Lecture 4 - Principle of Intervention PDF

Principle of Interventions Lecture 4  Objectives The Purpose of Intervention Developing Intervention Plan Evidence Based Practice Products of Intervention: Setting goals  Objectives  Process used  Context and environment Service Delivery Models Evaluat...

Principle of Interventions Lecture 4  Objectives The Purpose of Intervention Developing Intervention Plan Evidence Based Practice Products of Intervention: Setting goals  Objectives  Process used  Context and environment Service Delivery Models Evaluating Intervention Outcomes Prevntion of Language Disorders in Children ASHA’s Code of Ethics 2016 To be ethical, we must be able to show that intervention has led to changes in language behavior that would not occur if no intervention were provided.  To change or eliminate the underlying problem. To change the disorder. The Purpose of Intervention (Olswang & Bain, 1991) To Teach compensatory strategies. To change the environment. Developing Intervention Plan Once the purpose of intervention has been made, the SLP must develop an intervention plan. Similar to the assessment process, intervention plan must be carefully considered and planned. One of the important aspects in planning an intervention program is to involve using the available scientific evidence in choosing the appropriate therapy methods (EBP). What is the importance of EBP?! Evidence Based Practice Evidence-Based Practice is “ the conscientious, explicit, and unbiased use of current best research results in making decisions about the care of individual clients.” Oschner (2003). Integrating clinical expertise with the best available external clinical evidence.  Internal & external evidence. External Scientific Evidence Clinical Client Expertise Perspective Evidence Based Practice Formulating clinical questions for EBP the four “PICO” elements: P—Patient or Problem I—Intervention being considered C—Comparison treatment (such as the prevailing approach or no treatment) O—desired Outcome Products of Intervention: Setting goals Intend Products: Objectives Process used Contexts, or environments Objectives  Products of Intervention: Setting goals “Goal selection is one of the important aspects of our practice.” Kamhi (2014) Assessment results are the major source for goal setting. McCauley & Fey (2006) divided the intervention goals into three levels: 1. Basic goals: Identify areas selected because of their importance for functionality or because of the severity of the deficit; these are general goals and usually correspond to long-term objectives in an educational plan (e.g., new grammatical forms). 2. Intermediate goals: Provide greater specification within a basic goal; usually there are several levels of intermediate goals associated with each basic goal (e.g., auxiliaries, articles, pronouns). 3. Specific goals: Specific instances of the language form, content, or use identified as intermediate goals. These are considered steps along the way to the broader and more functional basic goals, and should be based on the child’s functional readiness, those which the child uses correctly on occasion or for which the child produces obligatory contexts without producing the target form (e.g., is, are; a, the, he, she).  Products of Intervention: Setting goals In other words, three levels of goals are: 1. Long-term goal:  Communication behavior that have been identified as the goals to be acquired over the course of the treatment program. 2. Short-term goal:  Designed to help in achievement of the selected long-term goals. 3. Behavioral objectives:  It is a statement that describes a specific target behavior in observable and measurable terms.  Zone of Proximal Development Concepts Zone of proximal development is the distance beyond between the child’s current knowledge of current independent functioning and potential level of level performance. It defines what the child is ready to learn with ZPD some help from a competent adult. SLP must be cautious while choosing specific behavior following the ZPD model. WHY?  Choosing a goal within the child’s basic knowledge is a waste of time. Current  Choosing a goal that is too far above the child’s current knowled level is a waste of time, too. ge base How do we know the child’s ZPD? Suggestions for Setting Priorities among Intervention Goals 1. Highest Priority:  Form and functions clients use in 10% to 50% of required contexts. 2. High Priority:  Forms and functions used in 0% to 10% of required contexts but understood in receptive tasks. 3. Lower Priority:  Forms and functions used in 50% to 90% of required contexts.  Forms that clients do not use at all and do not demonstrate understanding of in receptive task formats. Adapted from Eisenberg. S. (2014). Process used Intervention Approaches  Continuum of naturalness in intervention approaches.  Intervention activities can vary along the continuum of naturalness.  There are some activities that are very natural and closer to the real-life situations. For example: play in the child’s home.  Other activities are very structured and controlled. For example: drill-based activities in the clinic therapy room.  Some activities are in between Intervention Approaches Least natural Clinician-directed Approach Hybrid Approach Child-centered Approach Most natural Clinician-Directed Approach  This approach is highly controlled and specified, in which the clinician: Choose the tools that will be used in the therapy. Set how these tools are going to be used. Choose the type and frequency of reinforcement. Set the accepted forms vs the one that need to be eliminated.  It is less natural approach.  Example: drill or discrete trail interventions. Clinician-Directed Approach Pros  Maximize the opportunities for a child to produce a form, thus extends practicing using this new form  Provides highly structured, clinician controlled tangibly reinforced context of the behaviorist’s intervention.  Effective in eliciting a wide range of language forms.  It is suggested that children with severe disabilities perform better when clinician-directed approach is used. Cons  Limitation of generalization in natural settings  Clinician-Directed Approach Types of clinician-directed activities: 1. Drill: SLP selects a target → explains target response to the client → provides a training stimulus in a predetermined order → reinforces correct responses.  May include prompts, instructions, or models to imitate.  Pros: effective; highest rate of stimulus presentations and client responses.  Cons: less motivated. 2. Drill Play: SLP selects a target → explains target response to the client → provides a training stimulus within a motivated event (e.g., game, allow the child to choose a sticker, etc.) → reinforces correct responses.  Pros: more motivated than drill, efficient as the drill-based activity 3. Modeling: SLP selects a target → model the response using a third person (e.g., parents)→ the child listens → imitate the presented model (not immediately!)→ SLP reinforces the correct responses.  Obtained from the social learning theory.  Child-Centered Approach The child is in the driver’s seat! The clinician follows the child’s lead  The child chooses the material and the SLP follows his lead. It provides naturalistic setting. The clinician arranges activities, choose the material so that opportunities for the client to provide target responses occur as a natural part of play and interaction. Children view it as only playing.  The clinician may provide linguistic models when appropriate  No tangible reinforcers  No requirements that a child responds to clinician  No prompts or shaping of incorrect responses  Child-Centered Approach The main keys in this approach are: 1. Observe 2. Wait 3. Listen Once the child say or do something that can be interpret to a communicative behavior, the SLP must react (i.e., reshape, or reinforce, etc.,) SLP will react using different strategies. Check the language facilitation techniques! Also known as:  Indirect language stimulation, Language facilitation, Facilitative play, Pragmaticism, Developmental or developmental, pragmatic approaches  Child-Centered Approach  Pros:  Provides simple and accessible model of the mapping between the child’s actions and the language that can be used to describe them.  Suitable for children who would not cooperate in the clinician-directed approach and for very young children  More naturalistic, and realistic.  Provides the lead for the child and motivates him. (more comfortable)  Useful to elicit comments from children with ASD.  One of the optimal 1st step to use while working with very young children.  Generalization effect.  Therapy is play and fun!  Cons:  Some children do not respond to such approach.  Difficulties in keeping data.  Establishment of some behaviors can not be done by this approach.  Time consuming (sometimes)  Language Facilitation Strategies 1. Self talk- model how to comment on actions by matching our actions to the child’s actions. 2. Parallel talk- provide self talk for the child 3. Imitations- imitate what the child says, this may increase the chance that the child will imitate the clinician 4. Expansions- repeat what the child said adding the grammatical markers and semantic details 5. Extensions-comments that add semantic information to the child’s comments 6. Buildups and breakdowns- expand the child’s utterances then break it down to several phrase-sized pieces 7. Recast sentences- similar to expansions, but we expand the child utterances into a different type.  Hybrid Approaches It includes three major characteristics: 1. Targets specific language goals. 2. SLP maintains control in selecting activities & materials. BUT SLP carefully choose the materials that tempt the child to interact and spontaneously produce the targeted stimuli. 3. SLP uses stimuli that respond to the child’s communication and model and highlight the forms that being targeted. There are different forms of hybrid approach; which are: 1. Focused Stimulation 2. Vertical Structuring 3. Milieu communication training 4. Script therapy  Forms of hybird Approach Focused Stimulation:  SLP arranges the context in which it includes different stimuli that tempt the child to produce the targeted forms.  SLP helps the child succeed by providing many models of the target forms in a naturalistic context, or play  The child is not required to respond ONLY tempted Vertical Structuring:  It is a form of the expansion used to highlight target structure.  It is less naturalistic than the language facilitation techniques, the SLP provides the child with a specific nonlinguistic stimulus (e.g., picture) to target a particular form and attempts to elicit that form from the child.  Follows the expansion model.  Forms of hybird Approach Milieu communication training:  It applies operant principles to semi-naturalistic settings.  Includes 3 major components: 1. Environmental arrangement. 2. Responsive interaction. 3. Conversation-based contexts that use child interest, and initiation as opportunities for modeling and prompting communication in everyday settings- reinforce communication Script therapy  The clinician develops routines or scripts with the child in the intervention context- narrating activity- same every time- provides comfort. Contexts, or environments  Context of Intervention The context involves the physical and social settings in which the intervention takes place. Stimuli can be linguistic & nonlinguistic Choosing the nonlinguistic stimuli  Pictures, toys, real objects, etc.,  Apps, computer-based activities, etc.,  The choice of stimuli depends on the child’s age and child’s interest Timing  Timing is important in therapy.  SLP must decide when to present the stimulus Service Delivery Models  Service Delivery Models 1. The clinical model 2. The Consultant Model:  In this model, the SLP determines the objectives, procedures, and contexts, and provides these information to another person (i.e., parents) by giving models and instructions.  SLP does not work directly with the client. 3. The Language-Based Classroom Model:  SLP provides services in school setting.  “Pull-out” 4. Collaborative Models:  Also known as “push in”/inclusion.  Collaborate with the teacher in the regular classroom Evaluating Intervention Outcomes  Termination Criteria 1. Communication is within normal limits. 2. Goals & objectives have been met. 3. Client’s communication skills are comparable to his peers’ skills. 4. The client’s communication skills no longer impact his daily activities (i.e., socially, emotionally, academically, etc.) 5. The client has achieved the desired level of communication skills. 6. The client reaches a plateau in his performance.  Evaluating the Effectiveness of Intervention Ethical practice requires that we demonstrate that the changes observed would not happen without intervention. This can be proven by research. Prevntion of Language Disorders in Children  Prevention of Language Disorders in Children Levels of prevention  Primary: avoid disorder entirely  Secondary: identify and intervene early  Tertiary: provide rehabilitation  Prevention of Language Disorders in Children Primary prevention reduces incidence of communication disorders  Reduction in incidence leads to decrease in prevalence SLP’s prevention and the speech-language pathologist includes  Wellness promotion  Advocacy of public policy that promotes wellness  Participation in research that leads to identification of risk factors for communication disorders  Prevention of Language Disorders in Children The speech-language pathologist’s role in secondary and tertiary prevention: Secondary prevention  Early identification and intervention  Newborn hearing screening  Community screening  Kindergarten screening Tertiary prevention  Rehabilitation to reduce the disability associated with a disorder and increase functional, adaptive competence  Most common level engaged by SLPs  Conclusion Planning and evaluation language intervention program requires us to make a series of decisions. SLPs must thoroughly think about the general outcome. Then, step-by-step looks at the specific goals and objectives.  LTG → STG → Objectives To have an effective plan, the SLP must appropriately choose the stimuli, reinforcement, modify the context and timing in order to have better outcomes.