Core Vocabulary Intervention Barbara Dodd, PhD Honorary Professor, Audiology and Speech Pathology University of Melbourne Australia

Plan Planning CVI for a child in your own clinical context Discussion Introduction 2 - 3.15 How to implement CVI A treatment case study Questions BREAK Video of CVI: Questions 3.45 - 5 A bilingual case study Planning CVI for a child in your own clinical context Discussion List of Resources

Introduction

The ‘discovery’ of CVI: A brief description of the first case treated with CVI. MW (4;2) participated in clinical trial of phonological contrast therapy, in the 1980s, with 6 other children. He made no progress despite 36 weekly sessions. All the other children were able to be discharged with age appropriate speech. He differed from them in that he made inconsistent errors (TV as [pikeg] and [titɪn] and tomato as [mʌgʌg] and [tænʌwɔː]) MW had no oro-motor signs of childhood apraxia of speech (CAS). To establish consistent production of specific lexical items, a novel therapy approach was developed.

Outcome It took 8 sessions of weekly therapy to establish a consistent vocabulary of 50 words, at which point, consistency generalized A phonological contrast approach was successfully reintroduced to eliminate remaining errors. This case study raised two issues Were there other cases like MW? If so, what type of deficit in the speech processing chain causes inconsistent errors? Subsequent research has led to better understanding of a subgroup of inconsistent speech disorder, providing evidence for the need for differential diagnosis of children with SSD.

Why do some, otherwise typically developing, children make inconsistent errors? Only significant risk factors – perinatal difficulties, health issues in infancy. Incomplete mental representations of words. Fully specified lexical representation of words, but unable to assemble the correct phonological plan for pronunciation.

What does CVI aim to teach a child to do? Therapy targets words. Plan the production of a word’s sequence of phonemes using their intact mental representations. CVI makes children aware of the separate syllables in a word, and the sound segments in each syllable and how to produce that sequence to make the word.

Who benefits from CVI? Children with unintelligible speech due to inconsistent word production, age 2 –14 years. RCT shows 3 year olds have quickest positive outcome. Associated difficulties can include: Down syndrome, Hearing loss, Acquisition of a second language BUT NOT Childhood Apraxia of Speech

How should CVI be evaluated? Generalization of consistency to untaught words Accuracy: PCC, PVC.

How to implement CVI

Will (6;6) Midway through his first year at his local state primary school. Around 270 other students aged 5-12 years; 20 in his class. He is growing up in a rural town with a population of around 12,000 in south-west New South Wales, Australia. Will is the youngest of three children (sister 11, brother 9). His father is a warehouse manager; his mother works in a shop. They live in town, in a modern detached house, within walking distance of Will’s school. Will’s speech was often unintelligible, even to his mother. Referred to student clinic by local hospital SLP: Matt

Will’s Previous history Medical history: poor health as an infant and toddler. Paediatric assessment identified delayed fine motor skills and communication at 3 years. Speech pathology assessment at 4 years identified speech, language, attention and listening difficulties. Hearing tests have all been within normal limits. Psychological assessment at 6;0 reported average IQ performance, with better non-verbal than verbal scores. The assessor commented that Will’s ‘speech and language difficulties affected the results’.

Will’s Assessment Results Speech Diagnostic Evaluation of Articulation and Phonology Screen: 6/10 words were inconsistent on repetition, all sounds in error stimulable -> Inconsistency Assessment: 17 words (68%) were produced differently after 2 trials eg [bwɪdʒ], [brɪn] bridge; [ɒʔoʊkʊ], [ɒpoʊpʊ] octopus; [ʒʌp], [jʌmp] jump. -> Oromotor Assessment (DDK, isolated, sequenced movements): WNL Accuracy: PCC 50% and percent vowels correct; PVC 85% Language CELF: combined SS 70 (receptive > expressive language)

Diagnosis: Inconsistent Phonological Disorder Not childhood apraxia of speech because: No motor speech signs all speech sounds produced in error were stimulable no syllable segregation no groping. no distortion of speech sounds on DDK task rate and fluency were age appropriate Imitation better than spontaneous production

Setting up CVI for Will Child, Mother, Teachers: agreement to participate and their roles Selecting agent of therapy (besides SLP): mother Selecting the vocabulary: 20 words each Scheduling therapy: student clinic constraints Selecting number of words to be learned each teaching session Setting up a reward system: Will is a jigsaw fiend

Roles of Family and Teachers CVI’s success depends on family doing daily practice at home and teacher monitoring the vocabulary at school. Involve parents and teachers from the outset of intervention. Before the first intervention session, the child, family and teacher contribute to a list of 70 words they want to be part of the child’s functional vocabulary. These words are used in the treatment sessions. Family and school must monitor the consistency of their child’s best production of the words being targeted that week: in practice and spontaneously. Important: parents and teachers must understand that the primary target of the intervention is consistency not accuracy AND how to give feedback.

Selection of core vocabulary The child’s intelligible use of the functionally powerful words selected motivates the use of consistent productions. The types of words commonly selected are names (e.g., teacher, friends, pet), places (e.g., address, toilet), polite words (e.g., please, sorry), foods and the child’s favorite things. Words are not selected according to word length, syllable complexity or segments. Just make sure there is a range of word lengths, syllable shapes, speech sounds. Words are chosen because they are used frequently in functional communication. Number of words targeted per week is 5-10 initially, but increase the number as learning becomes easier.

Scheduling Therapy Individual Agent (home, school) present for some sessions Total time should not exceed 8 –10 hours to attain consistency of production and enhanced PCC that generalizes to untreated words. 2x30m week for 8 weeks 4x30m week for 4 weeks 1x40m week for 12 weeks Once per week is OK – just not as efficient, more sessions may be required.

Materials Equipment is minimal: pictures of the target words (with the written name beneath the picture or on the back); a box or bag for the vocabulary pictures; a wall-chart where words produced consistently can be glued; games that elicit multiple productions of target words rapidly. A DVD of text resources (e.g., teacher and parent information sheets, probe word lists) is available from the authors.

The Clinicians’ Role Sessions are paired: The first to teach 10 words’ best productions, and the second to drill production of those words. Teaching Session Words are selected at random from a bag or box; The clinician elicits the child’s best production of each word, one at a time, assembling its syllables and sounds, one by one; Then establish their best production (not necessarily completely accurate) in activities. Drill Session Activities elicit multiple productions; once established, move to carrier phrases.

Establishing Best Production Words are taught sound-by-sound. Use syllable segmentation, imitation and cued articulation (Passy, 1990), linking sounds to letters. Children with IPD are usually able to imitate all sounds. You are teaching the word’s phonemes and their orderː To teach ‘Joseph’, explain that Joseph has two syllables – [dʒou] and [sɛf]. The first syllable [dʒou] has two sounds, /dʒ / and /ou/, and the second syllable [sɛf] has three sounds /s/, /ɛ/ and /f/. The child attempts the first syllable – ‘Say [dʒ], say [ou] - receives feedback and makes further attempts after being given models and receiving feedback about each attempt. When the child’s best production of the first syllable has been established, the second - [sɛf] is targeted, and then the two syllables are combined - [dʒou-sɛf]’. If it is NOT possible to elicit a correct production then the best production may include developmental errors (e.g., [dousɛf] for Joseph, [tæmra] for camera).

Drill Sessions Games must elicit a high number of repetitions. Choose games that motivate the child. Initial picture naming games (e.g., stepping stones – with more than one picture on each stepping stone) can be followed by those requiring the target in a carrier phrase (e.g., picture lotto) and finally by story generation (asking for one, two or three of the target words). A child should produce about 100 responses in 30 minutes. It is not difficult to elicit 150 –170 responses in a 30-minute session of CVI. Practice at home Work out with the parent when practice will be done. Feedback on target words is essential. When a target word occurs in everyday communication give praise or request best production. Suggest parent models home practice sessions based on the drill clinical session – give parents copies of materials.

Feedback and treatment on error If a child says a target word correctly, give praise. ‘You said “sun”, that’s perfect: /s/- /ʌ/ - /n/ sun.’ Be explicit about any error made, and how it can be corrected. Say ‘You said [????]’ then explain how the word differed from the target and how it fix it. For example if the child’s target word was ‘sun’ and he produced [fʌ] the clinician would say “You said [fʌ], that’s different to how we say it. That had a [f] sound at the start but we need to make it a [s], then [ʌ] then [n]. Have another try at telling me what this picture is.” Don’t ask for an imitation of the target word. That provides the phonological plan. Instead, provide information about the plan, so children have to generate their own plan for the word.

Monitoring consistent production From the second teaching sessions, the child is asked to produce, three times, the set of target words that have been the current focus of therapy and home practice. Any word that the child can produce consistently is removed from the list of words to be learned. It may be placed on a chart / in a book showing what the child has achieved, and can be reviewed. Words produced inconsistently remain on the list (go back in the bag of words yet to be learned) to be addressed another week. Even though there are 50-70 target words that form a core vocabulary for the child’s intervention, such monitoring allows for words that have not been mastered to be attempted again. To monitor generalization, have pictures of some untaught words you ask the child to name 3 times, every second session from session 5.

Will’s therapy schedule Session Goals Content 1 Assessment Diagnostic Evaluation of Articulation and Phonology; trial therapy 2 Parent Interview Case history taking, explaining therapy, drawing up core vocabulary 3 Teaching 10 words Eliciting best production 4 Drill Practicing best production in single words and carrier phrases. At the start of session 5, test consistency of word learned in sessions 3 & 4. Repeat Teaching and Drill sessions 5 to 14 14 Reassessment DEAP Inconsistency Assessment. Assessment revealed use of [n] as a default syllable final consonant e.g. [ʃan] shark; [æpɪn] apple 15 Additional words targeted in therapy Additional words selected and taught to address accurate final consonant production, using a CVT approach. 16 Meeting: Parent, local SLP Follow-up materials (including new words) given to mother for home practice; SLP attended session and agreed to monitor Will’s progress but no continuing therapy available. ʃ ʃ

Outcomes At the end of therapy Inconsistency score was 32% on 3 trials of the DEAP Inconsistency Test (as compared to 68% at initial assessment). PCC was 67% (compared to 50% pre-therapy and few vowel errors were made). One year later Will (7;6) was referred for assessment of his expressive and receptive language. His teacher’s concern was Will’s ability to contribute verbally in class.   Inconsistency score was 20%. His residual errors included cluster reduction of some word final nasal + consonant clusters and occasional deletion of intervocalic consonants. PCC was 91%, below what might be expected for his age and his PVC was 100%. He was mainly intelligible in conversation.

Key Components of CVI CVI is for children who make inconsistent errors but have no signs of CAS. However, CVI is worth trying, to confirm CAS diagnosis. The ultimate goal of intervention is intelligible speech. The goal for a block of CVI is consistent production of ≥50 target words. Generalization of consistency to untaught words, improved accuracy. Session goals target specific words: achieve an appropriate productive realization of each target based on the child’s phonological system and phonetic inventory. This ‘best production’ may be correct or contain a developmental error. The second goal is for the child to consistently use the established ‘best production’ on elicitation and spontaneously.

Questions

Break

Video Clips

CVI for a bilingual child with IPD Hafis was referred to a study by the SLP who had assessed him at school, in the UK, aged 4;6. His parents had been concerned about his speech development since he was 2 years old. but had not sought advice about his speech because he was primarily exposed to Punjabi at home and they did not think an English-speaking SLP would be helpful. Hafis attended childcare from 3;0, then at school at 4;0; his first significant exposure to English. His older sister and parents started to speak some English to him at home, once Hafis started school.

Case History Hafis was born 4 weeks prematurely but normal pregnancy N0 serious illnesses, accidents; hearing WNL Normal developmental milestones. Parents both university-educated professionals, fluent speakers of both Punjabi and English. At the time of the study, Punjabi and English were spoken at home equally. Sister, 2 years older, fluent in Punjabi and English, had no speech difficulties.

Pre-intervention Assessment Assessed by English-speaking SLP, H’s mother elicited speech in Punjabi Performance on oro-motor assessment WNL. BPVT and TROG in English showed age-appropriate receptive language skills. Speech: Goldman Fristoe/DEAP consistency RAMP (Rochdale Assessment Mipurri Phonlogy, Punjabi Version), + 20 words x 3. Reliability: 93% English; 87% Punjabi, point to point

Speech Results Punjabi English PCC 1st Assessment 57.7% 44.9% PCC 2nd Assessment 53.4% 46.2 Inconsistency 45% 56% Phones missing none /Ɵ, ð, ʃ/ Errors in both languages – cluster reduction, stopping, voicing/aspiration, backing, de/affrication. Errors only in English: fronting, final CD, medial CD, gliding, consonant addition Errors only in Punjabi: initial CD, nasalisation

Core Vocabulary Intervention for Hafis Individual therapy with the clinician twice weekly. Therapy was provided only in English by an English-speaking SLP. Therapy sessions were alternately conducted in at home and school to allow liaison with both his teacher and parents. There were 16 (30minute) sessions over an 8- week period. His parents and teacher, determined a list of 55 words that were functionally ‘powerful’ for him (categories of people, food, school activities, places, television shows). His parents agreed to allow therapy to only target English because of the practical difficulties of targeting Punjabi words and also because of the research project’s aim to monitor cross-language generalization.

Core Vocabulary 10 words were targeted each week. Clinician elicited H’s best production of the 10 words. These words were targeted consistently by his parents and teacher throughout the week and revised in the second session with the clinician. Some target words were elicited correctly. For others, developmental errors were accepted. It was emphasized that the primary target Core Vocabulary is consistency not error-free production.

Progress during intervention In 8 weeks Hafis acquired consistent production of 52 words: The number of 10 words ‘learned’ in: Week One - 4 Monitoring Inconsistency % 60 Week Three - 5 50 Week Five - 7 30 Week Eight - 9 10 1 Month Post Therapy Review - 80% Consistent 20 What happened in Punjabi?

Generalization: % Inconsistency

Changes in Consonant Accuracy

Summary and Conclusions Hafis made inconsistent speech errors in both Punjabi and English We proposed that a deficit in phonological planning was causing errors in both languages, and that it could be successfully treated by core vocabulary intervention in only one language. H’s consistency and accuracy improved in English, the language targeted in therapy. Both generalized to untreated words in English and most importantly to the untreated language – Punjabi. That is, CVI targets post-lexical mental processing.

Planning CVI for a child in your own clinical context

Key Decisions Your role as clinician (e.g. Ax, training agents/student) Agent of therapy apart from clinician Scheduling clinician agent home practice Outcome decision criterion consistency accuracy

Discussion

Resources Dodd, B. & Poole, M. (2017). Will: A case of inconsistent phonological disorder: A three year follow-up. In B Dodd & A. Morgan (eds.) Intervention Case Studies of Child Speech Impairment. Surrey: J&R Press pp 223-246. Dodd, B, Holm, A. Crosbie, S. & McIntosh, B. (2010) Core Vocabulary intervention for inconsistent speech disorder In P. Williams, S. McLeod, S. & R. McCauley Interventions for Speech Sound Disorders in Children. New York: Brookes. pp 117-136. McIntosh, B. & Dodd, B. (2009). Evaluation of core vocabulary intervention for treatment of inconsistent phonological disorder: Three treatment case studies. Child Language Teaching and Therapy, 25(1) 9-29. DVD: Crosbie, Holm & Dodd. Needs adaption for each clinical context: growwords.com.au (information sheet for parents/teachers, forms, ideas for monitoring generalisation, video).