quality& quality&interven3on&for&cas& healthcare&and ... intevention to...

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Quality Interven3on for CAS

Erin Redle, PhD CCC-‐SLP [email protected]

Quality

•  “: how good or bad something is •  : a characteris3c or feature that someone or something has : something that can be no3ced as a part of a person or thing

•  : a high level of value or excellence” – Merriam Webster (hRp://www.merriam-‐webster.com/dic3onary/quality)

Healthcare and Quality

•  Two landmark reports negated the argument that health care providers did not need scru3ny: – To Err is Human: Building a Safer Health System 1999

– Crossing the Quality Chasm: A New Health System for the 21st Century 2001

•  Ins3tute of Medicine –  hRp://www.asha.org/Publica3ons/leader/2012/120731/Health-‐Care-‐Change-‐Ahead/

Accountable Care Act •  Focus on quality vs. quan3ty •  Among changes

–  Insurers must spend between 80 and 85% of every premium dollar on medical care; if exceed, need to rebate to customers

•  expected to rebate $1.1 billion this year –  Develop a na3onal quality improvement strategy that includes:

•  improve the delivery of health care services •  pa3ent health outcomes •  popula3on health

–  Create processes for the development of quality measures involving input from mul3ple stakeholders and for selec3ng quality measures to be used in repor3ng to

–  Importance of pa3ent-‐reported outcomes 4

Educa3on and Quality

•  No Child Lec Behind – Quality of Educa3on

•  Improve performance •  Scien3fically based research prac3ces in classroom •  Accountability, adequate progress

– Highly Qualified Teachers – Most Qualified Provider

Focus of Quality in Today’s Health Care & Educa3onal Landscapes

•  From the old view of quality – “you know it when you see it” to the new rela+onship between quality and value

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Defining Quality? n  Deming

n  “Measure of how well a product or service matches a need… defined broadly… to include such dimensions as product features, 3meliness, personal interface, reliability, durability, and consistency.” (Langley et al., p. 217)

n  The defini3on of quality depends on the stakeholders and/or consumers

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Stakeholder

•  Stakeholder= anyone who has an interest or a concern

Always Includes:

•  Pa3ents •  Parents •  SLPs •  Payor Source

May Include:

•  Administra3on •  Teachers •  Other team members •  Physicians •  Other referral sources

•  Regulatory sources

What is Quality for Pa3ents, Parents, Payors?

•  Great ques3on! What do parents want? •  Best answer: Ask them

– Some sugges3ons from the literature

•  Payors – That’s easy-‐ they want to NOT pay

What is Quality for SLPs?

•  Also a great ques3on •  What is quality to you?

– Mee3ng pa3ent/family goals –  Improvement in speech – Academic performance

•  How do you get there? – One might argue evidence-‐based prac3ce…

Evidence Based Prac3ce (Dollaghan, 2007)

External Evidence

Internal Evidence (Clinical Exper3se)

Pa3ent Preference

Accurate Diagnosis Selec3ng Interven3ons Implemen3ng Interven3ons Carryover Systems

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Where to Find External Evidence

•  Typical sources – PubMed – Eric – Psych Info – CINHAL

•  ASHA

Resources for Developing Processes

•  ASHA Resources – Prac3ce Portals

•  Evidence Maps – Evidence-‐Based Systema3c Reviews – N-‐CEP Compendium of EBP Guidelines and Systema3c Reviews

– Preferred Prac3ce PaRern Documents

Accurate Diagnosis

•  Not the focus of this presenta3on •  ASHA has new and improved resources, and a few recommenda3ons

•  Important because… – Guide treatment – Differen3al diagnosis – Prognosis – Access treatment

ASHA 2007 Definition

•  Preferred terminology is now Childhood Apraxia of Speech (CAS)

•  Key components of definition: –  Neurological childhood speech sound disorder –  Affects precision and consistency of movements that

effect speech sound production and prosody –  Occurs in the absence of other neuromuscular deficits

(e.g. abnormal reflexes, abnormal tone)

Need to Create the DDx Map 1)  Gather informa3on, create a symptoms list

–  Can be in wri3ng or in the physician's head

2) Lists all possible causes (candidate condi+ons) –  Again, this can be in wri3ng or in the physician's head but must be

done

3) Priori3zes the list by placing the most urgently dangerous possible causes at the top of the list 4) Rule out or treat possible causes, beginning with the most urgently dangerous condi3on and working down the list

–  Rule out-‐ use tests and other scien3fic methods to determine that a candidate candidate condi3on has a clinically negligible probability of being the cause

Possible Causes (Safety) •  Dysarthria (new onset) •  Speech disorder due to hearing loss •  Language Disorder

–  Recep3ve –  Expressive

•  Speech Sound Disorder –  Childhood apraxia of speech –  Phonological disorder –  Ar3cula3on Disorder

•  Other causes –  Compensatory speech strategies –  General motor disorder –  Cogni3ve deficits –  Idiopathic

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•  Clinical Assessment (per ASHA Preferred Prac3ce Guidelines, 2004) –  Relevant case history, including medical status, educa3on, voca3on

and socioeconomic, cultural, and linguis3c backgrounds –  Review of auditory, visual, motor, and cogni3ve status –  Standardized and/or non-‐standardized assessments including

•  Ar3cula3on tests •  Collec3on of spontaneous speech samples

–  Error analysis –  Independent phonemic analysis – Rela3onal phonemic analysis – Observa3on of intelligibility

–  “Assessment may result in the following… Diagnosis of a speech sound disorder, including childhood apraxia of speech.” (ASHA, 2004)

–  Prognosis

SSD Assessment Signs and Symptoms-‐ ASHA (2015)

•  ASHA Technical Report (2007) –  Inconsistent consonant & vowel errors in repeated syllables, words

–  Lengthened or disrupted co-‐ar3culatory transi3ons –  Inappropriate prosody or lexical stress

•  Other s/s –  Vowel distor3ons –  Intrusive schwa –  Limited consonant repertoire –  Other motor deficits –  Groping –  Difficulty with increasing complexity

–  ASHA CAS Technical Report (2007) “Thus, although we use the term CAS for children who are

the focus of the research reviewed in this document, it should be understood that the lack of a gold standard for differen3al diagnosis requires that all such classificatory labels be considered provisional.”

SSD Assessment from ASHA ASHA Diagnosis-‐ Prac3ce Portal (2015)

•  Under 3 very challenging – Comorbidi3es – Typical developmental errors vs. CAS – Co-‐occurring speech & language

•  Differen3al diagnosis – Dynamic assessment – Psychometrics of available assessments may not be sufficient (McCauley & Strand, 2008)

Establishing Local Consensus

•  Establish local consensus •  Within yourself •  Within your department •  Within your system •  Local professionals

•  Clinical guidelines/pathways –  Synthesizes, which aids both transla3on and implementa3on

***Ensures con3nuity of care/Personalized medicine

Decision Matrix Ar$cula$on Phonology CAS

Number of Errors 1 to 2 3 or more 3 or more Intelligibility Fair to good Fair to Poor Poor Errors within Sound Classes Yes or No Yes Yes Errors Across Sound Classes Yes or No Yes Yes

S$mulability Good Fair to Good Fair to Poor Consistent Errors Yes Yes No Vowel Errors No No Yes

Typical Developmental Errors Yes Yes Yes or No

Resistant to Tradi$nal Methods No No Yes

Delayed Speech Onset No Yes or No Yes Impaired Prosody No No Yes

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Personalized Medicine?

•  We have to consider personalized medicine! •  Broadly-‐ tailoring treatment to the individual characteris3cs, needs, and preferences of a pa3ent during all stages of care, including preven3on, diagnosis, treatment, and follow-‐up.

•  Ocen coined “right meds, right pa3ent, right dose, right 3me”

Reducing Variability •  Reduces variability, improving outcomes

–  Pediatric cancer –  Cys3c fibrosis –  Asthma –  Chronic kidney disease (Androes et al., 2004; McDowell, Chatburn, Myers, O'Riordan, & Kercsmar, 1998; Quon & Goss, 2011)

Selec3ng Interven3ons

•  How to do you know which interven3ons to select?

•  Hypothe3cally driven by – Diagnosis – Evidence – Goals

•  Speech? •  Language/Communica3on

Selec3ng Interven3ons

•  ASHA Describes 5 types for speech – Motor Learning – Linguis3c Approaches – Combina3on (motor + linguis3c) – Sensory cueing – Rhythmic/prosodic approaches

•  Also – AAC

Lexical Selec+on

Phonological Encoding

Syllabifica+on/ morphological encoding

Phone+c encoding/ Speech sound maps

Motor ini+a+on

Motor execu+on

Representa3on for “burritos”

/bɚitoz/

/bɚ-i-to-z/

/b-‐ɚ-i-t-o-z

Start the movements

“Burritos”

Feedback

“/trᴧk/”

Bohland et al., 2009

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Motor Learning

•  What is motor learning? – Condi3ons/prac3ce paRerns that support the long term reten3on of a skill and transfer to a new se{ng

– Prac3ce •  acquiring a skill; learning to do something •  E.g. produce an /s/

– Learning •  Retaining and using in new/novel situa3ons •  E.g. using /s/ in new se{ng, context

Motor Practice and Learning (Fitts & Posner, 1967)

•  Cognitive stage •  Associative stage

– Perform and refine skill – Closed loop

•  Autonomous stage – Skill becomes automatic – Open loop

CLOSED LOOP

-  Perception needed

-  Slow

- Allows for precision

OPEN LOOP

- Automatic

- Fast

- “Muscle Memory”

General Terminology

Schema Theory

Initial Conditions Somatosensory System

Motor Command

GOLF SWING

Schemas= memory representation

Recall schema= Initial conditions, execution, outcome

Recognition schema= Initial conditions,

sensory consequence, outcome of movement

Multiple GMP

Maas et al., 2008; Mass et al., 2014

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Specific Approaches

•  Integral S3mula3on (Gildersleeve-‐Neurmann 2007) – Originally proposed by Rosenbeck in the 70s – BoRom-‐up approach – Cueing includes “watch me, listen, do as I do” – Various modali3es, auditory and visual

Specific Approaches

•  Dynamic Tac3le & Temporal Cueing (Strand et al., 2006) –  Integra3on S3mula3on + Motor Learning – Mul3-‐modal cueing – Slowed rate – Responsive; dynamic; what does the child need between trials to support success

– Some eviden3ary support for approach

Motor Learning & CAS •  Edeal & Guildersleeve-‐Neuman (2011)

–  2 sets of targets (n=2); Integral S3mula3on Approach •  1 high (more than 100/15 min session) •  1 moderate (30-‐40/15 min session)

–  BeRer learning for high target •  Maas & Farinella (2012)

–  Random vs. blocked prac3ce (n=4); Dynamic Tac3le and Temporal Cueing Approach; 2 treatment phases

–  1 child= random beRer –  2 children= block=beRer –  1 child= no improvement in either –  Generaliza3on negligible for all

Motor Learning & CAS

•  Maas et al. (2012) – High frequency feedback vs. reduced frequency –  2 children= reduced frequency –  1 child=high frequency; more severe CAS symptoms –  1 child= no gains

•  Strand et al. (2006, 2000) –  Large effect sizes with DTTC 2x/day, 5x/week, 6 weeks (60)

•  Maas et al. (2012) – Modest effects 3x/week, 8weeks (24)

Specific Approaches

•  Rapid Syllable Transi3on (ReST) (Murray et al., 2012; Ballard et al., 2010)

•  Vary lexical stress paRerns in non-‐words – Motor learning included – Large number of targets per session – Reported to be for older children with mild to moderate disorders (Maas et al., 2014)

– Some evidence to support; not always generalized to novel words but tend to con3nue to improve

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ReST

•  Thomas et al., (2014) – 4x/week vs. 2x/week, 3 week – 2x/week s3ll get beRer – S3ll maintain gains – Don’t generalize to related skills as well as 4x/week

Specific Therapy Approaches

Other motor-‐based – Moving Across Syllables (Kirkpatrick et al.) – Easy Does-‐It Apraxia (Downing & Chamberlain) – Easy Does-‐It Apraxia Pre-‐school (Downing & Chamberlain)

Kaufman Speech to Language Protocol (K-‐SLP)

•  Focuses on shaping child's motor-‐speech –  Break words down into simplest components and build back up

–  Build off of what they do have, expand syllable shapes, consonant and vowel repertoires

–  Fade cues –  Errorless learning –  Strong reinforcement – No published research that I am aware of (ASHA, 2015)

Biofeedback

•  Preston (2013), Boyce (2015) – Ultrasound to teach /r/ and other lingual phonemes

– N=4, gains on at least 2 targets – Maintained 2 months

Linguis3c Approaches

•  Hodsen Cycles – Focus on paRerns of produc3on – Typical developmental norms

Phonological Awareness

•  Evidence to support using this in children with CAS

•  Know they are the most at-‐risk for later language and reading disorders

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Research Outcomes

•  Moriarity & Gillon (2006) – Phonological awareness approaches for

•  Speech production •  Phonological awareness •  Printed word decoding skills

– 3, 45 minute sessions for 3 weeks – 2 of 3 with significant gains for speech and

PA, able to generalize

PROMPT •  Prompts for Restructuring Oral Muscular Phone3c Targets •  Involves kinesthe3c and tac3le cues

–  hypothesized to provide greater input the motor system for both feedback and feed forward mechanisms

•  PROMT Cer3fica3on approach to provide this type of treatment

–  intensive (3 days) and expensive ($650 per person) –  Some children may not tolerate the therapist placing his/her hands on the child's face or ar3culators

Research for PROMPT The website for the PROMPT ins3tute lists and describes research studies, including 2 recently published studies demonstra3ng the efficacy of PROMPT therapy

–  Kadis and colleagues (2014) •  compared to a control group of children with typical speech development (and not receiving any interven3on)

•  children with CAS demonstrated more cor3cal thinning (desired outcome) than the control group acer 10 weeks

– Dale and Hayden (2013) –  (n=4) –  mul3-‐modality cueing associated with PROMPT = greater gains in measures of motor control, untreated word probes when mul3-‐modality cues used

Touch Cues •  Touch Cues (Bashir et al., 1984)

–  What are touch cues? –  Why touch cues? –  Be consistent for each session and have families use

same touch cues

–  Easy Does It Preschool (e.g. “popping sound” p) –  Known to benefit

•  Early word learning (Capone & McGregor, 2005 •  adults with dysarthria (Garcia & Cannito, 1996)

Sign and Gestures

•  Frequently recommend use of sign and/or gestures

•  What is the goal of the? •  Iconic gestures •  Long term literacy

•  Newmeyer et al., 2007 – Differences vs. typicals!

So what does this mean?

•  Can we select the BEST treatment?

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Implemen3ng Interven3ons

•  Not something we talk about •  Necessary •  Implementa3on of selected treatments

•  Process measures •  Influenced by co-‐occurring condi3ons

! Artic& Phonology& CAS&Target&Selection& "stimulability!

"developmental!sequence!

"stimulability!"patterns!of!phonemes!!!

"stimulability!"syllable!complexity!"functional!!!!!communication!!

Auditory&Awareness&

"discrimination!! "discrimination!"enhanced!auditory!input!

"discrimination!"enhanced!auditory!input!

Production&Practice& production!of!individual!phonemes!

Functional!communication;!production!of!patterns/classes!

Functional!!communication;!!motor!learning!

Feedback& feedback!of!correct!vs.!incorrect!production,!fading!out!cueing,!and!self"monitoring!as!able!

Target&Progression& mastery!of!individual!phoneme/!pre"sent!levels!of!phonemes!!

pre"set!cycles!of!target!phonemes/patterns,!regardless!of!accuracy!

Motor!based!progression!through!targeted!syllable!shapes!and!complexity!

Session&Structure& primarily!drill,!moving!towards!carryover!

Auditory!input/bombardment,!!drill,!!structured!carryover!activities,!pre"literacy!

Pre"literacy/auditory!bombardment,!drill,!structured!carryover!tasks!

Home&Program& individualized!to!patient!and!goals;!maximize!correct!trials!!

Quality Components

•  Target Selec3on •  Produc3on Prac3ce •  Feedback •  Target Progression •  Session Structure

Quality Components

•  Target Selec3on •  Produc3on Prac3ce •  Feedback •  Target Progression •  Auditory Awareness •  Session Structure

General Considera3ons for Therapy Approaches

•  Task specificity (Clark, 2003) •  Target complexity

•  BoRom-‐up •  Top-‐down

Target Selec3on •  S3mulability •  Developmental Sequence •  PaRerns •  Syllable Complexity •  Target Selec3on Complexity

–  Simple –  Complex

•  Func3onal Communica3on •  Frequency in Child’s Produc3on •  Parent Input

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What Should We Implement?

•  Motor learning – Distributed

•  Vary in how I do this – High volume

Implement Quan3ty

•  Structure Session – Start with targeted data capture – 50-‐100 trials

•  Under 5 minutes –usually under 3

– Use collec3on tools to help

Implement in Drill

•  Word lists – Random vs blocked – How to do this

Implement Quan3ty

•  How many trials are enough? •  Edeal and Gildersleeve-‐Neumann (2011)

– Over 100/15 min vs. 30-‐40/15 min

Implement Quan3ty

•  Tally during session – Apps

•  Metronome – BPM

•  Vary reinforcement schedule to increase produc3ons/aRempts

Implement Quan3ty

•  Play games with loaded carrier phrases – E.g. Guess who – /ch/

• Which one do you choose? •  Do you choose _____ or ______. •  My choice is ___.

– /th/ •  I think your person has ______. •  No, I do not think my person has ______.

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Quality Components

•  Target Selec3on •  Produc3on Prac3ce •  Feedback •  Target Progression •  Auditory Awareness •  Session Structure

Feedback

•  Monitor yourself!!! – Videotape

•  Visual tallys with + and – •  Balance language and praise effort •  Chips •  Apps

– Which team

How Do You Know When to Move On?

•  Can they prac3ce on own outside of therapy CONSISTENTLY correct???

•  More of a challenge with CAS

Quality Components

•  Target Selec3on •  Produc3on Prac3ce •  Feedback •  Target Progression •  Auditory/Phonological Awareness

Auditory Awareness

•  Discrimina3on •  Enhanced Auditory Input:

– Auditory Bombardment – Amplified Listening – Phonological/Phonemic Awareness – Naturalis3c Experiences

Discrimina3on

•  Can you tell the difference between sounds? •  Remember visual cues and how they may help vs. actual discrimina3on

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Auditory Input

•  Auditory Bombardment •  Amplified Listening

Phonological/Phonemic Awareness

Chris3na Yeager Pela3, PhD CCC-‐SLP

Why is Literacy Affected?

Stored phonological representation

Speech Sound Maps/Phone3c Representa3on

Stored phonological representa3on

Phone3c awareness/ phonemic awareness

Literacy

Vocabulary Language


Dependent


Dependent

Phonological Awareness Continuum of Development


Syllable Awareness

Rhyme Awareness

Beginning Sound

Awareness

Phonemic Awareness

SYLLABLE LEVEL SOUND LEVEL

Pentimonti (2012)

Carryover Systems •  How to facilitate prac3ce with the family

– Make it func3onal –  Relate to something they relate to

•  Sports, instruments – Auditory

•  Sounds of the week – Daily Prac3ce

•  Bathtub!! Before meals x3 •  Ge{ng into the car

–  Set up tex3ng/emails •  Evidence from chronic condi3ons (asthma, migraine)