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Evidence Based Practices for the Management of
School Age Speech and Language Disorders
Susan RvachewSchool of Communication Sciences and Disorders
McGill University
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Introduction to Evidence Based Practice
Part I
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Evidence Based Practice
• Integrate your own clinical expertise, the values and preferences of the child and the child’s family, and the best research evidence to make decisions about the services that you provide to a given child.
• American Speech-Language-Hearing Association. (2004). Evidence-Based Practice in Communication Disorders: An Introduction [Technical report].
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Facilitated Communication:A case study of the consequences of failing to apply EBP
• 1980: Crossly & Mcdonald develop FC for use with children with CP
• 1990: Blicklen publishes “Communication Unbound: Autism and Praxis” in the Harvard Educational Review
• 1990 to 1993: wide dissemination through published case reports and media reports
• 1991: Autism Society of America provides advocacy materials
• 1993 to 1996: series of research studies published that consistently invalidated the approach
• 1994: Myers publishes paper describing court cases in which FC was allowed in the court room to support allegations of child abuse
• 1996: ASHA publishes position paper stating that FC had no established validity
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Application of EBP
• Theoretical coherence
• Basic research
• Direct evidence (clinical trials)
• Appropriateness of context
• Professional experience
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Part II. Vocabulary Learning
1. Theory2. Basic Research3. Applied Research4. Application
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Pe
rce
ptu
al
Le
arn
ing
M
ec
ha
nis
ms
Co
gn
itiv
e L
ea
rnin
g
Me
ch
an
ism
s
Vocabulary
Phonology
Higher Language
Literacy
Skills
and
Academic
Success
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Part II. Vocabulary Learning
1. Theory2. Basic Research3. Applied Research4. Application
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Amount and Frequency Effects
• Overall amount of parent speech accounts for a substantial amount of variation in vocabulary growth.
• The relative frequency of exposure to specific words is related to the order of acquisition of those words.
• Huttenlocher et al (1991)
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Complexity of Input (Snow)
Density of sophisticated words
Embedding sophisticated words in helpful or instructive interactions
INPUT
AT AGE FIVE YEARS
Predicted 50% of variance in
Receptive Vocabulary
OUTPUT
AT AGE SEVEN YEARSWow! What a big
truck!
Wow! What a large
vehicle!
Look at this truck on the road. That’s
a large vehicle!
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Variations in InputHart & Risley (1995)
0
500
1000
1500
2000
2500
Professional WorkingClass
Welfare
Wo
rds
per
Ho
ur
48 M words
28 M words
12 M words
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How many repetitions are enough?
0.00
1.00
2.00
3.00
4.00
5.00
6.00
Pre-Test Post-Test
SLI - 3
SLI - 10
NL - 3
NL - 10
1.5 words
2.5 words
0 words
2.5 words
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Variations in InputHart & Risley (1995)
0
500
1000
1500
2000
2500
Professional WorkingClass
Welfare
Wo
rds
per
Ho
ur
48 M words
28 M words
12 M words
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Part II. Vocabulary Learning
1. Theory2. Basic Research3. Applied Research4. Application
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Explanation: DefinitionOut behind the big red barn at the edge of the walnut grove is a most magnificent pond shaded by an old oak tree. I'll tell you right now, before it's too late. It belongs to McFeeglebee.
A grove is a small group of trees (without underbrush).
And McFeeglebee absolutely forbids fishing in that pond. He's put up five signs to prove it. "Before I'll allow any little boys to fish in there," he says, "I'd rather remove it."
Forbid means that he won’t let anyone fish in his pond.
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Explanation: Synonym
Everyone warned him. "A pool is not the sea. You can't fish for free, it's stealing. Besides, there's all sorts of surprises in McFeeglebee's pond. Nobody knows just what is in there besides fish and old shoes and the things people lose. You'll catch something dangerous so you'd better beware. Fish in that pond? I wouldn't dare!"
But little Georgie P. Johnson just wiggled his nose and pretended not to hear, as if he had molasses stuck in his ear. Of fishing he was very fond, why should he fear McFeeglebee's pond?
Sea is another name for ocean.
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Explanation: Picture Support
All of a sudden with a bob and a jerk, the fishing line woke him. Grabbing the pole and holding on tight he used every muscle to fight what was without doubt the biggest of trout.
He pulled ten minutes before seeing that what he had caught was not a trout, but a huge grisly catfish. How could he have been so wrong? Its whiskers alone were a foot long!
You see here, this is the catfish. It’s a fish but it has whiskers like a cat.
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Penno et al. Study Design
Class A Class B
randomization randomization
Group 2 Group 1 Group 2
Story 1, explanations
Story 2, explanations
Story 1, no explanations
Story 2, no explanations
Group 1
Story 2, no explanations
Story 1, no explanations
Story 2, explanations
Story 1, explanations
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Results Overall by Ability Group
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Results: Explanations vs Retellings
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Repetitions by Ability Group
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Penno et al. Conclusions
• A combined approach to vocabulary instruction, providing both incidental learning from the story context and contextually relevant direct instruction, is more beneficial than either in isolation.
• Listening to stories did not overcome the ‘Matthew effect’.
• The intervention effects generalized to words that were not explained.
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Biemiller & Boote Intervention
• Definitions provided by teacher prior to first reading.
• Definitions provided ‘in-flight’ during repeated readings.
• Definitions provided by students if possible and by teacher if necessary on repeated readings.
• 4 to 6 new definitions provided per reading• 2 story comprehension questions to the
class after each reading.
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Design: Biemiller & Boote (2006; Study 1)
112 children in kindergarten, Grade 1, and Grade 2 classrooms
Week 1: Two books each read twice.
Explanations provided for half the target words.
Pretests
Week 2: One book read four times.
Explanations provided for half the target words.
Post-tests
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Biemiller & Booth: Study 1 Results
0
5
10
15
20
25
30
Two Readings Four Readings
Ga
in In
Pe
rce
nt
Wo
rds
De
fin
ed
Instructed
Uninstructed
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Biemiller & Boote: Study 2
• Teacher definitions provided for all words.
• Target words increased to 7- 9 for each reading.
• 4 readings for all books
• Reviews of vocabulary taught on previous days were added each day.
• An additional review of vocabulary in new contexts was added on the fifth day.
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Study 2 Results
• Large gains in vocabulary knowledge were observed at post-test (35% on average)
• Gains were largest in grade 1 (42%)• Gains for instructed words were much larger
than in the previous year (35% vs 22%)• Continued gains of about 6% were observed in
the 4 weeks following the immediate post-test• Word meanings transferred to new contexts
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Biemiller and Boote Conclusions
• The 41% gain in vocabulary knowledge that was observed between pretest and follow-up suggests that it is feasible to teach children 400 new words per year.
• This means teaching 1000 new words or about 25 words per week.
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Part II. Vocabulary Learning
1. Theory2. Basic Research3. Applied Research4. Application
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Part III. Narrative Skills
1. Theory2. Basic Research3. Applied Research4. Application
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Oral Narratives
Literacy
Skills
and
Academic
Success
Written Narratives
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Oral NarrativesAcademic
Success
Cognitive Skills
Social Skills
Linguistic Skills
Executive Function
Exposure
Scaffolding
Instruction
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Part III. Narrative Skills
1. Theory2. Basic Research3. Applied Research4. Application
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5-yr-old story (typical language)
• What do you see happening here?
• The dog is digging a bone so nobody can’t find it and then the dog leaves it. And then the squirrel comes and digs and he gets it.
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5-yr-old story (SLI)
• So tell me, what happens here?• A puppy bring him bone.• And then what?• Him walk away.• He walks away.• Then that digging it.• Who is? What’s that?• I don’t know.• It’s a squirrel.• Squirrel digging. Then he find the bone.
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Fey et al. (2004)
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
10.00
TL SLI NLI LNIQ
Na
rra
tiv
e Q
ua
lity
grade 2
grade 4
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Norbury & Bishop (2003)
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Part III. Narrative Skills
1. Theory2. Basic Research3. Applied Research4. Application
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NBLI: Lesson Activities
• Story Retell Task• SLP reads story containing 10 exemplars of target
grammatical form• SLP rereads the story component by component• Child retells the story component by component
• Sentence Imitation• 10 sentences pairs: target form vs contrast
• Story Generation Task• Child generates a story about a picture of a scene• SLP illustrates the child’s story for retelling by child
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Teaching Procedures
• Modeling sentences with the target forms
• Modeling narrative components: • setting, problem, resolution, complication,
ending
• Recasting phonological, sematic, and grammatical errors
• Verbal prompts to include missing components during story retell activities
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Let’s make up a story about this
picture. First, let’s talk about who’s going to be in our story and where our
story is going to take place.
The boy in the river. Here a tube and here another tube. This girl, her
pointing at him. Another girl looking at him. Here a bridge…and a waterfall.
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That’s right. The boy is tubing in the river. There are some big
rapids! Two girls are watching him.
Oh no! What do you think might happen in our
story?The boy fall in
the river!
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The boy falls in the river.
Can he swim?
No, him don’t know how.
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He doesn’t know how! That would be
scary! That’s a good ‘problem’ for
our story. A boy falls in the river but he can’t swim. How
will the boy get back to shore?
Him hafta yell “Help, help!” And she’ll save him.
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The boy was tubing in the
river. He fell in the water but he doesn’t know
how to swim. He yells ‘Help, help!’ and the girl saves
him. This is a great story. Let’s start over and tell this
story again.
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NBLI: Study Design
10 7 year old children with specific language impairment
Pretests
First Two Weeks (6 Sessions):
1 intermediate goal; 3 specific goals; 6 stories
Second Two Weeks (6 Sessions):
1 intermediate goal; 3 specific goals; 6 stories
Third Two Weeks (6 Sessions):
1 intermediate goal; 3 specific goals; 6 stories
Post-tests
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NBLI: Results
• 8/10 children exceeded the threshold for clinically significant improvement in Narrative Quality
• Little or no improvement for:• Number of different words• Developmental Sentence Score• Nonsense Word Repetition
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NBLI: Conclusions
• Children with SLI may have insufficient attentional resources to learn implicit grammatical targets in the context of an activity that provides explicit instruction in the production of narrative targets.
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Recent Modifications of NBLI
• Intervention implemented in small groups (2-3 children)• 12 sessions in 5 weeks• Stories modified to simplify vocabulary• Stories modified to target multiple grammar goals• Story grammar markers (‘story keys’) used to make story
grammar elements explicit• During novel story generation task, each group member
is responsible for a different story element• Sentences for imitation modified to ensure
meaningfulness when taken out of the story context• Future research will evaluate the NBLI when
implemented alone or in combination with FFW
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Part III. Narrative Skills
1. Theory2. Basic Research3. Applied Research4. Application
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Part IV. Phonology
1. Theory2. Basic Research3. Applied Research4. Application
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Development of Speech Accuracy
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VL
TT
TB
LP
GL
Development of Speech Accuracy
σ
O R
C V
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VL
TT
TB
LP
GL
Development of Speech Accuracy
σ
O R
C V
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VL
TT
TB
LP
GL
Development of Speech Accuracy
σ
O R
C V
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Part IV. Phonology
1. Theory2. Basic Research3. Applied Research4. Application
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Adult Produced /ɹ/ (left)Child Produced /ɹ/ Distortion (right)
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Perception Task
• Stimuli• 25 self-produced words (incorrect)• 25 self-produced words (corrected)• 25 other-produced words (incorrect)• 25 other-produced words (corrected)
• Task• Judge if the word was said ‘right’ or ‘wrong’• Judge if self-produced or other-produced
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Right/Wrong Judgments (younger group)
0
10
20
30
40
50
self+ other+ self- other-
Per
cen
t C
orr
ect
Jud
gm
ents
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Right/Wrong Judgments (older group)
0
10
20
30
40
50
self+ other+ self- other-
Per
cen
t C
orr
ect
Jud
gm
ents
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Production of /ɹ/
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Undifferentiated lingual gesture
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Part IV. Phonology
1. Theory2. Basic Research3. Applied Research4. Application
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SAILS demonstration
[ɹæt]
[wæt]
[jæt]
Speech Assessment and Interactive Learning System.
See www.avaaz.com for more information .
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Rvachew (1994): Study Design
Recruited 27 4 year olds with SSD who were unstimulable for /ʃ/
Random assignment
SAILS
/ʃ/ vs errors
SAILS
Cat vs Pete
SAILS
/ʃ/ vs /m/
Concurrent speech therapy for /ʃ/ using a behaviorist approach
Isolation, syllables, words, phrases, sentences
Assessment of perception and production of /ʃ/ 6 weeks later
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Rvachew (1994): Production Outcomes
-2.5
-2
-1.5
-1
-0.5
0
0.5
1
1.5
2
2.5
shoe vs. Xshoe shoe vs. moo cat vs. Pete
Su
mm
ed Z
Sco
res
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Rvachew et al., 2004: Study Design
EXPERIMENTAL
Pretreatment Assessment
Speech Therapy
Literacy Enjoyment
EXPERIMENTAL
Post-treatment Assessment
Follow-up Assessment
EXPERIMENTAL
Post-treatment Assessment
Follow-up Assessment
CONTROL
Pretreatment Assessment
Speech Therapy
Perception Training
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Control Condition
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Rvachew et al (2004): GFTA errors
Pretreatment Post-treatment Follow-up
10
20
30
40
19% resolved
50% resolved
controlexperimental
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Spectrographic Feedback
• Explain to the child that the goal is to lower the starting frequency of the third formant.
• Ask the child to say words that start with /ɹ/. • Help the the child find F3 in the spectrogram.• Challenge the child to lower the F3 starting
frequency in increments of about 100 Hz.• Provide phonetic placement and articulatory
instructions if necessary.
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Part IV. Phonology
1. Theory2. Basic Research3. Applied Research4. Application
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Part V. Phonological Awareness
1. Theory2. Basic Research3. Applied Research4. Application
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Phonological awareness
• The knowledge that spoken words can be segmented into abstract phonological units.
Phonological Word
σ σ σ
O R O R O R
Foot
N N N C
ð ə k l ɑ z ɪ t
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Example PA Tasks
• Say “vulbz” without the /b/ • [vʌlz]
• What sound comes after [ɪ] in the nonsense word “nigz” • [g]
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Parameters of Task Complexity
matching blending oddity elision
rime
onset
coda
cluster
cognitive load
phon
olog
ical
com
plex
ity
difficulty
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VL
TT
TB
LP
GL
Development of Speech Accuracy
σ
O R
C V
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mʌmi
dædi
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mʌmi
dædi
bɑdo
dɑ
bɛ
mæ
nænæ
no
ke
kʊki
wɑdʌ
wɑ
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mʌmi
dædi
bɑdo
nænæ
kʊki
wɑdʌ
dɑ
bɛ
mæ
no
ke
wɑ
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mʌmi
mæ
nænæ
no
dædi
bɑdo
kʊki
wɑdʌ
dɑ
bɛ ke
wɑ
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mæt
wɑn
mæn
dɑg
bɛd
no
kek mʌmi
dædi
bɑdo
nænæ
kʊki
wɑdʌ
mæd
dɑl
bæt
bæd
dɛd
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Part V. Phonological Awareness
1. Theory2. Basic Research3. Applied Research4. Application
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SpeechPerception
Phonological Awareness
Emergent Literacy
.39
.15
.48.21
.51 .93.48
.38
.96
Articulation
Vocabulary
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Speech Perception, Vocabulary and Phonological Awareness
30
40
50
60
70
80
90
100
60 70 80 90 100 110 120 130 140
Receptive Vocabulary
Sp
eech
Per
cep
tio
n
Cluster 1 PA = 22
Cluster 2 PA = 19
Cluster 3 PA = 11
Cluster 4 PA = 9
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Speech Perception, Vocabulary and Phonological Awareness
30
40
50
60
70
80
90
100
60 70 80 90 100 110 120 130 140
Receptive Vocabulary
Sp
eech
Per
cep
tio
n
Cluster 1 PA = 22
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Speech Perception, Vocabulary and Phonological Awareness
30
40
50
60
70
80
90
100
60 70 80 90 100 110 120 130 140
Receptive Vocabulary
Sp
eech
Per
cep
tio
n
Cluster 1 PA = 22
Cluster 2 PA = 19
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Speech Perception, Vocabulary and Phonological Awareness
30
40
50
60
70
80
90
100
60 70 80 90 100 110 120 130 140
Receptive Vocabulary
Sp
eech
Per
cep
tio
n
Cluster 1 PA = 22
Cluster 2 PA = 19
Cluster 3 PA = 11
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Speech Perception, Vocabulary and Phonological Awareness
30
40
50
60
70
80
90
100
60 70 80 90 100 110 120 130 140
Receptive Vocabulary
Sp
eech
Per
cep
tio
n
Cluster 1 PA = 22
Cluster 2 PA = 19
Cluster 3 PA = 11
Cluster 4 PA = 9
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PA and SSD/SLI
0
+ 1
- 1
Normal
Normalized SpeechNo LI SSD
No LI SSDNormalized Language
SSDLI
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70
80
100
Typical Resolved SLI Persistent SLI SSD
90
110
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Part V. Phonological Awareness
1. Theory2. Basic Research3. Applied Research4. Application
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Sound Foundations
• Targets• Initial /s/, /m/, /p/, /l/, /t/, and /æ/• Final /s/, /m/, /p/, /l/, and /t/• /ʃ/, /g/, and /ɛ/ were omitted from this study but are
normally part of this program
• Procedures• Worksheets for sound matching• Posters for identifying target words• Card games such as Snap• Dominoes-like game• Recorded jingles with alliteration
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Byrne et al: Study DesignRecruited 128 children from 4 preschool programs
Random assignment
Intervention
n = 12 groups
Control
n = 12 groups
Post-treatment assessment about 12 weeks later
Follow-up assessment at end of kindergarten
Follow-up assessment at end of grade 1
Follow-up assessment at end of grade 2
Follow-up assessment in grade 5
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Post-treatment Generalization
0
2
4
6
8
10
12
Pretest Posttest
Co
rre
ct
Re
sp
on
se
s
Experimental (Initial)
Experimental (Final)
Control (Initial)
Control (Final)
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Follow-up Assessments
• Nonword decoding significantly better in the experimental group through grade 5
• No significant differences for real word reading, spelling, or reading comprehension
• 16% of experimental group and 28% of control group scored below 75 on one or more reading tests in grade 5
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Word Building: Study Design24 children with poor reading skills at the end of first grade
Randomization
Word Building Intervention
20 sessions, 4 months
Provided with materials from America Reads
Pretest PA, decoding, word reading, passage comprehension
Post-test PA, decoding, word reading, passage comprehension
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Word Building Procedures
s a t
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Word Building Procedures
s a p
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Word Building Procedures
t a p
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Word Building Procedures
t o p
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Word Building Procedures
t o ps
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Word Building Procedures
t o p
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Sentence Reading Activity
• Silly Sentences• Can a sick kid kick a stick?
• Tutor provides scaffolding to help the child decode the words in the sentence.
• Playful discussion about the meaning of the sentence.
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Word Building Results
Word Attack
80
82
84
86
88
90
92
94
96
98
100
Pretest Post-test
Sta
nd
ard
Sc
ore
Experimental
Control
Word Identification
80
82
84
86
88
90
92
94
96
98
100
Pretest Post-test
Sta
nd
ard
Sc
ore
Experimental
Control
Comprehension
80
82
84
86
88
90
92
94
96
98
100
Pretest Post-testS
tan
da
rd S
co
re
Experimental
Control
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Phoneme Discrimination: Study Design
30 children, aged 8- to 10-years
“whole-class” assignment
Phoneme Discrimination Intervention
30 min, 3/wk, 4 weeks
No Intervention
4 weeks
Pretest: alliteration, rhyme, spoonerisms, and nonword reading
Post-test: alliteration, rhyme, spoonerisms, and nonword reading
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‘Phenomena’: Procedure
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‘Phenomena’: Results
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Phoneme Discrimination: Study Design
60 9-year-old children
Randomization
FastForWord
Pretest: phonological awareness, language, and reading
Post-test: phonological awareness, language, and reading
Earobics LiPS
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Interventions
• FastForWord• Computer intervention targeting a variety of
auditory, memory, and language skills
• Earobics• Computer intervention targeting a variety of
auditory and phonological awareness skills
• LiPS (Lindamood)• Small group intervention targeting auditory
processing and phonemic awareness at the articulatory level
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Improvements x Program
FFW EAROBICS LiPS
PA - + ++
LANGUAGE - - -
READING - - -
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Conclusions
• Programs that are narrowly focused on phonological awareness with little or no application to decoding are relatively ineffective in remediation reading deficits.
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Part V. Phonological Awareness
1. Theory2. Basic Research3. Applied Research4. Application
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Part VI. Limits of the Evidence
1. Program goals2. Administrative constraints3. Access to the evidence4. SLP effects
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Program Goals:Raise the Average OR Close the Gap
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Program Goal:Provide Services OR Label the Child
• Responsiveness to Intervention• 123 children received a 45 hour intensive
instruction program• Two years later only 8 of these children met
the criteria for special education
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Administrative Constraints:Six hours of therapy is not enough!
Treatment
N = 71
Watchful Waiting
N = 88
Still eligible for treatment receipt
62% 77%
Odds Ratio for Improvement > .25 s.d.
Auditory Comprehension 1.4
Expressive Language 1.1
Phonology 2.7
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Accessing the Evidence
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Therapist Effects
Best therapist
Worst therapist
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What makes the difference?• In psychotherapy:
• Outcomes were NOT related to:• Level of training• Type of training• Theoretical orientation• Gender
• Outcomes WERE related to:• Duration of therapy:
• LESS therapy BETTER outcomes
• Hypothesis:• Some therapists encourage dependency in their clients
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Barriers to the Application of EPB