Is job satisfaction related to therapy quality?
Biancone et al. (2014) reported that SLPs who reported a higher level of job satisfaction were also found to have higher quality therapy sessions. These researchers adapted The Classroom Assessment Scoring System (CLASS; Pianta et al, 2008) for speech therapy. The CLASS was designed as an observational tool to measure three broad domains: emotional support, instructional support, and classroom organization.
4. How is SLP caseload size related to service delivery?
Many SLPs report decisions regarding treatment intensity are more related to their caseload size than to child-level variables (e.g., severity of disorder; Brandel & Loeb, 2011). This revelation has substantial implications for child outcomes. Clinicians are making decisions that impact the speed and effectiveness of their treatments based largely on the context of the manageability of their caseloads (Katz et al., 2010).
5. What is the difference between caseload and workload?
A caseload model relies solely on counting the number of students on an SLP’s “roster”, with little consideration of other aspects of job responsibilities or how differing student populations entail different levels of preparation and treatment. A workload model encompasses all aspects of an SLP’s responsibilities, including direct services (e.g. evaluation, treatment, MTSS), indirect services (e.g. parent/staff training, classroom observations), and activities that support compliance with federal, state, and local mandates (e.g. Medicaid billing, preparation of IEPs; ASHA, n.d.e). The acknowledged difference between caseload and workload has resulted in ASHA no longer making caseload recommendations (ASHA, n.d.c). We strongly suggest the use of a workload calculator to best determine how and when to assign work responsibilities to SLPs. ASHA offers a free workload calculator and includes detailed steps for its implementation (ASHA n.d.f). To help schools that may be new to the idea of workload, we suggest the implementation guide offered by ASHA (ASHA, n.d.d) and the detailed example of a workload analysis by Mire (2007).
6. How does workload vary based on the different populations treated by SLPs?
Differences in student populations are one factor that make it necessary to consider a workload approach. Children with disabilities, for whom communicating functionally using natural speech is exceptionally difficult or even impossible, require intervention using augmentative and alternative communication systems (AAC; e.g., picture symbol-based communication boards, speech generating devices, tablet-based systems with AAC apps). ASHA’s most recent caseload survey indicates that 60% of school-based SLPs serve children with AAC needs (ASHA, 2018). AAC assessment and intervention is time-intensive, and research consistently finds that SLPs have a lack of time to prepare, coordinate, and deliver AAC services (Dowden et al., 2006; Fallon & Katz, 2007; Johnson et al., 2006; Kent-Walsh et al., 2008). The time-intensive services needed by students who use AAC make it imperative to use a workload approach.
7. Does it matter how we write IEP goals?
IEP goals serve very much like a roadmap for the services that the child receives. How do these goals relate to outcomes? Surprisingly there is a dearth of research in this area. Related to speech and language, Farquharson et al. (2014) and Goodwin et al. (2020) use the Revised Goals and Objectives Rating Instrument (R-GORI, Notari, 1988) to quantify the quality of IEP goals. Farquharson et al. (2014) explicitly examined goals related to speech sound production and reported that the majority of goals were functional and generalizable, but few were written in a way that the behaviors could be targeted by other educational professionals. By contrast, Goodwin et al. (2020) reported that the goals written for children with traumatic brain injury were not generalizable, but were measurable. Neither study tied the quality of these goals to child outcomes. As such, there is a need for more research to determine the extent to which goal quality is related to therapy quality and/or child outcomes.
8. What is intervention intensity?
Intervention intensity is a complex variable. According to Warren et al. (2007), there are five components of intervention intensity:
- Dose form - the activity in which the teaching moments/ active ingredients are delivered. For example, small group outside of the classroom; play-based activity.
- Dose - the number of teaching episodes within a session. For example, 75 speech sound production trials in one session.
- Dose frequency - the number of sessions received over a period of time. For example, two sessions in one week; 8 sessions in one month.
- Total intervention duration - the total period of time that the child receives the intervention (e.g., 3 months, 1 year, etc)
- Cumulative intervention intensity - the product of all the last three variables described above. Dose x dose frequency x total intervention duration. For example, a child who receives 75 trials per session, in two sessions per week, for 3 months (12 weeks) would receive a cumulative intervention intensity of 1800 trials.
Considering these five components, what is the optimal intensity that will result in the best outcomes? Interested clinicians are referred to Justice et al. (2017), who developed an algorithm to determine the most appropriate dosage for children with language impairments.
9. What is dosage?
Dose refers to the number of teaching episodes during one intervention session (Baker, 2012; Farquharson et al., in revision; Hitchcock et al., 2019; Justice, 2018; Warren et al., 2007). This is considered to be an “active ingredient” in therapy that yields change (Baker, 2012; Justice, 2018). Depending on the target/ goal of the therapy session, the dosage will change.
10. Is there a recommended dosage for speech and language therapy?
In speech sound therapy sessions, research suggests achieving 100 trials (or a dose of 100) per session. Word learning studies have shown that 36 exposures is the “sweet spot” for consolidation of new vocabulary (Storkel et al., 2017). In a systematic review, Sugden et al. (2018) indicated that, across 47 published phonological intervention studies, the minimum production dose was 23, and the maximum was 200, with an average of 77 trials per session.
11. How often should a child receive therapy in a given week?
Session frequency refers to the number of times a child is seen in a particular week. In the extant literature, frequency ranges across treatment studies from once per month to five times per week; the majority of studies implement two sessions per week (Baker & McLeod, 2011). Allen (2013) reported that for preschool children with speech sound disorders, a higher frequency of 30-minute sessions per week was more effective than a single 30-minute session per week. These data also accord with Farquharson et al. (2020), which indicated that children who receive a greater number of therapy sessions throughout an academic year demonstrate greater gains in phonological production, compared to children who received fewer therapy sessions.
12. Should therapy be provided in a group or in individual treatment sessions?
Small group therapy (e.g., 2-6 children) is the most frequent option used by school-based SLPs (Brandel & Loeb, 2011). However, most treatment studies implement individual treatment sessions (Baker & McLeod, 2011; Baker, 2012; Williams, 2012). A review of 255 studies found only five that empirically tested the impact of service delivery models on child outcomes (Cirren et al., 2010). Two of the five studies found no statistically significant difference between group vs. individual therapy sessions. However, Farquharson et al. (2020) suggested that children who received a greater number of individual school-based therapy sessions demonstrated smaller gains in phonological production accuracy, as measured by percent consonants correct (PCC), compared to children who received fewer individual school-based therapy sessions (Farquharson et al., 2020). These preliminary data indicate that group formats may be differentially associated with children’s outcomes - but more research is certainly needed.
13. Should all children receive services within the same delivery model?
There are service delivery options that may result in better child outcomes, require less direct time with the SLP, and that may provide preventative measures such that a child does not end up needing an IEP. First, in-class services (also known as inclusive services or “push-in”, but see Ehren, 2016) is effective for children with language impairments (Tambyraja et al., 2015). Zurawski (2014) outlines some frequently asked questions that SLPs can consider and work through regarding how to begin the process of inclusive practices for their own caseload, with detailed lesson plans. Similarly, Ehren (2000) includes a table of example activities suggested for in-class services. Next, a consultative model can be used in situations which the child does not need direct services. The SLP should consider what activities could be modeled for or taught to other instructional stakeholders that will alleviate the need for direct services from the SLP. Make a list of these activities and create brief training materials to support them. This can also be time-consuming to begin, but over time will be incredibly helpful—particularly for itinerant SLPs who travel to multiple buildings within a week.
14. How do the therapy variables of dosage and session frequency change based on service delivery models?
For SSD, programs such as Quick Articulation! (Brosseau-Lapre & Greenwell, 2019), Speedy Speech (Kuhn, 2006) and SATPAC (Flipsen & Sacks, 2015) provide shorter, high-dosage sessions which minimize time out of the classroom and maximize trials. Byers et. al. (2021) compared pre and post gains between group sessions (30 min. 2x/week) and individual sessions (5 min. 3x/week) over a 6-week period and found no significant difference between the groups. With both conditions producing similar gains, it may benefit a child to spend less time out of class. With regard to vocabulary, curriculum-based therapy is better accomplished through a collaborative approach when compared to a classroom-based model or a traditional pull-out model (Throneburg et. al., 2000). Time constraints/scheduling are the most frequent barrier to an SLP’s engagement in collaboration (Pfeiffer et. al., 2019). If possible, block time in your week for collaboration before scheduling students at the beginning of the year.
15. Does it matter who provides the treatment?
Certainly, SLPs are uniquely trained to provide therapy to students with communication needs; however, it is also reasonable to recognize we can collaborate with our school colleagues for the benefit of the students we serve. For example, secondary teachers were trained to modify their oral and written language instructional language which resulted in improvement in students’ written expression and listening comprehension (Starling et al., 2012). A recent survey of SLPs participation in Interprofessional Collaborative Practice (IPP) revealed low use of IPP by SLPs in initial evaluations, eligibility meetings, and therapy. Barriers to IPP provided by participants included time constraints, resistance from other professionals, and lack of administrative support (Pfeiffer et al., 2021). One of the ways we can leverage our influence and collaborate more is to focus on our roles as coach, independence facilitator, and advocate (Murza, 2019).
16. Does it matter WHO your teacher/SLP is?
Yes, it is very likely that this matters. Research in education, for example, found small positive effects in reading when black and white students were assigned to teachers of their same race (Egalite et al., 2015). The same was true for black, white, and Asian/Pacific Island students in math. In addition, lower-performing black and white students appeared to benefit when placed in a teacher’s class the next year that was the same race. ASHA’s membership is comprised of 92% white females across all settings (ASHA, 2020). The remaining 8% represent a variety of other races (Black or African American, Asian, American Indian or Alaska Native, Native Hawaiian or Pacific Islander, and Multiracial). As of fall 2018, 47% of students enrolled in public elementary and secondary schools were White, 14% were Black, 25% were Hispanic, and the remaining 11% representing Asian, Pacific Islander, American Indian or Native Alaskan, and Multiracial. Thus, there is likely to be a variety of races of children receiving services from primarily white female-identifying SLPs. However, race is not the only factor that contributes positively to outcomes. Hamre and Pianta (2005) found that first grade students at risk of school failure benefit from positive instructional and emotional classroom support provided by their teacher. The support provided decreased the risk of failure. Emotional support is defined as a positive classroom environment. Creating a therapy room that is a positive space for students includes addressing the following areas: personal bias, environment, instruction, and curriculum, in our case, therapy materials (Forrest & Alexander, 2004).
17. Does it matter what therapy materials you use?
As noted above, one way to ensure a positive classroom/therapy environment is through selecting culturally appropriate materials. As clinicians, we are to demonstrate our “cultural competence” by choosing materials and assessments that reflect the needs of our clients (American Speech-Language-Hearing Association [ASHA], 2017). SLP race is a greater predictor of diversity in materials selected than caseload diversity with black SLPs reporting selection of books with diverse characters when compared to white SLPs (Harris & Owen Van Horne, 2021). Material selection should be thoughtful and reflect the goals to be addressed as well as the diversity of your caseload.
18. What actually makes something evidence-based?
An ASHA committee on evidence-based practice (EBP) in 2004 stated EBP is “an approach in which current, high-quality research evidence is integrated with practitioner expertise and client preferences and values into the process of making clinical decisions” (ASHA, 2004). The Evidence Maps and Practice Portal on the ASHA website provide numerous resources to help SLPs make informed decisions with regard to a variety of clinically related topics (ASHA, n.d.a & ASHA, n.d.b).
19. For SLPs who have less flexibility in scheduling for service delivery - how should they start?
First, we recommend that clinicians start small. Pick one area/issue to work on for the academic year. Next, use the data. Based on the area/ issue of focus for the year, collect data to present to administrators. For instance, if providing services in a particular location or in a particular group size yields quicker change - use those data to suggest that this approach is used more consistently and widely. This is especially true if it resulted in more children being dismissed from services. To facilitate conversations between SLPs and school leadership, Farquharson et al. (2020) compiled a list of evidence-based action steps. These authors also review the ways in which administrators can recruit, support, and retain SLPs. SLPs can provide this article to their leadership team to summarize some of the research that supports better practices in schools.
20. What do you recommend for SLPs who are new to the idea of advocacy?
An effective way to start making change is to join state speech-language-hearing associations. State associations usually allocate funding for lobbying efforts through association dues. Additionally, many of the legislative issues that relate to occupational stress and burnout are actually governed at the state level, not at the national level. As such, although ASHA will often provide guidance or position papers to support SLPs’ advocacy efforts, the true change can only happen at the state level. We direct interested clinicians to Marante and Farquharson (2021) for a more in-depth discussion of the various ways in which clinicians can advocate.
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