Monday, May 16, 2011

How policy and traditional ideas prevent ideal speech therapy outcomes

There are several ways in which speech therapists are hindered in helping people.  Because much of what we do involves speaking, and speaking is something that happens all day, every day, it's natural to think that providing therapy to improve speaking would best be done in massive quantities. 

If you think of a doctor deciding how many stitches are needed to fix a gash, they'll look at size and depth and whatever else.  Wouldn't it be ridiculous to measure how effective doctors' stitching is, if every pt, regardless of the length of the cut, was given 1 stitch.  For very small cuts it might be enough.  For a 3 inch long gash it would probably be almost useless. 

Another example from one of the professors in the Communication Sciences and Disorders department at the University of Utah.  If you're sick, and you need a drug, you'll probably be given a dose amount to take.  If you take half of that, or a tenth of the needed dose, it may be less effective or entirely ineffective. 

In speech therapy there are many types of difficulties that are treated.  Each will have its own needs.  These needs will include differing needs as far as how many hours per day of therapy is needed.  Very severe cases require a lot of time.  Unfortunately, most people get less than an hour per week.  Supposing a person sleeps 8 hours per night, and is awake and communicating most of the rest, that's around 112 hours per week of talking, and less than 1 hour to improve it. 

The reasons for this are several.  Really there aren't enough speech therapists.  School districts and insurance companies have to pay more for more therapy, and so it's cheaper and simpler to give token therapy.  Some kids catch up just fine with 25 minutes per week of speech therapy.  But the ones that need therapy the most are the ones that suffer the most.  It's difficult for speech therapists to be the squeeky wheel at the school district.  When they advocate for more therapy for a child, they end up giving more therapy for that child, and neglecting other children because of it. 

Anyway, this is a paper I did in Advanced Research Design where I reviewed the research on the intensity of therapy (hours per week) and its effects on how well patients improved.  It's probably a little dry, and it's more a proposal to study a specific case that would be funding neutral, but it has some details about time intensity for therapy research with regards to autism, childhood apraxia of speech, and aphasia. 

The effects of decreasing session length and increasing session frequency while controlling for overall therapy time in children with /r/ to /w/ articulation errors.

By Jeff Keyes


            The field of speech therapy treats many disorders that are completely unrelated to each other.  Diagnostic groupings are different with respect to severity level, type of treatment needed, causes, effects, prognoses, and they vary along lines of gender, age, and populations.  The only things they have in common are that they are all related to communication, and they all tend to receive more or less similar numbers of hours per week in treatment.  There is no explicit or researched reason for this similarity, and it is a convention that has not been studied intensively, when there are so many other things that merit research.  Insurance payment regulations, school class structures, and traditional thinking also contribute to keeping hours and sessions to a minimum. 

Literature Review

            There are small groups researching time intensity in most of the major diagnostic areas, and the field has benefitted immeasurably from their findings.  The included chart was designed as a visual representation to underscore the need for providing the number of therapy hours per week supported by research.  The 2001 report from the National Research Council, titled Educating Children with Autism, suggests providing a minimum of 25 hours per week of total therapy time.  So, for autism, the “expected” line on the chart would represent the level of improvement that occurs on average for a child that is receiving 25 total hours of therapy per week.  A child receiving half of that therapy time would probably not make half the progress that would be made by a child receiving 25 hours per week.  They would make significantly less than half of the progress.  This is an assumption based on research that generally finds that few hours per week of therapy are ineffective, or have very limited effectiveness, whereas most of the exciting gains seen in autism research are the result of intensive therapy. 

            For aphasia, the “expected” line represents the amount of improvement made by a person with aphasia who is being treated for 2 hours per week.  The studies I have reviewed seem to imply that this is the average for long term aphasia treatment.  In this case, the pink “Aphasia” line represents the findings of Robey, (1998) and Bhogal, Teasell, and Speechley, (2003), both of which indicate that more therapy is more effective.  In Bhogal’s case, specifically, the research indicates that two hours per week of therapy is ineffective, while 8 hours per week is highly effective.  The “Aphasia“ line on the graph represents Bhogal’s findings.  Like the line for autism, these lines represent low intensity as ineffective and high intensity as “effective.”  There are no specific numbers to say that “ineffective” isn’t really just “less effective” therapy due to a lesser number of hours instead of actually less effective hourly rates of therapy.

            In childhood apraxia of speech, Hall, Jordan, and Robin, (2007) suggests that therapy last between 90 minutes and five hours per week.  Campbell, (1999) finds that children with apraxia of speech take more than five times longer to increase their speech intelligibility on the same parameters as compared to children with phonological disorders.  The CAS literature also supports increasing the frequency of sessions while decreasing their duration for better results. 

            Literature comparing the intensity of therapy generally views whether more hours of therapy is better than fewer hours of therapy, and for the most part notes that more hours per week are better.  Finding research that adds the additional step of calculating the hourly efficiency for both high intensity and low intensity therapy is difficult.  For example, if a group receives therapy for two hours per week and improves on a rating scale by 4%, then we could say that the rate of improvement is 2% per hour per week.  So if a group receiving therapy for four hours a week improves by 12%, this would be a rate of improvement of 3%.  This would not only help the child exit therapy faster, but it would reduce the overload that therapists experience as the children would spend less total time achieving the same results. There are probably as many cases in which greater time results in lower hourly improvement rates.  In these cases we might actually have to look at reducing time to achieve the same results, as Laing, et al., (2004) did in showing that phonological awareness could be increased at low intensities. 

            While an increase in total weekly therapy time that shows improved outcomes but does not show an hour by hour improvement in efficiency may not be advantageous from an efficiency or monetary view, it is still worthwhile for the clients when this is possible.  In some cases, such as growing children or very recent post-stroke patients, there is an additional dynamic of having a period of time where improvements are more dramatic due to an increased ability to learn that will diminish over time.  So even treatments that are more effective overall, though less effective by their hourly rate of improvement, will certainly benefit from further study and diligent research that works to present the objective arguments that will persuade payers to allow these therapies.

            Most of the data used as a basis for the graph below looks at differences in intensity and whether those differences are statistically significant.  They generally do not include enough detail to determine which is better on an hour to hour basis, so this has been inferred or drawn from a broader understanding of the research.  Theoretically, too little therapy is less effective, and too much therapy would also be less effective due to exhaustion.  The lines on the chart do not show a regression towards the mean at the upper hours per week because the research hasn’t been done.  For monetary reasons, the field at present is generally concerned with how little is too little, as opposed to how much is too much.  As actual hourly effectiveness numbers are found and included, some idea has to a more precise shape of the curves will become apparent.



            The rationale for the study of articulation therapy is that changes have been implemented in the treatment of children with basic articulation errors.  These changes involve maintaining the same overall amount of therapy time, but splitting the single long sessions into multiple short sessions.  Having been unable to find any studies comparing these two therapy conditions, and hearing the anecdotal reviews of the increased effectiveness of frequent short doses of therapy, it seems valuable to study this technique and compare its effects to traditional therapy.

Research Question

The question that will be answered by this study is this: would articulation therapy be more effectively given for 10 minutes 5 times a week than 50 minutes one time a week?  Additionally, a calculation about how much more effective one therapy is than the other will be performed.  This study is highly feasible in terms of scope, time, and money.  It should be a relatively easy thing for a working therapist to use some of his or her clients in one group or the other.  Technical expertise should not be an issue, as the therapy given is very basic and common for speech language therapists, and the study is fairly straight forward in objectively comparing two treatment conditions. 

The results of this study would be of interest to any speech language pathologist working in schools and looking for ways to help their client obtain better results faster.  The treatment groups are not novel, but the high frequency low duration technique has not been subjected to the author’s knowledge.  If one treatment does end up being significantly better than the other, then the children that were randomly selected for the less effective treatment should receive the better treatment.  This study is very relevant for clinical populations.  Additionally, it may play a small role in debates about the importance of frequency relative to duration in therapy. 


            The first step in determining the number of participants to be involved in the study is using statistical tools to see how many are needed to achieve statistical significance.  To be able to use parametric tests, the number of children in each group will need to be at least ten.  The children used in this study will be drawn from a single speech language pathologist’s caseload.  This allows for a single person to do all of the therapy, which removes one possible lurking variable.  While it is possible to have enough children on a case load, the criteria may exclude some of them.  In this case, a second speech-language pathologist will be included in the study.  The second clinician will be given numbers of clients distributed evenly between the two groups, to prevent treatment differences from affecting the study outcome.  Children that would be excluded from participating in this study would be those that have other disorders and those receiving other therapy.  This removes the chance of an overlapping treatment effect.  All children in the study would have an /r/ to /w/ articulation error.  Children would be randomly assigned into groups after controlling for SES, age, severity, gender, ESL status, and stimulability.

            Case histories would be used to help in determining inclusion or exclusion from the study.  Before treatment begins, a speech sample would be performed in a natural setting to obtain baseline information on the percentage of correct /r/ productions.  Another speech sample would be done at the end of the study to see outcomes.  It may be possible that the single session intensive group has better maintenance of their gains, as they will be accustomed to a full week between each treatment, so a third speech sample will be collected one month after treatment has ended to check maintenance of gains.  Inclusion of items with names involving /r/ may be needed for children with any avoidant behaviors for the speech samples.

            The course of treatment will move from discrimination, if needed, to production of the phoneme, to elicitation, generalization, and maintenance throughout the course of treatment.  Activities will be five or ten minutes in duration, and will follow a similar course for both groups.  While individuals may be at different points on the course of treatment, everyone from both groups will be on the same course. 

A series of stories, rhymes with alliteration and consonance using /r/, word lists using initial, medial, and final positioned /r/ will be used.  Activities performed with each child will be noted and watched, as there may be a tendency to involve more fun activities in the long sessions and more drill and intensive activities in the short sessions.  It does seem logical that there would be a reduced possibility of boredom, mental fatigue, and break-taking may be an inherent advantage of having shorter sessions, but for the purposes of this study, every attempt will be made not to allow it to affect therapeutic activities.

Data Analysis

Speech samples will be scored by individuals who are blinded to which group a sample comes from and which of an individual’s three samples is being scored.  Each examiner will rescore 25% of their own work to assure intrajudge reliability.  This will be done at the beginning, middle, and end of the scoring period.  As much as possible, the period in which scoring takes place will be short, to prevent drift.  Additionally, 25% of the language samples will be scored by more than one individual, in order to assure interjudge reliability. 

For each speech sample, the number of correct uses of /r/ will be divided by the total number of obligatory contexts.  The speech samples will be averaged with others from their group and time to be compared both within and between groups.  T-tests will be used to look for statistical significance.

Expected Results

            It is expected that there will be a significant difference in the results of the two groups.  Anecdotal evidence from the source of this study indicates a clinically significant impact on producing /r/ correctly.  The apparent spread of this practice to other SLPs in the Salt Lake valley would also indicate a growing belief in its superiority.  The /r/ phoneme is something used many times each day.  One would assume that any therapy to correct it would benefit from being performed daily as well.  Additionally, production of /r/ is relatively simple as compared to many other types of communication deficits.  It shouldn’t need cognitively challenging, long, and intense sessions of therapy to correct.


Bakheit, A., et al (2007). A Prospective, Randomized, Parallel Group, Controlled Study of the effect of Intensity of Speech and Language Therapy on Early Recovery from PostStroke Aphasia. Clinical Rehabilitation. 21, 885-894.

Bhogal, S., Teasell, R., and Speechley, M. (2003). Intensity of Aphasia Therapy, Impact on Recovery.  Stroke: Journal of the American Heart Association.  34, 987-993

Campbell, T. (1999). Functional Treatment Outcomes in Young Children with Motor Speech Disorders.  In A. J. Caruso & E. A. Strand.  (Eds.) Clinical Management of Motor Speech Disorders in Children, pg. 394.  Thieme Medical Publishers Inc., New York

Hall, P., Jordan, L., and Robin, D. (2007). Developmental Apraxia of Speech: Theory and Clinical Practice. (2nd Ed., pg. 200) Pro-ed Publishers, Texas

Kendall, D., Rodriguez, A., Rosenbeck, J., Conway, T., and Gonzalez, L. (2006). Influence of Intensive phonomotor rehabilitation on apraxia of speech.  Journal of Rehabilitation Research and Development.  43, 409-418

Laing, S., and Espeland, W. (2004). Low Intensity Phonological Awareness Training in a preschool classroom for children with communication impairments. Journal of Communication Disorders.  38, 65-82

Robey, R. (1998). A Meta-Analysis of Treatment Outcomes in the Treatment of Aphasia.  Journal of Speech, Language, and Hearing Research. 41(1) 172

Van Demark, D., Hardin, M., (1986). Effectiveness of Intensive Articulation Therapy for Children with Cleft Palate. Cleft Palate Journal. 23, 215-224

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