OutcomeBased Intervention: Practical Ideas For Practicing Clinicians

1
Outcome-Based Intervention Practical Ideas For
Practicing Clinicians

• Laura Green, Ph.D., CCC/SLP,
• Texas Womans University
• Joni Klecan-Aker Ph.D., CCC/SLP,
• Texas Christian University
• Karen McGehee, MS., CCC/SLP,
• Banner Health

2
(No Transcript)
3
Evidence Based Practice

• Involves the use of treatment methods that are
  supported by controlled and replicated research
  evidence.
• Requires an integration of best evidence for
  diagnostic and treatment methods with sound
  clinical expertise/judgment.
• Takes into consideration what is best for an
  individual patient and his/her preferences.

4
The Reality

• Treatment efficacy research represents only a
  small fraction of currently published articles in
  our disciplines major journals.
• Evidence based practice is more appropriately
  viewed as a process of using a variety of
  databases including systematic case studies to
  guide interventions.
• Evidence also needs to be evaluated within a
  context that asks, What type of intervention
  makes sense to me as a practicing clinician?

5
Clinical Questions

• What is the best choice of therapy for my client?
• Is this program theoretically sound?
• Does this therapy program work?
• How long with the therapy take?
• Where do I go from here?

6
Outcome-Based Intervention

• Systematic collection and reporting of client
  outcomes of our management
• Demonstration that the treatment provided is
  responsible for our clients behavioral changes
• Specialized research methodology
• The beginning of the evidence base

7
Practicing Clinicians Needed!

• Clinicians
• are on the front line
• have necessary clinical expertise
• know their clients well
• are naturally scientific thinkers
• are well-versed in data collection
• know how to look for outcomes

8
Where to Begin

• Identify a specific treatment program of interest
• Identify which clients would most benefit from
  this program
• Determine if there are any data supporting its
  use
• Examine scheduling and other logistical issues

9
Planning

• Remember that research plans can be directly
  derived from clinical lesson plans and
  interventions
• Organize/create data-collection materials
• Consider ethical conduction of treatment and
  protection of your clients
• Create a calendar that specifically schedules
  treatment and data-gathering sessions

10
Specifying Target Behaviors

• What we are teaching and measuring?
• An operational definition provides measurable and
  observable terms
• Describe the exact skill (following verbal
  directions), its level (2-step), its accuracy
  (90 accuracy across 2 sessions), the treatment
  stimuli, and the setting.

11
Baseline Measurements

• A baseline is a measure of response rates in the
  absence of treatment
• Baselines
• Establish a need for treatment
• Document improvement
• Allow us to modify if we dont see improvement

12
Baseline Data

• Create a set of exemplars of each of your target
• behaviors, gather stimulus items that will
  evoke these exemplars (e.g., picture cards), and
• prepare a recording sheet.
• Utilize criterion referenced measures like
• language sample and narrative analyses.

13
Baseline Examples

• Articulation of the /s/ phoneme at the word level
• Oral Narrative Skills
• Topic Initiation
• Eye Contact
• Academic Vocabulary
• Use of Derivational Morphology
• Essay Writing

14
Generalization Probes

• Probe Assessment of generalized production,
  based on treatment
• Generalized productions are those that are given
  to stimuli not used in training. They demonstrate
  the spread of learning from the old stimuli
  (trained) to new stimuli (untrained)

15
Data Collection Strategies

• Always have more than one measurement
• Check the reliability of the baseline data
• Select research/clinical design

16
Research/Clinical Designs

• ABA designs
• Test, treat and test
• ABAB designs
• Test, treat, test and treat
• Time-Series designs
• Establish stable baseline
• Begin treatment
• Measure treatment results
• Multiple-Baseline designs
• Have a number of different baselines
• Each baseline must be independent of the others
• Only treat one variable

17
Sharing Results/Research Benefits

• Local dissemination of results at workshops
• State presentations
• National presentations
• Publications at local, state and national levels

18
Examples of Outcome Based Intervention

• Working with school-age children with language
  disabilities
• Grades can be used as outcome data
• Automatic and natural multiple baseline design
• The speech-language pathologist targets one or
  two academic areas
• Grades prior to intervention serve as a stable
  baseline
• The clinician charts all grades during the course
  of treatment
• If treatment is effective, the grades that
  improve the most should correlate with the
  academic areas targeted by the clinician

19
Study to Improve Phonological Awareness Skills

• The study began with both standardized and
  criterion-referenced assessment
• The Lindamood-Bell program of phonological
  awareness was the treatment program that was
  implemented
• Therapy took place over the course of one
  semester
• Progress was measured using the same assessments
  administered prior to the onset of treatment

20
Results of Treatment

• All subjects made progress, although the amount
  of progress varied for each child
• Each child served as his/her own control
• This study was conducted by a graduate student in
  speech-language pathology under the supervision
  of a certified clinician
• Last year, the results of this treatment program
  were presented at the ASHA convention
• Currently, this investigation is being written up
  for publication
• The original clinician is now practicing and
  using this program with additional clients

21
Study to Improve Narrative Skills

• Narrative treatment targets
• Begin by designing a criterion-referenced
  assessment
• Example target Increase the complexity of
  narratives from level 2 to level 4
• Implement treatment program

22
Narrative Study cont.

• At the end of a pre-determined period of time (10
  weeks), re-administer the criterion-referenced
  assessment
• Treatment ends for the Christmas break
• When school resumes, re-administer the
  criterion-referenced assessment
• Continue therapy

23
Research in a Clinical Setting

• Public Schools
• Outpatient Clinics

24
Research in a Clinical/Public School Setting

• Roadblocks
• Benefits

25
Roadblock

• My caseload is too big to tackle research!
• School-based therapists often carry large
  caseloads across multiple schools
• Clinic-based therapists are held to productivity
  standards

26
Benefit

• When research is well-designed, lesson plans are
  born.
• Data collection schedules
• Treatment activities
• Treatment materials
• Work is initially more intensive, but the therapy
  planning burden is reduced over a long period of
  time across multiple clients

27
Roadblock

• Research cant fit into an IEP/POC.
• IEP goals most often defined annually
• They cover many areas and need to consider goals
  over a long period of time
• POC updates often dependent on clinic rules or
  insurance guidelines
• Research goals could be too narrow for an annual
  IEP

28
Benefit

• A well-designed treatment research protocol will
  yield clear data
• The research design will force you to write goals
  which are very clearly defined and measurable
• Remember that goals define a behavior you are
  trying to establish not a therapy activity you
  will use to reach that goal.

29
Roadblock

• I cant offer the consistency necessary for
  controlled studies.
• School schedules may break up the consistency of
  treatment
• Assemblies
• Vacations
• Pediatric outpatient no-show/cancellation rates

30
Benefit

• This is real-world treatment research
• We often ask about the application of rigidly
  controlled studies to the real world.
• Expected breaks can be written into the research
  design.
• The impact of inconsistent attendance can be
  addressed in the research
• Comparison to more consistently attending
  participants

31
Important Points

• Administration support
• Consent

32
Inferential Reading Comprehension A Treatment
Study

• Karen L. McGehee, M.S., CCC/SLP Tahoma School
  District, WA
• Laura B. Green, Ph.D.,CCC/SLP University of
  Washington

33
Participants

• J 5th Grade Female P 4th Grade Male
• Demonstrated a language disorder based on
  Washington state criteria
• Were served by the school SLP for expressive and
  receptive language delays
• Scored in the below average range on a
  standardized measure of reading comprehension
  with specific difficulty answering inferential
  questions.

34
Intervention Program Inferential Comprehension
Teaching Approach (Milosky Ford, 1996)

• Program
• Teach students to make predictions during
  reading
• Prompt metacognitive skills
• Encourage students to think about what they
  already know combined with what is stated in the
  text to put the pieces of the puzzle question
  together
• Lesson Set-Up
• Students read 2 passages from a 3rd grade reading
  workbook
• Students used target strategies (with clinician
  scaffolding) to answer 5 literal and 5
  inferential comprehension questions

35
Design and Plan

• Pre- and post- test measures, including a control
  measure, were selected
• Onset of treatment for each participant was
  staggered by one week
• Participants were seen individually for one 40-
  minute session per week for eight weeks
• Treatment data were taken during each session and
  probe data were taken after every 2 lessons

36
Treatment and Probe Data for Percentage of
Inferential Questions Answered Correctly
(BBaseline LLesson PProbe)
Participant J
Participant P
37
Pre- and Post- Test Data
38
Establishing Functional Reading Skills for a
Student with Down Syndrome

• Karen McGehee, MS CCC/SLP,
• Kalispell Regional Medical Center
• Laura Green, Ph.D. CCC/SLP,
• Private Practice

39
Literacy Issues for Students with Down Syndrome

• Few studies have focused on the process or
  progress of literacy learning in individuals with
  Down syndrome (Kay-Raining Bird, Cleave,
  McConnell, 2000)
• With exposure and training, many children with
  Downs become partially literate (Bird Buckley,
  1994 Oelwein, 1995).
• Little is known about how many of these children
  learn to read and the extent to which reading is
  mastered.

40
Our Student with Down Syndrome 16-year old S

• Has received special education services in all
  academic areas since the age of 3 (Speech, OT and
  PT were terminated in elementary school)
• Has expressed a strong desire to learn to read
• Has received reading instruction using Reading
  Mastery and other classroom-based programs
• Has severely dysarthric speech (most spontaneous
  utterances 2-4 words in length)

41
Intervention Structure

• 2 60-minute sessions weekly
• 40 sessions total (including assessments and
  probes) completed from April to September
• Daily home practice and review using treatment
  materials for a minimum of 30 minutes per evening
  

42
Pre-Treatment Test Results

• Number of sight words recognized 8
• Letter-sound naming 77 (missed e,h,q,u,x,y)
• Test of Auditory Analysis Skills 0 at all
  levels
• Word-family words read 1/24 words (3 words per
  word family)
• Comprehension could not be assessed

43
Treatment Objectives (Goal 80 accuracy)

• Orthographic Recognize 8 word families (at, in,
  op, ed, ug, est, ake) and words that contain them
• Phonological Establish auditory segmenting and
  blending skills at the phoneme level
• Orthographic Read 25 Dolch sight words visually
  presented within 2 seconds of presentation
• Reading in context Read sentences containing
  trained sight words word-family words and then
  follow a simple direction or answer a simple
  question

44
Monthly Probe Data 1st session of month
45
Post-Treatment Test Results

• Number of sight words recognized 46
• Letter-sound naming 92 (missed q,x)
• Test of Auditory Analysis Skills 100 accuracy
  at compound word and syllable levels 90 at
  phoneme level
• Individual word families read 18/24 words read
  from 8 word families (untrained)
• Reading Comprehension 60 accuracy for
  responding to directions/questions containing
  both trained sight word family words

46
Questions
47
Audience Discussion Questions

• Can you think of a particular treatment program
  you are doing right now that would lend itself to
  outcome-based research?
• What would be the benefits of undertaking outcome
  based research?
• How are you currently measuring progress in
  therapy?