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Evidence-Based Practice and AAC

Evidence-Based Practice and AAC. SLA G304 Kim Ho, PhD CCC-SLP. Why is Evidence-Based Practice so important?. Provides best possible Dx and Tx Addresses the research-to-practice gap Meets increasing demands for accountability. Evidence-Base Practice Defined.

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Evidence-Based Practice and AAC

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  1. Evidence-Based Practice and AAC SLA G304 Kim Ho, PhD CCC-SLP

  2. Why is Evidence-Based Practice so important? • Provides best possible Dx and Tx • Addresses the research-to-practice gap • Meets increasing demands for accountability

  3. Evidence-Base Practice Defined “ . . . the integration of best and current research evidence with clinical/educational expertise and relevant stakeholder perspectives to facilitate decisions for assessment and intervention that are deemed effective and efficient for a given direct stakeholder” (Schlosser, 2003, p. 256).

  4. Stakeholders • Direct Stakeholders • Indirect Stakeholders • Immediate Community Stakeholders • Extended Community Stakeholders

  5. The EBP Process • Developing a well-built question • Selecting evidence sources and executing the search strategy • Examining and synthesizing the evidence • Applying the evidence • Evaluating the application of the evidence • Disseminating the findings

  6. I. Ask a Well-Built Question • Use the CESPO framework to ask a Well-Built Question Client Environments Stakeholders Problem Outcomes

  7. CESPO Example • Client – 4-year old child with autism Environments – self-contained preschool; integrated preschool • Stakeholders – preschool teachers; SLP; parents • Problem – Will use of AAC hinder/enhance natural speech production? • Outcomes – more effective communicator

  8. II. Selecting evidence sources • Text books • General databases • Specialized databases • Database of Abstracts of Reviews of Effects • Hand searches • Reviews of the literature

  9. Example (from Schlosser, 1993 ASHA) • Database search • DARE (1996-2002) • “autism” and “communication”; yielded 6 references but none focused on AAC and autism • CINAHL –Cumulative index to Nursing allied health literature( - 2002) • “autism” and “communication” and “review;” “autism” and “augmentative and alternative communication;” yielded 5 reviews on autism and AAC some of which included sections on natural speech production but did not focus on this issue

  10. Medline (-2003) • “autism” and “communication” and “review;” yielded 4 reviews, some of which included sections on natural speech production • PsycINFO (-2003) • “autism” and “augmentative communication” and “review;” yielded 3 reviews, some of which included sections on natural speech production

  11. Database search to find individual studies • Medline (-2003) • “autism” AND “communication” AND (“clinical trials” [MeSH terms] OR “research design” [MesH terms] OR “evaluation study” [MeSH terms] OR “clinical trial” [PT])

  12. PsycINFO (-2003) • “autism” and “augmentative communication” and (LA=ENGLISH) and ((PT=CLINICAL-TRIAL) or (PT=EMPIRACAL STUDY) or (PT=EXPERIMENTAL-REPLICATION) or (PT=FOLLOWUP-STUDY) or (PT=META-ANALYSIS) or (PT=TREATMENT-OUTCOME-STUDY))

  13. Hand searches • Review of speech output in Augmentative and Alternative Communication (2003) – 1 relevant review and 1 relevant study • ISAAC conference proceedings 2000 & 2002 – 1 systematic review (Millar et al., 2000): 3 studies • ASHA Convention abstracts 2001 & 2002 – 1 systematic review (Correa & Nye, 2001) • Schwartz et al. (2003) – 3 studies

  14. Use Quality Filters: CINAHL • Topical subheadings: • Diagnosis, evaluation, review, systematic-review, therapy, therapeutic-use, and utilization • Document type • Research, clinical trial

  15. Use Quality Filters: MEDLINE • Publication type • Meta-analysis, review, academic review, tutorial • Practice guideline, consensus development conference • Randomized controlled trial, clinical trial • MeSH term • Clinical trials, research design, evaluation study

  16. III. Examining and Synthesize the Evidence 1. How good is the evidence? • Changes in D.V. attributed to the I.V. • Consider • Hierarchies of evidence • Treatment integrity • Interobserver agreement

  17. III. Examiningand Synthesize the Evidence (Cont’d) 2. What is the social importance or significance of the evidence? • Social validity • Consumers satisfied with all results?

  18. III. Examining and Synthesize the Evidence (Cont’d) 3.What is the transportability of the evidence • External validity • Generality of Conditions • Generality of Subjects/Participants • Generality of Communication Partners • Generality of Settings • Generality of Treatment Agent • Generality of Materials

  19. Example Cont’d Studies found suggest that: • PECS instruction increases spontaneous natural speech (Charlop et al., 2002) • Manual signing instruction increases natural speech to a greater extent than does PECS instruction (Anderson, 2002) • Simultaneous communication, and alternating between speech alone and simultaneous communication yield better speech than signing alone (Yoder & Layton, 1988)

  20. Example Cont’d • Computer-based instruction with synthetic speech increases natural speech more than without speech output (Parsons & LaSorte, 1993) • Pre-treatment vocal imitation skills predict natural speech production (Anderson, 2002; Yoder & Layton, 1988)

  21. Ex Cont’d: Applicability • The n of single-subject studies < 9, only 1 study per rec, so generality may be compromised • However, several participants are the same age as Sam • However, 3/4 studies participants with vocal imitation skills at onset (like Sam)

  22. IV. Apply the Evidence • No evidence that AAC hinders natural speech • Preliminary evidence that AAC may facilitate speech • Sam’s vocal imitation skills may be an indicator that speech may improve • Comparison studies are scarce

  23. IV. Apply the Evidence Cont’d • Preliminary evidence suggests manual signing might be more beneficial than PECS • Speech output appear advantageous • Seems to help to speak and sign

  24. V. Evaluate and VI. Disseminate • Monitor whether natural speech improves • Seek help from qualified researchers • Share your experiences in writing

  25. Critically Appraised Topics • Preferred categorization format for quick studies in EBP • A brief “summary of a search and critical appraisal of the literature related to a focused clinical question”

  26. Key Parts of CAT • Purpose • Reviewer • Proposed Re-evaluation • Well-built questions • Search strategies and results • Appraisal • Conclusions

  27. Sample CAT • Title: Impact of AAC Intervention on Natural Speech Production in Learners with Autism • Reviewer/s:Ralf W. Schlosser and Doreen M. Blischak • Type of CAT: Related to Tx/Intervention

  28. Sample CAT Cont’d • Well-built Question Sam is a 4-year old child who was recently diagnosed with autism. He is unable to meet his daily communication needs in his preschool with natural speech. He has recently learned to imitate words such as “mama,” “dada,” “quack-quack,” and “bye-bye.” . . . His parents want to know, which AAC approach(es) best support natural speech development?”

  29. Sample CAT Cont’d:Search Database Search (to identify reviews) • DARE (1996-2002) “autism” and “communication;” yielded 6 references, but none focused on AAC and autism • CINAHL (inclusive 2002) “autism” and “augmentative and alternative communication” and “systemic review” [DT] – document type and similar combinations; yielded 3 reviews but not focused on autism

  30. Data Base Search Cont’d • ERIC (-2002) “autism” and “communication” and “review;” “autism” and “augmentative and alternative communication” yielded 5 reviews on autism and AAC some of which included sections on natural speech production but did not focus on this issue • Did same for Medline and PsycINFO – to identify reviews

  31. Hand Search • Found special issue of AAC on speech output; 1 relevant study • ISAAC proceedings • ASHA Convention abstracts • Millar et al. (2003) • Schwartz et al. (2003)

  32. Sample CAT Cont’d • Data base Searches (to identify studies) • CINAHL (-2002) “autism” AND “augmentative and alternative communication” • ERIC (-2002) “autism,” AND “communication,” “autism” AND “augmentative and alternative communication”

  33. Medline (-2003) “autism,” AND “communication,” AND (“clinical trials” [MeSH terms] OR “research design [MesH terms] OR “evaluation study” [MeSH terms] OR “clinical trial” [PT]) • PsycINFO (-2003) “autism” and “augmentative communication” and (LA=ENGLISH) and ((PT=CLINICAL-TRIAL) or (PT=EMPIRICAL-STUDY) or (PT=EXPERIMENTAL REPLICATION) or (PT=FOLLOWUP-STUDY) or (PT=META-ANALYSIS) or (PT=TREATMENT-OUTCOME-STUDY))

  34. Sample CAT Cont’d • Date: The search was completed August 10, 2003 • Proposed re-evaluation: August 2006 • Citations (those that are relevant)Relevant Narrative Reviews (sections) Bondy & Frost (1998); Bondy & Frost (2001); Goldstein (2002); Koul, Schlosser, & Sanscribrian (2001); Mirenda (2001); Mirenda & Erickson (2000); Schlosser (2003a); Schlosser (2003c); Schlosser & Blischak (2001); Sigafoos, & Drasgow (2001): Sundberg, & Michael (2001)

  35. Sample CAT Cont’d: Citations • Relevant Systematic Reviews (to locate appraised studies) Schwartz, Nye, & Correa (2003); Millar, Light, & Schlosser (2000); Millar, Light, & Schlosser (2003) • Relevant studies (Suggestive evidence or better) Charlop, Carpenter, Le, LeBlanc, & Kellet (2001); Kouri (1988); Parsons, & LaSorte (1993); Yoder, & Layton (1988)

  36. Sample CAT Cont’d: Excluded Studies • Inconclusive evidence Bondy & Frost (1994); Bonta & Waters (1983); Dyches (1998); Fulwiler & Fouts (1976); Kravits et al. (2002); Schwartz et al. (1998); Sigafoos et al. (2003)

  37. Sample CAT Cont’d: Applicability • Examine and synthesize the evidence • Consider: • Internal validity • Social validity • External validity

  38. The n is < 9 per study, only 1 study per recommendation • Generality is compromised; • However • Several participants are of the same age as Sam • 3/4 studies included participants with demonstrated vocal imitation skills at onset (like Sam)

  39. Sample CAT Cont’d: Conclusions It is plausible that: • PECS increases spontaneous natural speech (Charlop et al., 2002) • Manual signing increases natural speech production to a greater extent than does PECS (Anderson, 2002) • Simultaneous communication or alternating between speech alone and simultaneous communication yield better speech production than signing alone (Yoder & Layton, 1988)

  40. Sample CAT Cont’d: Conclusions • Computer-based instruction with synthetic speech increases natural speech production compared to computer-based instruction without speech output (Parsons & LaSorte, 1993); and • Pre-treatment vocal imitation skills predict natural speech production (Anderson, 2002; Yoder & Layton, 1988)

  41. Issues and Concerns with EBP • How does EBP fit with current decision-making in AAC? • Weight of evidence versus weight of the stakeholders perspectives • What skills are needed to implement EBP? • How support clinicians to use EBP process? • Explicit instruction is needed in each of the steps • Fit between research and practice

  42. Relevant Stakeholder Perspectives Decisions Clinical/Educational Expertise Research Evidence Adapted from Schlosser & Raghavendra (2003)

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