Efficacy of the SATPAC Approach for remediating persistent /s/ errors Stephen Sacks, M.A., CCC-SLP SATPAC Speech, Fresno, CA & Peter Flipsen Jr., Ph.D., S-LP(C), CCC-SLP Pacific University, Forest Grove, OR Disclosure-Stephen Sacks Financial: • • • Owner and Developer of SATPAC Speech and receives royalty payments. Receives royalty payments from Marshalla Speech & Language. Consultant for the Bureau of Education & Research and receives honorarium compensation. Nonfinancial: • Board Member of the Oral Motor Institute Disclosure – Peter Flipsen Jr. • No financial or non-financial conflicts to report Outline • What are persistent speech errors? • Current approaches to treatment • The SATPAC Approach • Study design and results • Discussion • Questions Persistent Speech Errors • Frequently encountered on school caseloads • • Mild distortions of /s, z, r, l/. Hard to justify more than limited treatment. • • Minimal impact on intelligibility? Usually little impact on academics? • Have proven difficult to correct with traditional methods • Ingrained bad habits? Management Options? • • Traditional therapy but more Tx time? • Unlikely; no more time available Ignore? • • Probably not a good idea. Negative peer reactions • • Reduced adult expectations • • See Crowe Hall (1991), Madison & Gerlitz (1991), & Silverman & Paulus (1989). See Overby et al. (2007) & Lass et al. (1988) Possible increased risk of emotional and behavioral problems • See Beitchman et al. (1986) Management Options? • • Modify the therapy sequence? • • Concurrent task sequencing (Skelton, 2004). Relatively unstudied so far. Modify feedback? • • Electropalatography? • Still somewhat expensive and requires considerable training Spectrograms? Ultrasound? Speech Buddies? • All relatively unstudied. The SATPAC Approach • • Systematic Articulation Training Program Accessing Computers. • www.satpac.com Combines the use of: • • • 1. Non-words based on facilitating contexts (with transition to real words) • • Helps get around ingrained bad habits, and Takes advantage of coarticulation 2. Computer generated stimulus lists • • Progressively move through ever more challenging contexts, and Avoid other error sounds that may interfere or are not in the student’s repertoire. 3. Practice at normal (or near-normal) speaking rate • • • Avoids odd prosody, and Promotes normal motor planning, and Promotes generalization from an early stage Multimodality Approach to /s/ Remediation Use of /t/ Sound (and other unusual things) • /s/ is not mentioned • Mouth is open which is not normal for /t/ (but only temporarily) Use of an Auditory Visual Model to Contrast Correct/Incorrect “EET” Production Use an Applicator Stick for Visual Tactile Feedback (EE-point) Tongue Tip Pointing for Visual, Tactile-Kinesthetic Feedback page 33 Tongue Pops for Visual, Tactile-Kinesthetic Feedback EE Point Tip for Visual, Tactile-Kinesthetic Feedback Tongue, Lips and Jaw Differentiation EET for Auditory, Tactile-Kinesthetic Feedback KF Second Session EETS for Auditory, Tactile-Kinesthetic Feedback The French /t/ page35 Systematic Articulation Training Program Accessing Computers SATPAC Procedure ChecklistEstablishment Phase Practice Phase-Criteria for Completion 80%+ accuracy on the first 4 lists @ 140 BPM 80%+ accuracy on List 5 at a normal conversational rate with no slowing down on the target sound Practice Phase Lists 1 and 2 Practice Phase-Lists 1 and 2 Practice Phase Lists 3 and 4 Practice Phase-Lists 3 and 4 Practice Phase List 5 Contrastive Stress Practice Phase-List 5 Generalization/Transfer Phase Generalization/Transfer Phase TALLY COUNTER Generalization/Transfer Phase Phrases Generalization/Transfer Phase Short Sentences Generalization/Transfer Phase Sentences Generalization/Transfer Phase Short Contrasts Generalization/Transfer Phase Contrasts Current Study • • • • • • Sacks, Flipsen, & Neils-Strunjas (in press) revealed significant improvement in persistent /s/ with the SATPAC approach when administered by the first author (who is also the program designer). Attempting to replicate using other clinicians trained in the approach. Between groups alternating treatments design Measure baseline performance, treat group 1 while group 2 waits. Then measure performance on both and treat group 2 while group 1 waits Measure both groups again and re-measure after an additional 12 weeks to check for maintenance. Participants • 13 children recruited from two public schools. • 7 males; 6 females – initial age 6;11 to 8;8 (Mean = 7;11) • No previous speech or language treatment rec’d. • 8/13 monolingual English speakers; 5/13 bilingual but English dominant. • All presented with either dentalized or interdental versions of /s,z/ • • Dentalized = sounds distorted Interdental = may or may not sound distorted but looks atypical Progress Measures • Measured production accuracy of /s/ in: • • 1. CPAC /s/ probe (words and sentences; Secord & Shine), and 2. conversational speech • Allowed for measurement of performance in the structured context of therapy and to monitor generalization. CPAC /s/ Probe Treatment Plan • • Participants randomly assigned to two groups • • • Group 1 (n=7) included 5M; 2 F; ranged in age from 6;11 to 8;8 Group 2 (n=6) included 2M; 4 F; ranged in age from 7;5 to 8;3 No significant age difference Individual treatment sessions by 2 clinicians who were trained on the approach • • • Focus only on /s/ Each clinician saw about half the children in each group 12 weeks of treatment; 1 X 15 minute session per week = 180 minutes of total treatment. • 180 total minutes of therapy. Observations about Treatment • Variation between SLPs • One SLP administered the program more faithfully than the other and consequently showed significantly better results (7/8 90%+ in conversation vs. 2/5 90%+ when study was completed). • All completed Tx but 3 (2 from Group 1) moved at the end of the school year and were no longer available at follow-up. • Net result: missing any follow-up data for 1 participant. Group Results (CPAC probe) Change in CPAC /s/ Accuracy over Time Tx Group 1 2 90 80 CPAC Mn % 70 60 50 40 30 20 10 0 Tx Group Time period 1 2 1 1 2 2 1 2 3 1 2 4 Group Results (Conversational Speech) Change in Conversational /s/ Accuracy over Time Tx Group 1 2 70 60 Conv Mn % 50 40 30 20 10 0 Tx Group Time period 1 2 1 1 2 2 1 2 3 1 2 4 Individual Results • Not all participants achieved the same results • 6/12 (3 from each group) followed an “ideal” pattern. Saw change on both measures immediately after therapy and it was maintained at follow-up. % Correct /s/ over Time Participant = JH Participant = AG Y-Data % Correct /s/ over Time Y-Data • time time Individual Results • • 1/12 showed immediate change after treatment on CPAC probe but no generalization to conversation until follow-up. 1/12 showed gradual change over time on CPAC probe but no change in conversation until 24 weeks posttreatment. % Correct /s/ over Time % Correct /s/ over Time Participant = PJ Participant = AS Y-Data Y-Data • “Delayed” generalization? time time Individual Results • At least one participant showed gradual improvement to acceptable levels by initial follow-up but regressed at 24 week follow-up % Correct /s/ over Time Y-Data Participant = TT time Individual Results • 3/12 participants showed little or no change in one or both measures. % Correct /s/ over Time Participant = EL Participant = SL Y-Data Y-Data % Correct /s/ over Time time time % Correct /s/ over Time Y-Data Participant = EP time Overall Results and Conclusions • • Group results show obvious effects for both the CPAC probe and conversational speech. Individual results showed obvious signs of improvement for 8/12 participants to acceptable levels of performance on both measures. • • Doesn’t work for everyone. With a relatively short treatment period (12 weeks) and relatively brief sessions (15 minutes per week), the SATPAC Approach appeared to be effective at correcting persistent /s/ errors. Future Directions • Need to determine efficacy with other errors (/r/, /l/). • Need to evaluate whether each component is absolutely necessary. • • E.g., are the specific “establishment” procedures necessary or can any technique to establish good /s/ work? E.g., how crucial are the nonsense stimuli? • Need to determine why some don’t respond to the therapy. Questions?