Group therapy? Parents as therapists? What's the state of the evidence for Speech Sound Disorders. Bronwyn Carrigg, December 2010 On behalf of NSW EBP Paediatric Speech Group

Clinical Questions : 1.Parent v Clinician administered Treatment for SSD 2. Individual v Group Treatment for SSD We needed Comparative studies; parent v clinician v no Rx individual v group v no Rx other variables controlled (eg dose, Rx approach) We found few comparative Rx studies with no Rx control, rather Rx 1 v no Rx Rx 2 v no Rx Rx 1 v Rx 2 Rx 1 Rx 2

. Clinical Question 1: In children with Speech Sound Disorder; does parent administered intervention compared with direct SLP intervention lead to equal, or better, improvements in speech intelligibility? (4 papers) Parent v No Rx (x1) Clinician v No Rx(x1) Clinician v Parent v No Rx(x1) Clinician v Combined Parent/Clin(x1) Clinician v Parent(x1)

Broen, P. & Westman, M. (1990) Project Parent: A preschool speech program implemented through parents, Journal of Speech and hearing disorders, 55, Parent Treatment v No treatment.17x1.5 hour sessions/wk of group parent training +individual review of child Results: Children’s phonological skills improved when taught by parents, under weekly direct supervision and training from a clinician compared to a group of children receiving no treatment Rx group=12 children. Control group=8 children Rx approach targeted phonological patterns & natural classes *no comparison of therapy approaches

Lancaster, G., Keusch, S., Levin, A., Pring, T. & Martin, S. (2010). Treating children with phonological problems: Does an eclectic approach work. IJLCD, 45(2), Experiment 1: ClinicianTreatment v No Treatment. 8x30min session/wk for 3 months. Pa involved. Delayed Rx app. Results: Significantly more change during treatment periods Experiment 2: Clinician Rx v Parent Rx v No Treatment. Clinician Rx. 15x30min session over 6 months Parent Rx. 2 hour group training + 6 weekly reviews. Results: children treated by therapists showed strongly significant gains children treated by parents showed lesser but significant gains No change in untreated children *Rx approach used was eclectic. 5 or 6 children per group, exp 1 is not comparative

Ruscello, D.M; Cartwright, K.B; Shuster, L.I (1993) The use of different service delivery models for children with phonological disorders Journal of Communication Disorders 26, Clinician Rx v Combined parent-clinician Rx (minimal pairs) All 12 children received 2x1hour session/week for 8 weeks. Combination Rx parents received 3 hours additional training. Group 1: clinician administered all 16 therapy sessions. n=6 Group 2: clinician administered 1 session/week. n=6 parent administered 1 session/week (Speech Viewer) Results: Both groups improved significantly. No significant differences between groups. High level of therapist involvement in both groups. *lack of No Treatment control, use of ‘speech viewer’ with 1 group

Eiserman, W., McCoun M., Escobar, C. (1990) A cost- effectiveness analysis of two alternative program models for serving speech disordered preschoolers. Journal of Early Intervention, 14: ( follow up studies 1992, 1995) Clinician Rx v Parent Rx Group 1: Clinician administered Rx 1 hour/week in pairs. n=20 Parents not in sessions. No set home practise Group 2: Parent administered Rx. 40 min/fortnight parent & child with clinician demonstrating & providing feedback - individual mins home practise 4x/week. n=20 Results: Parent Rx and Clinician Rx equally effective. No difference in program cost, if parent time excluded. If parent time included, clinician program more cost effective. *different volume of therapy; lack of No Treatment group; approx 7 months of Rx,

Clinical Bottom Line Both clinician administered and parent administered (with high levels of clinician input) lead to more significant improvements in speech intelligibility than no treatment. In the only study comparing clinician administered Rx, parent administered Rx, and no Rx: children treated by clinicians made significantly more gains than children treated by parent. However both Rx groups resulted in significant gains when compared to the no treatment group. *Points to consider; - Need to attend to definition of ‘parent administered therapy’ - Level of therapist input was generally high - Are all parents equally able to administer Rx? - Particular/new skills sometimes needed to train parents?

. Clinical Question 2: In children with Speech Sound Disorder, does individual intervention compared with group intervention lead to equal, or better, improvements in speech intelligibility? (4 papers)

Problem: 4 papers but none answered question… No studies designed to compare group and individual Rx. Found studies that; Compare group v group with diff Rx approach (Rvachew 99) Compare group v group with different intensity (Page 94) Compare group with no Rx (Denne 2005) Group with no comparisons (Montgomery 89) Compare individual v individual with diff Rx approach Compare individual with no Rx ? easier to answer question about group v no Rx, but service delivery decisions require information about comparative Rxs and cost effectiveness. Limited research.

Additional Clinical Issue relating to Service Delivery In children aged 3-6 years with speech and language impairments of unknown origin, how many sessions are required for significant improvement? 1x paper relevant to our current topic Not research paper where variables are controlled Contains outcome measures data

Jacoby, G.P., Lee, L., Kummer, A.W., Levin, L., & Creaghead, N. A. (2002) The number of individual treatment units necessary to facilitate functional communication improvements in the speech and language of young children. AJSLP, 11, 370 Retrospective analysis of patient charts. 234 children 3-6 years Initial and post treatment Functional Communication Measures Functional Communication Measures developed by AHSA as part of National Outcome Measure System (NOMS) project FCMs are disorder specific 7 point rating scales, 1=least function

*ASHA 0-6 yrs Functional Communication Measures (FCMs) Rating Scales for Articulation/Intelligibility Levels 1-7, See Jacoby 2002 appendix A for levels 1-7. Examples of levels; Level 1: Speech cannot be understood even by familiar listeners Level 2: Child’s production of simple words is rarely intelligible to familiar listeners. Child’s speech is unintelligible to unfamiliar listeners Level 3: Child is occasionally intelligible in connected speech to familiar listeners. Child’s production of simple words and phrases is rarely intelligible to unfamiliar listeners Level 7: Child’s connected speech rarely calls attention to itself more than would be expected of chronological peers, and participation in adult- child, peer, and directed group activities is not limited by speech intelligibility. (*Developed by, and property, of American Speech-Language-Hearing Association)

Results Majority of children with identified speech and /or language disorder(s) of unknown origin improved by at least 1 FCM following 20 hours of therapy As the number of treatment units increased, the FCM level improved (statistically significant for artic/intell + spoken lang) Children with lower initial functional abilities generally required more units of therapy to demonstrate improvements than children with higher ability levels

Implications for E 3 BP External evidence Internal evidence (from client factors & preferences) Internal evidence (from client factors & preferences) Internal evidence (from clinical practice) Internal evidence (from clinical practice) (Concept of E3BP from Dollaghan, 2007) Insufficient evidence to guide clinical decisions re: use of parents, and group therapy with CERTAINTY Need for clinicians within our group to gather data from clinical practice & compare Need to consider how individual client factors, such as parents’ motivation or children’s characteristics influence outcomes

References Broen, P. & Westman, M. (1990) Project Parent: A preschool speech program implemented through parents, JSHD, 55, Carson, Rvachew S, Rafaat S, Martin M (1999) Stimulability,Speech Perception Skills and the Treatment of Phonological Disorders. AJSLP, 8(1),33-43 Denne M, Langdown N, Pring T, Roy P. (2005) Treating children with expressive phonological disorders: does phonological awareness therapy work in the clinic? IJLC, 40,4, Eiserman, W., McCoun M., Escobar, C. (1990) A cost-effectiveness analysis of two alternative program models for serving speech disordered preschoolers. Journal of Early Intervention, 14: Lancaster, G., Keusch, S., Levin, A., Pring, T. & Martin, S. (2010). Treating children with phonological problems: Does an eclectic approach work. IJLCD, 45(2), Montgomery, J. K., & Bonderman, R. I. (1989). Serving preschool children with severe phonological disorders. LSHS, 20, Page, F., Pertile, J., Torressi, K., & Hudson, C. (1994). Alternative service delivery options: The effectiveness of intensive group treatment with pre- school children. AJHC, 23, Ruscello, D.M; Cartwright, K.B; Shuster, L.I (1993) The use of different service delivery models for children with phonological disorders JCD,26,193

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