The Effectiveness of an Indirect Treatment Approach: Symbols versus Signs for Facilitating Speech Ou

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The Effectiveness of an Indirect Treatment
Approach Symbols versus Signs for Facilitating
Speech Output in a Late Talker Emily R. Baumann,
M.S. Cynthia J. Cress, Ph.D. University of
NebraskaLincoln Poster presented at the ASHA
Conference November, 2008, Chicago, IL.
Abstract Little research has explored the impact
of AAC in deliberately facilitating speech
development. This study explored the effects of
a modeling approach for AAC (i.e., sign language,
picture symbols) to indirectly improve speech
output in a child with motor speech involvement
and expressive language delays. Results indicated
that both strategies, sign and picture symbols,
improved speech output without direct prompts to
speak during intervention and maintenance, but
that the two strategies did not differ from one
another. The improvements associated with both
strategies suggest that AAC is a viable
intervention option to target improved speech in
children with expressive delays.

• Background
• Using direct prompting or modeling treatment that
  relies on imitation may not be effective for
  children with limited initiation or verbal
  imitation skills (Strand MacCauley, 1999).
• Children with expressive difficulties who use AAC
  maintain or increase their use of speech during
  AAC interactions (Millar, Light, Schlosser,
  2000 Glennen McPartland, 1999).
• AAC may indirectly support speech by reducing
  childrens frustration and physical exertion, so
  that they are more capable of coordinating the
  complex neuromuscular processes of speech
  (Blischak, Lombardino, Dyson, 2003 Remington
  Clarke, 1996).
• Research Questions
• 1. Will the participant reach criterion for
  communication initiations with picture symbols?
• 2. Will the participant reach criterion for
  communication initiations with sign language?
• 3. Will the participant have fewer trials to
  criterion for communication with picture symbols
  versus signs?
• 4. Will the participant increase the frequency
  of speech output in target words after they are
  introduced in picture symbols or signs?
• 5. Will the participant have fewer trials to
  criterion for spoken words when introduced
  through picture symbols versus sign intervention?
• 6. Will the participant generalize spoken
  productions between phonetically matched words
  more effectively for picture symbols versus sign
  language instructions?
• It was expected that AAC (pictures or signs)
  would facilitate communication as well as speech
  output in a young child who was a late talker.
• It was expected that the participant would
  increase his use of target words once they were
  communicated in pictures or signs.
• It was also expected that picture symbol
  intervention would be associated with faster
  acquisition and generalization of target spoken
  words than sign intervention because of the
  potential for nontransient self-cueing with a
  visual symbol.

• Procedures
• Treatment goals a) systematically encourage D to
  use picture symbols and signs to communicate, and
  b) model speech associated with those symbols and
  signs to indirectly facilitate increased speech
  output.
• Treatment strategy Modeling strategies from
  Milieu Teaching (Kaiser, 1993) were embedded into
  Prelinguistic Milieu Teaching (PMT) play contexts
  for this study (Yoder Warren, 1998).
• Treatment targets Three treatment groups of six
  words each (3 pairs of words matched for target
  phonemes), randomly ordered by treatment group
• Sign or symbol presentation of the word with
  simultaneous verbal mapping of the word was
  embedded into a play scheme, with a naturally
  occurring opportunity for the child to repeat
  that play scheme.
• If D did not produce the target play scheme at
  that opportunity with a sign, symbol touch, or
  spoken word, he was prompted to Show me X . D
  was not prompted to Say X in any experimental
  phase.
• Criterion for successfully learning a target word
  was production of the target word through one of
  the assessed modalities in 6 of 8 opportunities.
• Video recordings of the interaction were scored
  for number of opportunities in which D produced a
  target word through speech, sign, or symbol
  touch, as well as treatment integrity by the
  experimenter. Percent agreement was 84 for Ds
  behaviors and 77 for the experimenters
  behaviors. Cohen's Kappa was .69 for Ds
  behaviors and .65 for the experimenters
  behaviors.

• Discussion
• Results indicated that both strategies, sign and
  picture symbols, improved speech output without
  direct prompts to speak during intervention and
  generalization, but that the two strategies did
  not differ from one another.
• The improvements associated with both strategies
  suggest that AAC is a viable intervention option
  to target improved speech in children with
  expressive delays.
• The indirect AAC model had a clear and rapid
  effect on the childs spoken word productions,
  although Ds productions of symbols and signs as
  mediators to speech were not learned to criterion
  as predicted.
• Clinical Implications
• AAC can be an effective strategy for indirectly
  prompting spoken productions without explicitly
  directing the childs attention to their speech
  (Say X).
• Providing access to visual strategy to express
  the word may facilitate childrens speech
  production even if the child does not use the AAC
  strategy to communicate a message.
• AAC supports and does not interfere with spoken
  intervention goals for children with expressive
  delays, even for children with age-appropriate
  motor, language or cognitive skills

• References
• Blishak, D. M., Lombardino, L. J., Dyson, A. T.
  (2003). Use of speech-generating devices In
  support of natural speech. Augmentative and
  Alternative Communication, 19, 29-35.
• Glennen, S., McPartland, L. (1999). But wont
  they stop talking? Speech development after AAC
  implementation. Presentation at the American
  Speech-Language-Hearing Association convention,
  San Francisco, CA.
• Kaiser, A. (1993). Parent-implemented language
  intervention An environmental system
  perspective. In A. Kaiser D. Gray (Eds.),
  Enhancing children's communication Research
  foundations for intervention Vol. 2 (pp. 63-84).
  Baltimore Brookes.
• Millar, D., Light, J., Schlosser R. (2006). The
  impact of augmentative and alternative
  communication on the speech production of
  individuals with developmental disabilities A
  research review. Journal of Speech, Language, and
  Hearing Research, 49, 248-264
• Remington, B., Clarke, S. (1996). Alternative
  and augmentative systems of communication for
  children with Downs syndrome. In J. Rondal, J.
  Perea, L. Nadel (Eds.), Down syndrome
  Psychological, psychobiological and
  socio-educational perspectives. London Whurr
• Strand, E. A., McCauley, R. J. (1999).
  Assessment procedures for treatment planning in
  children with phonologic and motor speech
  disorders. In A. J. Caruso, E. A. Strand
  (Eds.), Clinical management of motor speech
  disorders in children (pp. 73-107). New York
  Thieme
• Yoder, P. J., Warren, S. F. (1998). Maternal
  responsivity predicts the prelinguistic
  communication intervention that facilitates
  generalized intentional communication. Journal of
  Speech, Language, and Hearing Research, 41,
  1207-1219

Figure 1. Percentage of Play Opportunities in
which Target Spoken Words were Produced
Figure 2. Percentage of Play Prompting
Opportunities at which Target Symbols and Signs
were Produced

• Results
• Symbol and Sign Use (Research questions 1, 2, and
  3)
• Baseline
• Participant did not respond to prompt to use
  symbols or signs for target words
• Treatment
• Participant did not meet criteria (75) for
  either symbols or signs
• Able to match all symbols and signs with
  associated objects and actions during play
• Given prompted play opportunities, participants
  symbol or sign productions ranged between 0-33
• Maintenance
• Spontaneous use of symbols and signs did not
  occur
• Spoken Productions
• Baseline
• Participant did not speak target words during
  symbol intervention, participant produced target
  word dog from the sign group once during two
  sessions
• Treatment
• Quickly demonstrated production of target words
  to criteria, shown across each of the three sets
  of target words
• Sign treatment took one additional session for
  spoken words to reach criterion other treated
  word groups reached criterion concurrently - no
  differences between AAC intervention modalities
• Maintenance
• Continued to produce spoken target words in both
  symbol and sign groups with minimal prompts not
  at same level as treatment
• Spontaneous spoken productions of target words
  ranged between 0-66 of opportunities

• Participant
• 3.4-year-old boy with expressive language delays
  (D)
• Communicated through signs, gestures,
  vocalizations, and speech approximations.
• D had 60 spoken words or approximations in his
  repertoire, frequently unintelligible
• D often used conventional sign language and signs
  that he and his family had made up.
•  Pre-treatment assessment using formal and
  informal measures showed
• - significant expressive language delays (5tile
  on Battelle for age)
• - difficulty producing speech sounds,
• - inconsistent speech sound error productions,
• - poor ability to imitate speech (task refusal
  for verbal imitation)
• - receptive language skills above normal limits
  (99tile on Battelle for age)