Perspectives on Individual Differences Affecting Therapeutic Change in Communication Disorders

Amy L. Weiss

• Publisher: Taylor & Francis
• Year: 2012
• Print ISBN: 9781848728875
• eBook ISBN: 9781136950148
• Edition: 1
• Topic: Psychology
• Subtopic: Cognitive Psychology & Cognition
• Index: Psychology

This volume examines the ramifications of individual differences in therapy outcomes for a wide variety of communication disorders. In an era where evidence-based practice is the clinical profession's watchword, each chapter attacks this highly relevant issue from a somewhat different perspective. In some areas of communication disorders, considering the variance brought by the client into the therapeutic 'mix' has a healthy history, whereas in others the notion of how individual client profiles mesh with therapy outcomes has rarely been considered.

Through the use of research results, case study descriptions and speculation, the contributors have creatively woven what we know and what we have yet to substantiate into an interesting collection of summaries useful for therapy programming and designing clinical research.

1
Perspectives on Individual Differences Affecting Therapeutic Change in Communication Disorders

Prologue

Amy L. Weiss

As my career as a provider of clinical services to persons with communication disorders has evolved over more than 30 years, I have been struck by several aspects of treatment delivery that were not obvious to me when I was a novice. To begin with, I continue to be overwhelmed by the proliferation of new information that has been made available to speech-language pathologists (SLPs) and audiologists through the efforts of creative and hardworking colleagues focusing first on what was known as treatment efficacy research and more recently on investigations aimed at amassing evidence-based practice data (Dollaghan, 2007). It is nearly impossible to open a scholarly journal that focuses on communication disorders today without finding at least one article with the term “evidence-based practice” in its title. Certainly this trend serves as a response to the ongoing call for accountability in the services we provide, not only to the people we serve but also where reimbursement by third-party payers is concerned.

It is clear to almost anyone invested in selecting the most appropriate intervention approaches for individuals with communication disorders that evidence-based practice has taken center stage with its three decision-making components: (a) What does carefully designed research tell us works? (b) What does our clinical experience suggest will work? and (c) What are the preferences of the particular clients we serve (and their families, of course)? Although several authors have tackled the issue of how professionals can balance these three perspectives in the field of communication disorders (Dollaghan, 2007; Gillam & Gillam, 2006), many professional SLPs and audiologists continue to express concern over how to most appropriately weigh these factors in therapy decision making (E. Strand, personal communication, April 18, 2008).

Second, I recognize that we cannot be cavalier about the heterogeneity of the populations of individuals with communication disorders that we serve and the obvious impact that has on determining best practices. Instead, we have to take the individual differences of our clients into account in both data collection and clinical decision making. Let’s take a fairly transparent example to illustrate this point. Not every child with a hearing loss has had the same auditory experiences or the same benefits from auditory input as the standard textbook case, even if that hearing loss looks ostensibly identical when mapped on an audiogram. It can be hypothesized that each child brings to the therapy setting a different history of identification and amplification, even children with a supposedly identical hearing loss, that may contribute a different and more appropriate interface with a particular treatment regimen (see Teagle & Eskridge, Chapter 12, for more information on the particular variables taken into account by professionals serving children with hearing impairments).

Investigators focusing on the efficacy of intervention approaches appear to deal with the issue of heterogeneity in one of two ways, either by utilizing single-subject designs to carefully capture the essential differences inherent in individual clients (see Gierut, 1998) or by attempting to mitigate the presence of individual differences through larger-scale studies (Rvachew & Nowak, 2001; Rvachew, Rafaat, & Martin, 1999). Each approach brings its own set of problems to the interpretation of findings. In the first case, the statistical design allows for a participant to serve as his or her own control. Individual differences between subjects are assumed, and that is one reason why multiple single-subject cases are often reported simultaneously in one article. In the second case, where larger numbers of participants are incorporated into a treatment study, it is assumed that the individual differences presented by these participants will cancel each other out, minimizing the variability in participants’ performance.

In a perfect world, professional service providers are able to make inferences about the usefulness of particular interventions when the participants described in treatment studies are similar to clients/patients on their own caseloads. Making such inferences from a single-subject design experiment is more valid if the researcher has provided the reader with a finely tuned description of the participants, taking care to include details that potentially have an impact on the outcome (e.g., age of identification of hearing loss, age at which amplification was supplied, etc.). What is lost in single-subject designs, however, is the ability to make a statistically powerful statement about the inferences of the findings, either positive or negative. Large-scale studies with random assignment of subjects to treatment conditions are more attractive to many consumers of research because findings reflect less of the individual variance that may affect outcomes. Unfortunately, as researchers in communication disorders are well aware, finding large numbers of persons representing low-incidence disorders can be a difficult or impossible task. To that end, selection criteria may be broadened to ensure that a sufficiently large subject population is recruited. Adopting that solution greatly reduces the ability to infer that clients from an individual SLP’s caseload will respond the same way that participants in a study responded on average to therapeutic regimens. My purpose here is not to support one approach to accruing evidence-based practice data to the exclusion of the other approach. The reality is that our subject populations are inherently more likely to range from 1 to 40 than in the thousands or tens of thousands, as they may for carefully controlled studies comparing drug regimens, for example.

Third, my naïve view of intervention as a new SLP more than 30 years ago posited that successful therapy was mostly about me, my performance as a clinician, and the type of intervention activities I selected. However, over the course of those years as an SLP, I have become interested in exploring the integral role played by the client in determining the success or failure of intervention. Specifically, what does an individual client bring to the therapeutic table?

The topic of the interface between individual differences and therapy progress was discussed in more detail in an earlier article (Weiss, 2004) with a recounting of a clinical experience I had had many years ago as a graduate student assigned to a young, highly unintelligible preschooler. This child made it evident to me that clients I work with likely differ in terms of their motivation, as well as their ability to change. In brief, the child made several explicit comments concerning his recognition that he was talking like a much younger child (e.g., “You think I talk like a baby”). It was not long after these comments were made that the child demonstrated an exponential, positive increase in his intelligibility. This was not a controlled study and so there is no way to make any useful generalization about the relationship between the two occurrences, the comments reflecting self-awareness and rapid improvement in speech intelligibility. This anecdote has stuck with me, however, and although I do not design objectives to elicit comments from preschoolers about the self-perception of their lack of intelligibility, you can be sure that I listen carefully for them. For this particular child, there was a correlation between the two occurrences. Note that I have taken care not to say anything about causality.

It also interests me that within the field of communication disorders, the topic of the client’s share of the therapeutic relationship is considered to a greater or lesser extent depending on the particular disorder. For example, in the area of stuttering, it is not unusual for most SLPs to discuss at some point what the impact of a client’s stuttering is on his or her activities of daily living (ADL). Please note that I am aware that for those who follow a fluency-shaping approach and favor operant techniques to reduce stuttering, there is often no reference to stuttering except as an isolated behavior, and therefore, the impact of stuttering on ADL is of relatively minimal concern. However, the degree to which a communication disorder impacts on a client’s ADL provides the clinician with some perspective on the client’s probable motivation to make changes in his or her typical communication behaviors. Again, note that I am not suggesting that for our clients who stutter, the elimination of stuttering is necessarily the only viable outcome. That is my acknowledged bias as an SLP. Changing speech behaviors to foster more successful communication is a worthwhile goal and will probably be defined by the client along with collaboration from relevant family members and a clinician.

Consider a different setting and a different population of individuals with communication disorders. It is much less likely that as a matter of course, SLPs in the schools will provide their clients with questionnaires to determine their level of motivation for change. More often it appears that the SLP forms an opinion about the client’s investment in therapy in an indirect manner. When homework is not completed, when the client is not willing to work at the upper limits of his or her capacity, or when the client consistently shows up for therapy sessions several minutes late, the message of low motivation is conveyed. Furthermore, it may not just be about clients and their abilities. Kwiatkowski and Shriberg (1993) referred to a client’s contribution to therapy as the intersection of capability and focus. The partnership formed between the client and clinician to some extent dictates the level of success in therapy in many cases. We may already be calling this interaction rapport—the working relationship that is built between the clinician and the client. However, the measurement of rapport may entail more than the likelihood that a young client will remain seated during therapy or a somewhat older one will show up on time with homework in hand. Rapport may be enhanced by the degree to which the client buys into the therapy plan developed by the clinician. This is a side benefit to creating goals and selecting targets that are meaningful to a particular client. That is, if I am a client who can understand why learning a certain technique will be useful to me, or if I can see that the technique works, I am that much more invested in the outcome. Any SLP who collaborates with classroom teachers to find out the science or history unit being addressed before selecting vocabulary or reading materials for a school-age client with literacy-learning issues is ultimately doing so to make therapy more relevant. With perceived relevance presumably comes more attention and motivation from the client.

A focus on communication disorders affecting language development presents yet another perspective on individual differences and outcome. Much of my clinical career has been spent working with children who had diagnosed language disorders or who were at risk for developing language disorders. When not working directly with young clients, I was investigating (or musing about) how the language development patterns I observed reflected both general trends and individual differences (Goldfield & Snow, 2009, p. 285). In the area of child language disorders, it has been my experience that SLPs are more likely to consider the level of language competence the child possesses going into therapy and the particular style of language learning exhibited by the child to be two of the most essential factors prescribing the course of therapy and its relative rate of progression toward a favorable outcome, more important than the child’s motivation to learn, per se. When Bates, Dale, and Thal (1995) explored the individual differences observed in children’s language development, they addressed variability in the rate of development within specific language components (e.g., semantics) and across language components (i.e., comprehension outpaces production for most children), as well as reported differences among children related to language-learning style. These investigators went so far as to conclude that “the Average Child is a fiction, a descriptive convenience like the Average Man or the Average Woman” (Bates et al., 1995, p. 151). This statement throws into disarray the assumptive usefulness of normative data to the exclusion of monitoring evidence of the individual differences represented by our clients.

The purpose of this text was to compile the contributors’ responses and reflect on how their perspectives on the relationship between clients’ individual differences and therapy outcomes may inform us about practice in the field of communication disorders. To that end, I asked a number of my colleagues who are SLPs and/or audiologists both inside and outside the United States to consider the area of communication disorders they have focused most of their professional attention on and write about their perceptions of how the notion of individual differences fits with therapy outcomes. That is, I asked them not only what the available research says to them that aids in their clinical decision making but also how their own clinical experiences square with the notion that clients treated for communication disorders are not uniform in their ability to benefit from therapy. I purposely gave the authors very little guidance about how to go about that mission because I did not want any template followed that might stifle their clinical problem-solving creativity.

Each contributor agreed that she or he was cognizant of the crucial effect of personal factors on therapy outcomes, and as you will see, the authors differed quite strikingly in how they attacked the questions presented. Some used a case study approach to illustrate different outcomes stemming from individual differences. Others paid close attention to the evidence-based practice model that we have become so very used to in our literature within the last several years. For others, where there was a heartier research base available, you will notice less speculation and more of a review of the research literature. I believe that most of the authors will agree, however, that they were forced to make more speculations than they may have been entirely comfortable with. I include myself in that group.

The topics covered in this text range from an overview of the individual differences in children’s acquisition of social language competencies to the very specific topic of the individual client differences that influence changes in stuttering behavior when the Lidcombe Program is implemented. Given the expanded scopes of practice experienced by audiologists and SLPs over the time I have practiced, it would have taken a text at least twice the size of this one to cover every disorder and every context of practice, so it is probably wise to consider the chapters that have been included as a first wave of attack on an intriguing topic. It is our collective hope that you will find the chapters both informative and thought provoking.

References

Bates, E., Dale, P., & Thal, D. (1995). Individual differences and their implications for the theories of language development. In P. Fletcher & B. MacWhinney (Eds.), Handbook of child language (pp. 96–115). Oxford, United Kingdom: Basil Blackwell.

Dollaghan, C. (2007). The handbook for evidence-based practice in communication disorders. Baltimore: Paul H. Brookes Publishing Co.

Gierut, J. (1998). Treatment efficacy: functional phonological disorders in children. Journal of Speech, Language, and Hearing Research, 41, S85–S100.

Gillam, S., & Gillam, R. (2006). Making evidence-based decisions about child-language intervention in schools. Language, Speech, and Hearing Services in Schools, 37, 304–315.

Goldfield, B., & Snow, C. (2009). Individual differences: Implications for the study of language acquisition. In J. Berko Gleason & N. Bernstein Ratner (Eds.), The development of language (7th ed., pp. 285–314).

Kwiatkowski, J., & Shriberg, L. (1993). Speech normalization in developmental phonological disorders: A retrospective study of capability-focus theory. Language, Speech, and Hearing Services in Schools, 24, 10–18.

Rvachew, S., & Nowak, M. (2001). The effect of target-selection strategy on phonological learning. Journal of Speech, Language, and Hearing Research, 44, 610–623.

Rvachew, S., Rafaat, S., & Martin, M. (1999). Stimulability, speech perception skills, and the treatment of phonological disorders. American Journal of Speech-Language Pathology, 8, 33–43.

Weiss, A. (2004). The child as agent for change in therapy for phonological disorders. Child Language Teaching and Therapy, 20, 221–244.

2
“The Social Stuff Is Everything”

How Social Differences in Development Impact Treatment for Children With Language Impairment

Bonnie Brinton and Martin Fujiki

Introduction

A number of years ago, we conducted a study looking at the social competence of elementary school-age children with language impairment (LI) (Brinton, Fujiki, Montague, & Hanton, 2000). This work involved detailed observations of the children in a variety of contexts, including cooperative work and playground interactions. Each of the children then participated in a social communication intervention study that was followed by a repeat of the detailed observations conducted before the study began. As a group, these children performed more poorly than their typical peers on almost every measure of social competence we employed. They were less well accepted by peers, had fewer friends, and were rated by teachers as being more withdrawn and less sociable than their typical classmates. As individuals, however, some notable differences were evident. Six of the children were in the same first-grade classroom. Despite the generally poor social performance of the group, one child with LI was one of the most popular children in the class. Conversely, another child was singled out by peers as being the most disliked and feared student in the classroom. Although the children with LI, as a group, were not more aggressive than expected, this particular child was highly aggressive.

As noted, the children diagnosed with LI participated in cooperative work groups that involved two typical peers. In these interactions we found something we did not expect, although in retrospect it now seems rather obvious. The children’s ability to interact effectively in these groups was influenced not only by their language skills but also by their social abilities. The child who showed high levels of aggressive behavior had difficulty working effectively with peers. Over the course of four cooperative learning group sessions, she took materials from the other children, criticized her peers, told them to “shut up,” pushed them out of the way to get materials, and on one occasion hit another child. Needless to say, her interactions during the cooperative learning group were less than satisfying to her peers. Two other children were rated as...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Foreword
• Contributors
• Chapter 1 Perspectives on Individual Differences Affecting Therapeutic Change in Communication Disorders: Prologue
• Chapter 2 “The Social Stuff Is Everything”: How Social Differences in Development Impact Treatment for Children With Language Impairment
• Chapter 3 Individual Differences in Word Learning: Implications for Clinical Practice
• Chapter 4 Individual Differences in Bilingual Children’s Language Competencies: The Case for Spanish and English
• Chapter 5 Perspectives on Individual Differences in Preschool Children With Specific Language Impairment
• Chapter 6 Individual Differences in Underlying Oral Language Competencies Associated With Learning to Read: Implications for Intervention
• Chapter 7 Individual Differences in Intervention Response in Children and Adults With Autism Spectrum Disorders
• Chapter 8 Benefiting From Speech Therapy: The Role of Individual Differences in Treating Children With Speech Sound Disorders
• Chapter 9 Consideration of Individual Differences in Speech Development, Outcome, and Management: Children With Cleft Lip and Palate
• Chapter 10 Uniqueness and Individuality in Stuttering Therapy
• Chapter 11 Individual Differences That Influence Responsiveness to the Lidcombe Program
• Chapter 12 Predictors of Success for Children With Cochlear Implants: The Impact of Individual Differences
• Chapter 13 How Focus on Individual Differences Informs Our Clinical Practice for Individuals With Communication Disorders: A Summary and a Look Ahead: Epilogue
• Author Index
• Subject Index