Intensive scheduling improves outcomes

By Donna Ridley, MEd, CCC-SLP

An intensive schedule of therapy can be a catalyst for real change in students with speech production disorders.

These disorders can be difficult to correct, particularly in school-age children with resistant errors that have become habituated. They may present with a distorted /r/, a lateral lisp, or a more generalized pattern of overall poor intelligibility.

There are often underlying motor speech issues, such as dysarthria and/or dyspraxia. Children may have been treated for years, with partial, minimal or no success. Motivation can be low, even with well-behaved children who are not openly resistant to therapy. While they may acknowledge a problem, such as their /s/ being "slushy," they typically think they sound OK and may not have a mental construct of achieving a different speech pattern.

A traditional model of speech therapy—once or twice weekly, individually or in a group—generally is not effective for children with these complex disorders. The time on task may be spaced too far apart to effect change.

The first part of each session usually must focus on getting the child back to where he or she had been at the previous session. This may require warm-up exercises, a review of cues, and sometimes a motivational pep talk. The session also may include games for therapeutic reasons or to bolster waning motivation and instruction in home practice. All of this may reduce the time available for actual therapeutic activities.

In contrast, therapy provided on a more intensive schedule can be a catalyst for real change. When sessions are close together in time, memory issues—such as helping the child recall the error pattern, the correct pattern, and the tactile and auditory feedback differences between the two—have little impact. The child experiences how correct and incorrect patterns are different with less reliance on memory.

New patterns are stabilized via massed practice. This works to "overwhelm" the old, incorrect patterns, and allows them to be replaced with new, correct ones. When therapy is intensive, home practice may not be needed, so the time set aside to explain homework assignments can be used for actual therapeutic activities.

I developed the Two-Week Intensive Daily Speech Therapy Program as one approach to treatment for this population.¹ A child is seen five days a week, Monday through Friday, for two weeks, usually for 30-minute sessions. No deviation is permitted. If more therapy is needed beyond two weeks, it is provided on a less intensive schedule.

The session typically begins with a brief (one- to two-minute) gross motor warm-up, sometimes followed by oral-motor activities for children whose problems have an oral-motor component. All of this generally takes less than five minutes.

The child and therapist then immediately begin to work on modifying actual speech production. Most children quickly make changes in placement and/or movement patterns when sessions are close together.

Therapeutic activities may include modification of tongue, lip or jaw positions; silent rehearsal of positions and movement; production of target speech sounds and syllables at slow or fast speeds; attempts with and without audio feedback; practice of self-correctionbehavior in a role-played situation; or variations of other therapeutic activities on a hierarchy.

Speech practice materials may alternate between real words and phrases and nonsense syllable patterns, which are effective for interfering with deeply embedded automatic responses. A hand counter can be used to tally the number of correct responses for the session. The child's score is graphed and compared with the output on the previous day.

The goal is to increase response rate and, ultimately, the speed of accurate production. Games rarely are used or needed until a child reaches the level of practice in connected speech.

While typical of any session of speech production disorders treatment, these goals and activities are more likely to comprise the majority of session time during an intensive schedule. Review is rarely needed. Homework may be given—not so much for actual practice but to get children into the habit of practicing for those who will need continued therapy. They can more easily commit to practice and remember to do it when sessions are closer together. Success is usually better, and the report of practice and consequences of doing or not doing it are quickly apparent.

Home practice assignments are limited to tasks that will be successful without therapist input. The practice must be accurate to have any value.

Ned, a bright 9-year-old, presented with a consistent lateral lisp for all sibilants. His history included unsuccessful therapy as a preschooler and at age 7. After orthodontic problems and allergies were ruled out, he began two weeks of daily sessions.

On the first day Ned was shown the difference between a correct and laterally produced sibilant, followed by the use of various hands-on techniques for establishing the correct pattern. The next day he produced a centrally emitted air stream, albeit inconsistently. By the fourth day he was much more consistent at the level of single words; and he was using correct sibilants in short phrases, with conscious effort, by the fifth day.

After a weekend break, Ned was using correct sibilants during structured speech with about 90 percent accuracy. He had been so thrilled with the progress he could hear, he reported, he worked on his speech all weekend. The remainder of the second week resulted in the desired end result of complete carry-over. A recheck of his speech 10 weeks later confirmed that his speech patterns were accurate and produced at normal conversational speed—good indicators that new, correct patterns truly were carried over.

Other models and schedules can be used to deliver more therapy intensively. Sue Sexton, MA, CCC-SLP, devised a service delivery model called 5 Minute Kids to use in the public schools with students working on articulation skills.² Her data support the efficacy and efficiency of this approach.

Some school districts schedule therapy three or more times per week for children with motor-based speech disorders. Others are experimenting with total minutes per semester, rather than weekly minutes, on the individual education plan (IEP). This approach allows for flexibility in how the minutes will be provided.

Another approach is to schedule children with speech disorders three or four times weekly for the first several weeks and then decrease the frequency. Summer sessions and camp programs are ideal for arranging intensive, short-term schedules.

When therapy is delivered intensively, children with speech production disorders almost always will achieve better outcomes.

References

1. Ridley, D. Two-Week Intensive Daily Speech Therapy Program. Accessed online at http://www.home.earthlink.net/~donna.ridley.slp/id2.html.

2. Sexton, S.M. 5 Minute Kids: A drill-based program for individual articulation therapy. Accessed online at www.speakingofspeech.com.

Donna Ridley is an author and an instructor with Ages and Stages LLC, a continuing education company based in Las Vegas, NV. She can be reached at donna.ridley.slp@earthlink.net.