Testing Phonological Interventions for Francophone Children: An RCT – with Susan Rvachew
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Testing Phonological Interventions for Francophone Children: An RCT – with Susan Rvachew

The way that we think about speech disorders
has changed quite a lot in the last few decades. Initially, I think, in our profession we thought
about speech sound disorders in terms of the surface characteristics of the children’s
speech. So, they are not speaking very clearly, when we teach them, we need to go in and teach
them how to articulate sounds more clearly. So there has been a lot of focus on the surface
characteristics of the child’s speech. And then, more recently, we’ve come to understand
that there’s a lot more going on down underneath your iceberg, and a lot of research of what
we call levels of representation. So I had done some modeling of how all these
levels of representation were linked together so the children’s knowledge of vocabulary,
their perception of speech sounds, their phonological awareness, and their articulatory accuracy
— so their ability to say speech sounds accurately — and looking at how that related over time
to their ability to learn to read. I had this model of how these different levels
of representation related to each other, but modeling is not — it’s a way to develop hypotheses
about causal relationships, but you can’t exactly make claims about causal relationships.
So I had wanted to do some intervention trials so that I could be more clear about what the
causal relationships were. At the point where I got where I said, okay I’m ready to do some
intervention trials to test these hypotheses more clearly, at the same time the local hospital
came and they said, “We’re a bit distressed, we have to cut our, we have to ration our
service quite severely and go back to only six weeks of intervention.” There is no clear research on this, there
are no randomized controlled trials or anything, but there is a lot of descriptive research,
and that research suggests you can’t get a very good outcome in only six weeks. You might
be able to do some good, but you’re not going to be able to have really measurable outcomes
in terms of speech intelligibility or functional outcomes. So they said, “What should we do?” So Françoise had just started in my lab as
a doctoral student, but she had actually been working at the same hospital as the speech
language pathologists for quite a few years, and she had been treating their Francophone
patients. So she had a lot of questions about how to do speech therapy better, but also
how to treat the French-speaking children because there wasn’t a lot of research on
that, and they were treating them as if they were English-speaking children — not a good
idea. So she had a lot of questions, too. We had designed an intervention for them that
was actually 12 weeks long, but the components were very low cost. So we thought, you can
do this for almost as low cost as a 6-week intervention with a speech pathologist. So
we designed this intervention so it would solve the problem for the hospital: How can
you provide a lower-cost intervention when there are resource constraints, but also how
can we study the relationship between all these variables — vocabulary, phonological
awareness, perceptual knowledge, and articulation learning — in these kids. And we’ll get the
theory piece and the more pragmatic questions all in one study. And — Do it in French!
Which was huge, a lot of questions all at one time. In retrospect, we should not have
been surprised by this, but the biggest surprise is that French is not English. We had to develop all of the outcome measures
for the research ourselves. The errors that children make in French are very different
from the errors that children make in English. The whole time that we were doing the study
we were always just running to keep up, running to keep up. Because we would start making
a test for phonological awareness or something, then we’re like, “Oops, that’s wrong, we have
to start again.” Because, ridiculously — we know at an intellectual level that French
is not English. But we didn’t really quite understand the implications of that until
we started working with those children. People are always saying, “You can’t just translate
things from English to Spanish” — or whatever language you’re working in. But oh man, in
that ever true. So, what we had done with this study is that
we mixed and matched these different components. So every child received an intervention that
on the surface of it looked kind of the same. They received six weeks of individual therapy.
Then in the second six week, this was the low-cost part, the children when for phonological
awareness intervention in small groups, which is something that’s very low cost because
almost anybody can do phonological awareness therapy. You could have high school students
do it as volunteers or speech communication disorders assistants, anybody. So they did
these little small group phonological awareness intervention. And while the kids were doing
that, we brought the parents in as groups, and we taught them to do an intervention at
home. So we had these three components. But the
components had different flavors. The individual intervention could be targeting articulation
accuracy in the standard way — very standard, traditional articulation therapy — which
we called our output-oriented intervention. Or it was focused on listening to speech — a
very input-oriented intervention. The children were presented with a lot of high-quality
speech models by listening to stories that had the sounds that they were being taught.
Or they would listen to speech and make judgments about the speech. So the clinician would present
correct and incorrect versions of the word, and the child would have to say if it was
the right one or the wrong one. They wouldn’t have to say that, but there would be little
games that would do different things if the word was said correctly or incorrectly. And
then, at some point towards the end, like the fifth or sixth session, if the child would
choose to say some of the words, then we’d say, okay, we’ll do some minimal pairs production
therapy and we would do a little bit of production therapy. But there was almost no speech practice,
it was nearly all through the listening modality. The parents would watch these interventions,
so they would see the speech pathologists implementing them. Then in the second 6 weeks, the parent intervention
had two different flavors. In one case, we would teach the parents how to do standard,
traditional articulation therapy. Or we would teach the parents how to read to their children
at home, using what’s called a dialogic reading approach — read to the children, ask questions
while you’re reading. So, we had these two different kinds of parent interventions. And then we mixed and matched these all up
— so that we ended up with four different types of interventions. Two of them are coherent,
in one case the parent is teaching their child how to articulate sounds accurately, and that
is matched up with what the speech therapist is doing. So you have a nice, coherent progression
of therapy. In the other case, the dialogic reading parent intervention is nicely coherently
paired with that listening intervention that the speech therapist was doing. Because they
are all very similar kinds of procedures. Then we had two possibilities where they are
mixed up, so that they’re not coherent. So we found out a few things that are important.
All of the interventions were more effective than having no intervention. Because we had
this other waitlist control group. So that’s good. If you do therapy with kids, they get
better. The really — I think people might find it
surprising — is that the children who had the intervention that was nearly all listening
made just as much gain for articulation accuracy as did the children whose intervention was
totally 100% of the time focused on articulation accuracy. And both of those groups with the
coherent match ups of the parent intervention and the individual therapy, they also made
equivalent gains for phonological awareness. Then they two interventions in the middle
that were all mixed and matched or not very coherent — they did not make as good gains. So, I think there’s some important messages
there. The thing is, in some ways our results are
similar to some things that other people have found. So, Anne Hesketh in the United Kingdom,
she also found that an intervention that is focused on kind of the metalinguistic aspects
of speech can be as effective as your traditional articulation therapy. She found that out. When speech pathologists see this, they say,
“Well, this intervention works, that intervention works, that intervention works. It doesn’t
matter what I do. I can do any therapy, it’s all going to be good. I can just pick whatever
I’m comfortable with, whatever the parent is comfortable with, it doesn’t matter what
I do, it’s all going to work.” I think that that’s actually the wrong message.
It does make a difference what you do. Because what we found is that how we combine these
components mattered. I think the reason that it matters is that intensity matters. When
we’re helping children learn how to speak clearly, there are all these different levels
of representation that are involved. There’s perceptual level, there’s the lexical level,
there’s the articulatory level, and so on. And you have to tackle at least one of these
levels with enough intensity that the child learns. And if they get learning at one of
those levels, you will get generalization to the other levels. But you have to at least
get learning at one level, and you have to have enough intensity at that level to get
that learning. And that’s why it was so important for our interventions to be coherent — that
the speech therapist and the parent were working together and tackling the same levels of representation. Which is not the same as somebody saying,
“Well, I can be eclectic, I can do anything. I can pick this therapy or that, or this procedure
or that. Because actually the decisions that you make and the way that you choose your
procedures, and the way that you combine them together makes a difference. It really makes a difference what you do.
You could choose procedures, combine them together in a coherent way, and have a good
outcome. You could choose procedures, combine them together in a non-coherent way, implement
them badly, etc. and not have a good outcome. And I think this is actually good message
for speech pathologists: We’re professionals, we’re very highly trained. It makes a difference
what we do.

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