Evidence Based Practices for the Management of School Age Speech and Language Disorders

1. Evidence Based Practices for the Management of School Age Speech and Language Disorders Susan Rvachew School of Communication Sciences and Disorders McGill University

2. Introduction to Evidence Based Practice Part I

3. 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].

4. 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

5. Application of EBP • Theoretical coherence • Basic research • Direct evidence (clinical trials) • Appropriateness of context • Professional experience

6. Part II. Vocabulary Learning Theory Basic Research Applied Research Application

7. Perceptual Learning Mechanisms Literacy Skills and Academic Success Vocabulary Phonology Higher Language Cognitive Learning Mechanisms

8. Part II. Vocabulary Learning Theory Basic Research Applied Research Application

9. 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)

10. Predicted 50% of variance in Complexity of Input (Snow) INPUT AT AGE FIVE YEARS OUTPUT AT AGE SEVEN YEARS Wow! What a big truck! Wow! What a large vehicle! Look at this truck on the road. That’s a large vehicle! Density of sophisticated words Embedding sophisticated words in helpful or instructive interactions Receptive Vocabulary

11. Variations in Input 48 M words 28 M words 12 M words

12. How many repetitions are enough? 2.5 words 2.5 words 1.5 words 0 words

13. Variations in Input 48 M words 28 M words 12 M words

14. Part II. Vocabulary Learning Theory Basic Research Applied Research Application

15. Explanation: Definition Out 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.

16. Explanation: Synonym Sea is another name for ocean. 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?

17. Explanation: Picture Support You see here, this is the catfish. It’s a fish but it has whiskers like a cat. 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!

18. Penno et al. Study Design Class A Class B randomization randomization Group 1 Group 2 Group 1 Group 2 Story 1, explanations Story 2, explanations Story 1, no explanations Story 2, no explanations Story 2, no explanations Story 1, no explanations Story 2, explanations Story 1, explanations

19. Results Overall by Ability Group

20. Results: Explanations vs Retellings

21. Repetitions by Ability Group

22. 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.

23. 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.

24. Design: Biemiller & Boote (2006; Study 1) 112 children in kindergarten, Grade 1, and Grade 2 classrooms Pretests Week 1: Two books each read twice. Explanations provided for half the target words. Week 2: One book read four times. Explanations provided for half the target words. Post-tests

25. Biemiller & Booth: Study 1 Results

26. 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.

27. 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

28. 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.

29. Part II. Vocabulary Learning Theory Basic Research Applied Research Application

30. Part III. Narrative Skills Theory Basic Research Applied Research Application

31. Literacy Skills and Academic Success Oral Narratives Written Narratives

32. Exposure Cognitive Skills Academic Success Linguistic Skills Social Skills Scaffolding Oral Narratives Executive Function Instruction

33. Part III. Narrative Skills Theory Basic Research Applied Research Application

34. 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.

35. 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.

36. Fey et al. (2004)

37. Norbury & Bishop (2003)

38. Part III. Narrative Skills Theory Basic Research Applied Research Application

39. 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

40. 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

41. 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.

42. 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!

43. The boy falls in the river. Can he swim? No, him don’t know how.

44. 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.

45. 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.

46. 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

47. 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

48. 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.

49. 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

50. Part III. Narrative Skills Theory Basic Research Applied Research Application