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2/25/2016
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Changes in Articulation and PerceivedResilience in Children with ChildhoodApraxia of Speech (CAS) Following
Multisensory Intervention
Mississippi Speech-Language-Hearing Association
Annual Continuing Education Conference
Jackson, Mississippi
March 3, 2016
DuBard School for Language Disorders
Maureen K. Martin, Ph.D.,CCC-SLP, CALT, QI
Daphne Cornett, M.S.,CCC-SLP, CALT, QI
Missy Schraeder, M.S.,CCC-SLP, CALT, QI
Susan Perry, M.S.,CCC-SLP, CALT
Department of Child andFamily Studies
Lindsay Wright, Ph.D.
Center for ResearchSupport
J. T. Johnson, Ph.D.
Disclosure Statements
Financial:
Susan Perry – Employed by the DuBardSchool for Language Disorders, TheUniversity of Southern Mississippi
Presentations are included in salaried duties.
Nonfinancial:No relevant nonfinancial relationship exists.
Founded in 1962 by Etoile DuBard
Clinical division of the Department of Speechand Hearing Sciences
Serves as the full-time public school placementfor 80 students with severe speech, oral orwritten language (including dyslexia), and/orhearing disabilities
DuBard School for Language DisordersThe University of Southern Mississippi
Outclient therapy services provided forindividuals with less severe disabilities
Evaluation services
DuBard School is a national training site for theDuBard Association Method®
DuBard School for Language DisordersThe University of Southern Mississippi
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DuBard Association Method®
A phonetic, multisensory structured languageapproach
Systematically organized; Instruction consists ofincremental units of language/speech
Student experiences more success than failure
Martin, M.K. (2012). Oral and written communication disorders. Arlington,TX: The Fowler Group
DuBard Association Method®
As skills are mastered at each level,material is organized into larger and,gradually, more complex units related tocommunication until the child no longerexperiences multiple uncertainties aboutlanguage, speech, and reading.
Martin, M.K. (2012). Oral and written communication disorders. Arlington,TX: The Fowler Group
Components of Multisensory Interventionusing the
DuBard Association Method®
Visual
Auditory
Tactile
Motor-Kinesthetic
Phonetic
Linguistic
Structured
Systematic
Incremental
Cumulative
DistinctiveFeatures of the
DuBardAssociation
Method®
1. No program to buy or sell; however,professional training is required for maximumsuccess.
2. Use of Northampton symbols, which are highlycorrelated to written English. Northamptonsymbols are organized into primary andsecondary spellings.
Distinctive Features of theDuBard Association Method®
As part of theNorthampton symbolsystem, 1’s and 2’s
are used todifferentiate betweengraphemes that are
written the same waybut are saiddifferently.
Distinctive Features of theDuBard Association Method®
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3. Precise articulation is required from thebeginning.
4. Cursive script is used
o More visual differences are present vsmanuscript
o Letters in words are connected so wordsare seen as units
o Easier motorically
Distinctive Features of theDuBard Association Method®
5. The use of colordifferentiation.
Distinctive Features of theDuBard Association Method®
6. Teaching begins at the level of thephoneme
7. Modification of temporal rate
8. Individual student’s book made as studentprogresses through the method
9. Instruction in phonetic rules is delayed untilupper levels of the method.
Distinctive Features of theDuBard Association Method®
The DuBard Association Method® is
appropriate for children who have a
developmental age of 3 years on a
nonverbal cognitive basis.
For an individual to make the most progress,
the intensity of intervention
must correspond to the
severity of the disability.
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• Receptive and/or expressive language disorder
• Auditory processing disorder
• Deaf/hard-of-hearing
• Dyslexia/Specific Learning Disability in Reading
• Adults
• English language learners (ELL)
• General education
• Childhood Apraxia of Speech (CAS)
Who can benefit from theDuBard Association Method®?
• Neurological speech sound disorder
• Precision and consistency of movements underlyingspeech are impaired
• Absence of neuromuscular deficits
• Core impairment in planning and/or programmingmovement sequences
• Results in errors in speech sound production andprosody
Childhood Apraxia of Speech (CAS)
ASHA Position Statement on CAS, Retrieved from www.ASHA.org/policy
Few studies of intervention for CAS
Yoss and Darley (1974) – long period of therapyoften resulted in minimal improvement
Blakely (1983) – estimated therapy would lastfrom three to ten years, depending on severity
Moriarty and Gillon (2006) – slow progressusually associated with CAS
Childhood Apraxia of Speech (CAS)
Murray, McCabe, & Ballard, 2014 –Reviewedsingle-case studies (n=23), or case series ordescription studies (n=19)
Found 3 treatments to have enough evidenceto support efficacy: Integral Stimulation/DTTC,ReST, and Integrated PhonologicalAwareness Intervention
Childhood Apraxia of Speech (CAS)
Twelve students, ages 3-8 to 10-3, diagnosedwith CAS were enrolled in the DuBard Schoolfor Language Disorders at The University ofSouthern Mississippi.
Most students presented with significantcomorbid conditions.
One student had no comorbid conditions.
CAS and Phonetic, MultisensoryStructured Intervention
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Professional staff consisted of six ASHA-certifiedspeech-language pathologists, one of whom wasalso a master’s level educator of the deaf.
All professional staff met the requirements for beingHighly Qualified for K-4 as outlined by NCLB, 2001.
All staff (including teacher assistants) wereextensively trained in the DuBard AssociationMethod®
CAS and Phonetic, MultisensoryStructured Intervention
DuBard Association Method® wasimplemented daily in the classroom.
This approach included both reading andwriting components simultaneously with thedevelopment of articulation skills.
CAS and Phonetic, MultisensoryStructured Intervention
Articulation, mean length of utterance(MLU), and speech intelligibility weremeasured using the ArizonaArticulation Proficiency Scale – ThirdRevision (AAPS-3)
CAS and Phonetic, MultisensoryStructured Intervention Maximum Total Score = 100
Not simply a count of accurate productions,as 67 sounds are tested
Each sound given a weighted value from0.5 to 7.0 reflecting how frequently it occursin American speech
Sum of all values = 100
AAPS-3 Total Score
Because Total Scores are linked to the actual rateof speech sound occurrence, these scores“express a real sense of how often distortedsounds are likely to occur in the examinee’severyday speech” (Fudala, 2000, p. 13).
Incorrect phoneme with value of 2.0 wouldindicate that 2% of speech would be incorrect.
AAPS-3 Total Score
ə (schwa) = 7.0
ɪ (-i-) = 6.0
t = 4.5
n = 3.5
eɪ (a-e) = 2.0
AAPS-3 Total Score
ð (th) = 2.0
m = 1.5
f- = 1.0
-f = 0.5
ɵ (th) = 0.51
2
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AAPS-3 Total Score
Mean Range
Pre-test 56.38 45.5 - 75.5
Post-test 91.08 73.0 - 100.0
F(1,11)=85.39, p<.001
95.0-100.0: Sound errors are occasionallynoticed in continuous speech
85.0-94.5: Speech is intelligible, althoughnoticeably in error
70.0-84.5: Speech is intelligible with carefullistening
60.0-69.5: Speech intelligibility is difficult
45.5-59.5: Speech usually is unintelligible
0-44.5: Speech is unintelligible
AAPS-3 Speech Intelligibility Values
Used to compare results to others of thesame age (and gender, for young children)
Mean = 100, Standard Deviation = 15
AAPS-3 Standard Score AAPS-3 Standard Score
Mean Range
Pre-test 64.75 <55 - 75
Post-test 85.83 67 - 100
F(1,11)=41.35, p<.001
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Mean Length of Utterance (MLU)
Mean Range
Pre-test 3.8 1.2 – 6.7
Post-test 7.0 2.9 – 10.3
F(1,11)=25.98, p<.001
Pre-Intervention Gain =
Developmental Age
CA
Pre-Intervention Gain =
18 months
66 months= 0.273
Gain Made During Therapy orIntervention Efficiency Index (IEI) =
Age equivalency (post) – Age equivalency (pre)
Length of therapy
IEI =24 months - 18 months
19 months= 0.316
Proportional Change Index (PCI)
IEI (Gain made during therapy)
Pre-Intervention Gain
PCI =0.3160.273
= 1.159
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Pre-Intervention Gain =
Developmental Age
CA
Pre-Intervention Gain =
18 months
49 months= .367
Gain Made During Therapy orIntervention Efficiency Index (IEI) =
Age equivalency (post) – Age equivalency (pre)
Length of therapy
IEI =72 months - 18 months
23 months= 2.347
Proportional Change Index (PCI)
IEI (Gain made during therapy)
Pre-Intervention Gain
PCI =2.347.367
= 6.395
ProportionalChange IndexStudent
1
2
3
4
.
10
.
12
1.159
1.889
2.367
3.106
.
10.648
.
18.000
Ability to adapt to, and overcome, a challengingsituation
Relationship between individual and theenvironment
Changes over time; can vary based on differentstressors during a person’s life
No correlation between resilience and maturationfound in the literature
Resilience
1. Child has to be “doing okay” in terms ofbehavioral expectations
2. Child must have significant exposure to risk oradversity that poses a serious threat topositive outcomes
Resilience – Two Major Judgments
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• Social and academic achievements
• Happiness or life satisfaction
• Normative mental health and conduct
• Overall absence of undesirable behavior
Resilience – Criteria forGood Adaptation
• Positive attachments with caregivers orother adults
• Intellectual skills
• Self-regulation
• Positive perception of self
• Faith, hope, and a sense of meaning
Resilience – Protective Factors
• Supportive and prosocial friends
• Bonds to effective schools and otherprosocial organizations
• Communities with positive services
• Cultures that provide positive standards,rituals, relationships, and supports
Resilience – Protective FactorsResilience Assessment of ExceptionalStudents (RAES) (Perry & Bard, 2001)
• Teacher Rating Form (completed by SLP)
• Parent Rating Form
• Three broad constructs measured:o Exceptionality Problem-Solvingo Social Supporto Resilience Behaviors
Resilience – Data Collection
1. Exceptionality Problem-Solving
• Planning for needs
• Knowledge of exceptionality
• Alternative thinking
Resilience Assessment ofExceptional Students (RAES)
2. Social Support
• Mother/Teacher
• Immediate Family
• Extended Family
• Community/School
Resilience Assessment ofExceptional Students (RAES)
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3. Resilience
• Positive peer relations
• Self-efficacy/Locus of control
• Positive adult relations
• Modeling/Active social skills
Resilience Assessment ofExceptional Students (RAES) Positive Peer Relations
• Starts conversations with peers
• Stands up to bullies
• Shows others how to do things
• Shows leadership with peers
• Able to introduce people to each other
• Attends social events such as parties
• Popular with peers due to friendliness
RAES: Resilience
Self-efficacy/Locus of Control
• Completes homework independently
• Seeks help only when needed
• Shows enthusiasm for learning
• Attributes grades to ability
• Attempts new tasks without feat
• Self-reliant in carrying out tasks
• Self-confident about ability to learn
RAES: Resilience
Positive Adult Relations
• Helps family with daily living tasks
• Volunteers to help parents and teachers
• Follows parents’ and teachers’ rules
• Will attempt work such as runningerrands
• Responsible for personal belongings athome
RAES: Resilience
Modeling/Active Social Skills
• Acts as a model of helpful behavior
• Attempts to compensate for learningproblems
• Tries to stop arguments
• Models or imitates positive behavior of others
• Strives for perfection when completing tasks
• Understands how others feel
RAES: Resilience
Parent Rating Form and Teacher Rating Form
• Parents and SLPs/Teachers rated each child’slevel of success in basic subject areas and/orIndividual Education Plan (IEP) goals.
• Items rated in terms of Frequency and Need toImprove
RAES: Resilience
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RAES: Resilience
Frequency scale:
0 = Never
1 = Sometimes
2 = Often
3 = Very Often
Need to Improve scale:
0 = Strongly Agree
1 = Agree
2 = Disagree
3 = Strongly Disagree
RAES: Resilience - Frequency
Rater Time Interaction
Positive PeerRelations
Parent >SLP
Time 2 >Time 1
NS
Self-Eff./Locusof Control
Parent >SLP
Time 2 >Time 1
NS
Positive AdultRelations
NSTime 2 >Time 1
NS
Modeling/ActiveSocial Skills
Parent >SLP
NS NS
RAES: Resilience – Need to Improve
Rater Time Interaction
Positive PeerRelations
NSTime 2 >Time 1
ParentSLP
Self-Eff./Locusof Control
NS NSParentSLP
Positive AdultRelations
NSTime 2 >Time 1
NS
Modeling/ActiveSocial Skills
NSTime 2 >Time 1
ParentSLP
Articulation and Resilience
Study limitations:
1. Small sample size
2. Heterogeneous sample
3. Lack of a true comparison group
4. More intensive intervention thantypical settings
DuBard School for Language Disorders
The University of Southern Mississippiwww.usm.edu/dubard