From the Desk of Ann Kummer
In April of this year, I was perusing journal articles when I came across an article that really caught my attention. The article described a study that compared the effects of two different service delivery models on the speech outcomes of children in school speech therapy. The findings of the study really resonated with me based on my experience. Therefore, I contacted the authors to do this 20Q article for us. First, let me introduce the authors of this article:
Beth Byers, MS, CCC-SLP is a clinical supervisor and instructor at Lamar University. Her research interests include improving the workload approach for school-based SLPs, school-age language and literacy, and improving understanding of treatment intensity factors for speech sound disorders in the school setting.
Monica L. Bellon-Harn, PhD, CCC-SLP is the Diane H. Shaver Chair and Professor of Speech and Hearing Sciences at Lamar University. Dr. Bellon-Harn’s research focuses on intervention and service delivery issues related to speech and language disorders as well as recruiting and supporting minority students into communication sciences and disorders professions. Recently, her research has extended to consumer health informatics and digital therapeutics.
In this 20Q article, these authors discuss evidence from their study, which supports the efficacy of providing shorter, but more frequent treatment sessions for mild-moderate speech sound disorders in contrast to what is typically done in a school setting. This finding is very consistent with motor learning/motor memory research, which has shown that the provision of frequent sessions (and practice) is more effective than the provision of less frequent, yet longer sessions. Treatment intensity (dose) is also discussed in this article, which is also consistent with motor memory research, which has shown that progress is directly related to the number of correct repetitions (dose) of the motor movement.
This article will help clinicians to schedule therapy in a more efficient and effective way for maximum progress in the shortest amount of time. Therefore, it is well worth your time.
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: Flexible Scheduling in the School Setting: Evidence-based options
After this course, readers will be able to:
- Identify treatment intensity factors related to speech sound disorders.
- Describe evidence-based justification for implementing a new delivery model for mild-moderate speech sound disorders in the school setting.
- Describe ways to increase flexibility with scheduling in the schools.
In this article, we will be discussing our recent research regarding efficient and effective service delivery scheduling in a school setting (Byers, Bellon-Harn, Allen, Saar, Manchaiah, & Rodrigo, 2021).
1. What are the most noted challenges faced by school-based SLPs and what are the possible solutions?
In 2018, ASHA published results of a survey collected from 4,500 ASHA-certified school-based SLPs. These SLPs reported the top 5 challenges of this setting as:
- large amount of paperwork;
- high workload/caseload;
- limited time for collaboration;
- budget constraints; and
- incorporating optimal service delivery models.
Recent research exploring optimal treatment intensity can guide us for challenge #5. Implementing these optimal models may help reduce challenges #1 and #2 by helping these students reach goals faster, which in return could assist with challenge #3 by providing more time for collaboration.
2. What is treatment intensity and how are treatment intensity factors defined?
Intervention intensity is a multidimensional construct including dose, session frequency and length, total treatment duration, and cumulative treatment intensity (Warren et al., 2007). These intensity parameters interact with each other and should be considered in relation to each other (Schmitt et al., 2017).
- Dose refers to the number of times an active ingredient is delivered within each therapy session. The active ingredient may be characterized as the specific number of teaching episodes that SLPs provide within a session or the number of production trials (Allen, 2013). Dose can also be conceptualized as therapeutic input (e.g., placement cue; model) and client act (e.g., production trials; Baker, 2012).
- Session frequency refers to the number of sessions provided per unit of time and session duration refers to the number of minutes spent in each session.
- Total intervention duration refers to the total time period in which an intervention is provided (e.g., 6 weeks).
- Cumulative intervention intensity is the product of Dose × Session Frequency × Total Treatment Duration, which provides a summary metric of dose (Warren, 2007).
3. In the public-school setting, what is the typical frequency and duration for children with speech sound disorders?
Session frequency refers to the number of sessions provided per unit of time. Session frequency parameters reported in research studies mirror clinical practice data (i.e., 2–3 times per week; Baker & McLeod, 2011; Sugden et al., 2018). In a systematic review of 134 studies, Baker and McLeod (2011) reported that the session duration in research studies about treatment with children with SSD was 30- or 60-min sessions, which is not consistent with clinical reports that have indicated the majority of children in schools are seen in sessions that last between 21 and 30 min (Brandel & Loeb, 2011; Mullen & Schooling, 2010). It seems common for school-based sessions to follow business-as-usual (BAU) methods that typically include two sessions per week for 30 min via pull-out service delivery models (Brandel & Loeb, 2011; Mullen & Schooling, 2010).
4. Why do school-based SLPs typically rely on this frequency and duration?
Intervention intensity and service delivery model decision-making do not happen independently of other constraints in school settings. SLPs consider their entire workload and children’s other instructional requirements when making decisions. Ubiquitous BAU models may be the default due to the complexity of decision-making. However, determining the appropriate service delivery model and intervention intensity for a given disorder and treatment approach is paramount to ensuring that SLPs are using time and resources wisely to reach adequate treatment outcomes (Brosseau- Lapré & Greenwell, 2019). Additionally, it may seem overwhelming to implement these changes when SLPs have been using the same model for a number of years. They may also feel a lack of support from administration and/or a lack of time to implement changes.
5. How is dose defined in SSD treatment approaches?
The majority of research that reports dose in SSD studies characterize it as child production trials (Sugden et al., 2018). However, if SLPs are to establish intervention intensity levels, all active ingredients in the sessions, including feedback on performance, need to be specified (Baker, 2012; Maas et al., 2008). It may be beneficial to calculate both therapeutic input and production trials across activities. In that way, school-based SLPs can have some direction of how to balance therapeutic input and production trials within a specific time period. In this study, we examine dose characterized as separate measures of therapeutic input and production trials.
Therapeutic input consisted of clinical provision of knowledge of performance and knowledge of results (Ruscello, 1993). Knowledge of performance refers to specific information to the child regarding accurate speech sound production, such as feedback on articulator placement. Knowledge of results refers to the qualitative information provided to the learner in reference to response accuracy. Knowledge of results and knowledge of performance were both provided throughout the therapy sessions and used in one of two measures of dose (i.e., dose as characterized by therapeutic input).
6. What do we currently know about dose thresholds for speech improvement?
Of the studies examining dose characterized as production trials, results indicate that, for children with more severe SSD, greater dose may be required to effect change. Williams (2012) reported on three studies that examined contrastive approaches with preschool children with moderate-to-severe SSD. Taken together, a minimum dose of at least 50 production trials and duration of at least 30 sessions at a frequency of 2 times per week may be required for improvement on the Systemic Phonological Protocol. A dose below 50 trials in a 30-min session and fewer than 30 sessions appeared to have limited impact on outcome measures. The suggested dose was 70 trials per session for approximately 40 sessions.
When considering children with childhood apraxia of speech (CAS), dose per session may need to be even greater. Edeal and Gildersleeve-Neumann (2011) studied the role of increased dose (i.e., child production trials) with two children with CAS. Results suggest that a higher frequency treatment dose of 100–150 production trials per session and longer treatment duration are more beneficial than low-frequency treatment dose and shorter treatment duration. Neither of these studies focused on mild-moderate speech sound disorders in a school setting; therefore, the current study was needed to make recommendations for dose with students in the school setting who present with mild-moderate SSD.
7. What service delivery models were compared?
In the BAU (business as usual) condition, children received group sessions 2 times per week for 30 min per session for 6 weeks. The BAU model was designed to represent commonly used service delivery models in the schools (2x per week, 30-minute group sessions). In the EXP (experimental) condition, children received individual sessions 3 times per week for 5 min per session for 6 weeks. Across the 6-week time period, the BAU group received a total of 360 minutes of therapy and the EXP group received a total of 90 minutes of therapy.
8. What were the clinical profiles of the children enrolled in the service delivery conditions?
Sixteen of the 22 children included in the study were receiving speech therapy services provided through the school prior to the start of this study. These children did not exhibit oral motor deficits as reported on their school assessments. Six children who met the inclusion criteria were not previously enrolled in school speech therapy services. These children had not previously been assessed by the school SLP, but classroom teachers referred them for this study. An oral mechanism exam was conducted on these children, and no oral motor deficits were identified. Sixteen children included in the study obtained scores indicating a mild SSD, and six obtained scores indicating mild-moderate SSD. Examples of targets included: /r/, /s/, /θ/, /ð/, /k/, /g/.
Of the 22 children, five were enrolled in kindergarten, six in first grade, five in second grade, and six in third grade. Nine were girls, and 13 were boys. Ages ranged from 5 years 2 months to 9 years 11 months.
9. How did you select targets for treatment?
Target selection was client specific. Sounds were selected based on stimulability in that sounds that were highly stimulable and produced in multiple word positions were not selected. Sounds were also selected based on those that had the greatest negative impact on connected speech and/or were not developmentally appropriate. Speech sound errors for all children were characterized with distortions rather than sound substitutions or omissions, with the exception of /k/ and /g/. Sounds were targeted in treatment words that were either high word frequency or low neighborhood density, because such words are more facilitative of generalization (Gierut et al., 1999; Morrisette & Gierut, 2002). Word frequency refers to the number of times a given word occurs in a language (Morrisette & Gierut, 2002), whereas neighborhood density refers to the number of phonologically similar words that differ by a phoneme substitution, deletion, or addition (Morrisette & Gierut, 2002). An online tool of high-frequency, low-density words was utilized to make target word selections (https://slpath.com/highfrequencywordlist. html; Taps, 2007).
10. What were the outcomes of the study regarding gains and how was that measured?
Pre-treatment and post-treatment probe sets were provided. Ten exemplars for each target sound were used as probe sets for pre- and post-measures. These exemplars were not used during treatment. Probes were designed to have only one target sound per word. Probes with the sound in initial and final position were single-syllable words, while those in the medial position were multisyllabic word. For example, /s/ in initial and final position was presented in single-syllable words preceding and following different vowels (e.g., /ɪ, ʌ, u, i, ɑ, ɑʊ/). In the medial position, /s/ was presented in two bisyllabic words and one trisyllabic word. This provided clinicians with good information regarding production of target sounds. A team of three licensed, certified SLPs scored all pre–post probe data as accurate or inaccurate production of the target sounds. Gains from pre- to post probe measures were obtained by calculating the difference between pre–post percentage of words correct on the probes.
Overall, gains from pre- to post probe were not different between the BAU condition and the EXP condition, meaning both groups made gains. This data helps support flexible options in service delivery for this population of students.
11. What were the outcomes of the study regarding dose and cumulative intensity?
The clinician provided more therapeutic input, and children produced more trials per session during the BAU than the EXP sessions. Therapeutic input was provided on average 31 times a session in the BAU group, and 27 times per session in the EXP group. Productions trials occurred approximately 62 times per session in the BAU condition and approximately 41 times per session in the EXP condition. In sum, when looking at each individual session, dose was higher in the BAU group than the EXP group.
However, when looking at cumulative intervention intensity, there was not a significant difference between the BAU and EXP conditions (i.e., Median = 702 and 762 trials, respectively). Remember, cumulative intervention intensity is the product of dose, frequency, and total intervention duration.
12. What role did dose play in understanding cumulative intervention intensity?
One contributing factor to the impact of alternative service delivery models on speech outcomes is the amount of therapeutic input and production trials provided per individual session. Dose, described as therapeutic input and production trials, appears to play an important role in understanding service delivery models. As mentioned above, when looking at cumulative intervention intensity, there was not a significant difference between the groups. This means that the students in the EXP group were essentially provided a similar number of opportunities for production trials and feedback. This is important considering that the BAU group received 360 minutes of therapy and the EXP received 90 minutes of therapy. Results indicated that whether it was the BAU or EXP condition, the clinician provided a sufficient number of trials per child for change in performance to occur.
Take away: If the number of trials per session is high, it may require fewer, shorter sessions when working with children with mild or mild–moderate SSD to effect change. Basically, we can accomplish the same outcome in less time!
13. What dose is needed for children with mild-moderate speech sound disorders to see change in 6-weeks? (i.e., What should I aim for in each session to see change?)
According to the results of this study, an average of 50 production trials were elicited each session. Therapeutic input was provided an average of 30 times per session. Therapeutic input consisted of both knowledge of results and knowledge of performance. Research shows that providing more knowledge of performance (articulator placement, etc.) is necessary early on in treatment; whereas, as therapy progresses and the student is producing more trials accurately, you can shift to knowledge of results and decrease feedback in general to help the student begin to self- correct and then generalize correct productions outside of the treatment setting.
14. What other research is needed to help us understand optimal treatment intensity in the school setting?
In this study, we looked at progress made across a 6-week time period. We need additional data on generalization to better understanding optimal treatment intensity. Participants in this study fell in the mild-moderate range of severity (any that fell in the severe category were not included in the study) but identifying and categorizing students specifically by those with a phonological impairment versus articulation impairment will be helpful. The group sizes in this study consisted of 3-4 students; however, some SLPs may have groups closer to 5-6 participants and this could affect overall results and should be considered in future studies.
15. Do children with mild-moderate speech sound disorders make progress in 5-minutes, 3 per week, compared to children who receive therapy 2x a week for 30-minutes in a group setting?
Short answer: Yes!! The EXP group made similar gains when compared to the BAU group. According to this study, children can achieve adequate goal attainment in speech sound accuracy while experiencing less time removed from academic activities via alternative service delivery models, such as the EXP condition.
16. What are the benefits of implementing 1:1; 5-minute sessions?
One reason to select shorter, more frequent individual session is because children experience less time removed from the classroom. Children in the BAU condition missed a total of 270 additional classroom curriculum minutes (or 4.5 hr of class across 6 weeks) for change statistically equivalent to those of their peers who participated in the EXP condition. Implementing individual 5-min sessions 3 times per week may decrease the demand on the teacher to make up required instructional time and provide the SLP with more time to manage other workload responsibilities. Additionally, it is less challenging for the SLP to reschedule a missed session that is 5 min in duration versus 30 min in duration. The students were seen individually and provided the SLP an opportunity to focus on that student without distractions from other students. On a side note, we all know the struggle of having the pull students from desired activities such as music, PE, library, art, etc. In our informal observation, this quick burst of therapy seemed beneficial in that the students seemed motivated to participate knowing they would return quickly to those activities.
17. Won’t I spend more time traveling back and forth to get kids than actually being in therapy?
This is a good question. For the older participants, teachers sent them at their designated time, so this did not involve any extra time on the part of the clinician. For the younger students, the clinician set up a station in the grade level pod (or you could do this in a grade level hallway). This will allow quick access to the students without walking back and forth from the speech room to the classrooms. Since the therapy is drill based, it does not involve toting around large amounts of materials!
18. What if I already held my IEP/ARD meetings? What’s the best solution to changing those IEPs without returning to an ARD meeting?
Here is an example letter that could be sent home:
For the upcoming school year, we are hoping to implement a change in scheduling for your child. We are proposing a reduction in speech therapy time for your child. Currently, your child is set to receive therapy for 30-minutes, 2x per week in a group setting; however, based on recent research, we would like to implement 3x per week, 5-minute, individual sessions.
Research shows that children in this alternative delivery model (3x per week, 5-minute sessions) receive adequate opportunities to produce target sounds and see gains similar to longer, less frequent sessions (30-minutes, 2x per week).
Benefits to implementing this new service delivery model:
- Less time spent outside of the classroom
- Individualized therapy with no distractions from peers
- No wasted time in therapy
- Gains in speech sound production
At the end of the fall semester, we will review progress made to ensure that this is an effective model for your child. If we do not feel it is appropriate, we will make revisions to their IEP, with your permission.
*You can then provide signature lines or options for further explanation or discussion with parents who may have questions or concerns.
19. Would this be appropriate for RTI?
Absolutely! The potential impact of 5-min sessions, 3 times per week on speech sound production outlined in this study, points toward application in a response-to-intervention (RTI) model. Tier 2 includes supplemental instruction for those who require additional intervention and is conceptualized as noncategorical short-term, relatively intense, high- quality instruction (Justice, 2006). The Individuals with Disabilities Education Act of 2004 included broad references to RTI components, which leaves interpretation of specific implementation policies and procedures to local education agencies. In other words, there is more than one way to deliver Tier 2 instruction. SLPs have the opportunity to design programs to fit the needs of a specific school population or structure (Ehren et al., 2007). Swaminathan and Farquharson (2018) describe RTI as an approach that should be considered for children with SSD to manage caseload and improve workload. Research indicates that using RTI for SSD is effective and may be a more efficient process than placing the student on an Individualized Education Plan (Mire & Montgomery, 2009). Utilizing intense, individualized session with adequate dose within an RTI model may address both SLP work related factors and child outcomes.
20. How do I get started with this service delivery model?
- Identify students who may be possible participants (rule out any with severe SSDs and/or language impairments). We recommend starting small- perhaps one grade level.
- Develop a sample schedule to present to administration.
- Bring evidence supporting this type of model and create a document with listed benefits of implementing this new model (Tip: you can simply copy and paste from the benefits listed in this 20Q article!)
- Send IEP amendments to parents for approval to switch to this delivery model.
- Implement the model across a semester and be sure to keep data! This will help support expanding the new model to all grade levels for students who qualify.
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Byers, B & Bellen-Harn, CM (2020). 20Q: Flexible Scheduling in the School Setting: Evidence-based options. SpeechPathology.com, Article 20458. Retrieved from www.speechpathology.com.