A review of Plural Publishing’s “Here’s How…” Series

Maria L. Munoz, PhD, CCC-SLP
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Today I received an e-mail asking if I could recommend anything comparable to the Recipe SLP books that addresses treatments for children. So, I decided it was a good day for a review. I should point out that there is a conflict of interest since I publish how-to books. Though it feels a bit like comparing a note I write to a friend to Facebook!

The closest thing I’ve found is Plural Publishing’s “Here’s how…” series. I have skimmed through most of the 8 books in the series and have in front of me “Here’s How to Do Stuttering Therapy” and “Here’s How to Do Early Intervention for Speech and Language: Empowering Parents.” Other topics include dementia, autism, apraxia of speech, speech and language learning, and core treatment skills. The price of each book ranges from about $60-$90.

My general impression of the series is that the books vary greatly in regards to how many pages they devote specifically to treatment.   The disorder oriented books generally provide an overview of the communication impairment and assessment practices which are foundational to treatment planning. I noted in some books that the overview accounts for the bulk of the book. However, HHTD Stuttering Therapy covers treatment planning and implementation more thoroughly than some of the other books in the series. Author Gary J. Rentschler overviews treatment for children separately from adults/adolescents as their needs are different.  He guides readers through the process of clinical decision making. Dr. Retschler provides sample lesson plans and case examples to assist the reader in applying the information.

The general intervention books, such as HHTD Early Intervention for Speech and Language: Empowering Parents by Karyn Lewis Searcy, are specifically dedicated to treatment planning and implementation. Ms. Searcy provides an overview of early intervention, techniques to help parents facilitate language, and issues related to documentation. I appreciated that Ms. Searcy views both the child and the parents as learners and teaches the reader to do the same. Tables, figures, and case examples are used effectively to provide instructions, illustration, and application for the reader.

Of the books in the series I looked at, I think these two books address treatment most extensively. Since they are not designed to be an in depth look at any single treatment, the descriptions of some treatment approaches are relatively brief which may leave practitioners with questions regarding facilitating use of the strategy and and managing any challenges.

Do you have a go to how-to book you can recommend?


Considering Domains of Treatment vs. Outcomes

Maria L. Munoz, Ph.D., CCC-SLP
Founder and Contributing Author, Recipe SLP

Over the course of the year I will periodically blog about ideas and topics that caught my attention at the 2014 ASHA convention.  I don’t take a lot of notes at convention, instead I focus on getting enough information so that I can do some digging on my own. What more can I learn about this topic that can influence my thinking and clinical practice?

The Session:  Living With Aphasia: Framework for Outcome Measurement (A‐FROM) Presenters: Aura Kagan, Nina Simmons-Macki, Mary, Boyle, Roberta Elman, Kathryn Shelley

A-FROM is a model of aphasia assessment and outcome measures built around the framework established in the World Health Organization International Classification of Functioning and a social approach to aphasia (see Kagan, et. al 2006, Simmons-Mackie, et al. 2008, and a summary of Kagan et al., 2008 ).

The ICF identifies four domains of health status: body functions and structures (BFS; e.g. language, cognition, speech), activities and participation (A&P; what we do with language, etc), environmental modifications (EM), and personal factors (PF).

Simply put, the premise of the A-FROM model is that language impairment, which is what we most often measure, is only one of a number of factors the we should consider when assessing aphasia. We must consider social functioning, supports and hindrances in the environment, and personal factors unique to the individual to identify the impact of aphasia on the individual and the anticipated treatment outcomes. The model seeks to capture how these areas intersect and the impact on the patient as a unique, whole, and social being.

I teach the WHO-ICF and A-FROM to my students so I’m familiar with the models. What was new to me was the importance of distinguishing the ICF domain(s) targeted by the treatment from the ICF domain(s) of the anticipated treatment outcomes. So, why is this distinction important? I’ll use Semantic Feature Analysis (SFA) as an example.

Semantic Feature Analysis (a treatment that uses features to increase activation of, and access to, target words), as originally designed, is a BFS treatment (it seeks to restore lexical access).  If I am looking for BFS outcomes then I want to to see how the improvement generalizes to untrained words. My choice of stimuli is guided by words I think will facilitate generalized improvement in language. If I want to facilitate A&P outcomes, I might select stimuli from a set of functional words; in this case the treatment is BFS (restoring access to these words) but the outcome is both BFS and A&P. I can also modify SFA to target A&P in treatment method and outcome by using it to teach the patient circumlocution as a compensatory strategy for anomia. In this case, the purpose of SFA is not to restore lexical access (BFS) but rather to teach the patient a way to bypass the anomia to improve communicate effectiveness (A&P).

In the past, I have worked with students on how to think about the ICF domain of the treatment as an initial step in beginning to understand what the treatment is intended to do. Differentiating the ICF of the treatment outcomes will help clarify what the treatment is intended to do, how to structure the treatment to meet those goals, and selecting ways to measure the outcomes.




Recipe SLP price increase

We’re excited by all the positive feedback we’re getting about the Recipe SLP books. More are coming soon! We wanted to let everyone know that, due to a change in international tax law, we will be raising the prices of our books in the next few days.  This is the last chance to buy at the original price.  You can find our books at: Amazon, pdf’s and other formats can be found at Smashwords, iBooks, and B&N.


The Cost of Evidence-based Practice

Maria L. Munoz, PhD, CCC-SLP           www.recipeslp.com

I was writing a paper for a journal that was new to me.  I wanted to familiarize myself with the writing style so I searched for the journal online. I quickly learned it would cost me $40 to download each article and over $100 to purchase the whole issue. Since I have a university affiliation I was able to access the article at no cost to me but it got me thinking about the cost of evidence-based practice.

I must confess that my first thoughts were rather selfish, as I don’t see any of this money but could really use it.  The production and review of scientific articles is conducted primarily by the volunteer efforts of the scientific community.  We do this to disseminate our work, support the publication of high quality work, and advance scientific inquiry. For most of us, our jobs require us to publish regularly. Our most tangible reward is continued job security.

My next thought was for speech-language pathologists who do not have a university affiliation.  How do they gain access to evidence not published in ASHA journals? My guess is that they don’t. Evidence-based practice has costs associated with it in both time and money.  Finding time to formulate a clinical question and conduct a literature search to make treatment decisions for a particular client when productivity is 80-90% is incredibly difficult if not impossible.  Additionally, the costs of individual articles are prohibitive. Fully understanding the evidence for a particular treatment may take integrating information across a number of articles, which costs both time and money.

So what is a clinician to do?  Here are a few suggestions…

  • Develop a corpus of evidence-based treatments you can use across a number of clients. The treatments currently available as Recipe SLP titles (Response Elaboration Training, Semantic Feature Analysis, and Reducing Aphasic Perseveration) are ones that I use routinely with clients and can modify to use with a variety of aphasia types and severities.
  • Identify sources that have summarized the evidence for you.  Recipe SLP titles summarize the available evidence and provide links to articles available online. Dr. LaVae Hoffman publishes Talking EBP, a newsletter that addresses EBP issues for school-based clinicians. The ASHA Practice Portals summarize key issues for a growing number of clinical and professional topics. Speechbite is an online database of intervention studies related to speech-language pathology that provides the identifying information and abstract for the articles.
  • Identify journals that provide some or all of their issues at no cost.  EBP Briefs  is a peer-reviewed journal addressing EBP issues across many topics relevant to SLPs.   The Academy of Neurologic Communication Disorders and Sciences (ANCDS) makes most of their practice guidelines available online.  Proposals from the Clinical Aphasiology Conference can be searched using an online database and most of these can be downloaded at no cost.

What EBP resources do you use?


Why theory matters in speech-language therapy, Part 2

Maria L. Munoz, PhD, CCC-SLP                                    www.recipeSLP.com

Last week I used the treatment to Reduce Aphasic Perseveration (RAP) to address some of the reasons I think theory is important for planning and implementing effective speech-therapy treatments.  RAP is based on a particular theory of perseveration and requires the patient to understand perseveration and learn to monitor their occurrence. What if the patient does not have the auditory comprehension needed to benefit from RAP?

I worked with a patient with moderate-to-severe global aphasia whose speech was limited primarily to two words. Comprehension was limited to single words and short phrases, and required frequent repetition and gesture.  My sense was that he was not a good candidate for RAP because he did not have the comprehension skills need to understand the purpose of the treatment. Additionally, his responses seemed more like stereotypies than perseverations interfering with a purposeful response. As he progressed in therapy, his responses started to seem more perseverative but still I felt that RAP would be confusing for him. So, what were my options?

Well, I started by going back to theory (I would suggest reading Jackie Stark’s overview of treatment of perseveration in the SIG 2 Perspectives published in December of 2011).  Dr. Anna Basso (2004) suggests that perseveration is fundamentally no different from any other paraphasia. Rather than targeting perseveration directly, clinicians target anomia. As naming accuracy improves, perseverations (along with other paraphasias) will decrease.

Based on this theory of perseveration, we hypothesized that treating naming would indirectly decrease perseverations. We used a traditional cuing hierarchy paired with a speech-cuing hierarchy to increase the patient’s ability to name functional actions and objects.  We measured outcomes related to both naming accuracy and the number of perseverations in order to confirm our hypothesis.

So, how did theory guide our clinical practice? It led us to a treatment approach that was a better fit for our patient. The theory gave us a rationale for our treatment methods and greater confidence that our treatment would have the anticipated benefit. It helped us to identify the behavioral outcomes we needed to measure to track the effects of treatment.

As my understanding of the theories of perseveration expands, my treatment options increase and my patient’s benefit.

Basso, A. (2004). Perseveration or the tower of Babel. Seminars in Speech and Language, 25 (4), 375-389.


Why theory matters in speech-language therapy

The whole concept behind Recipe SLP is to make the evidence and methods for specific clinical practices affordably and easily accessible for speech-language pathologists and students.  That said, I am very aware that the evidence is limited or non-existent for many of the treatments we routinely use, sometimes due to the particular communicative needs of a specific client. That’s where I think theory comes in very handy.

I developed Reduing Aphasic Perseveration (RAP) in response to the needs of a patient who was referred to me for therapy.  What stood out to me in the assessment was the severity of her perseveration.  During conversation and on the language assessment her responses were limited almost exclusively to one of two words (for no obvious reason).  Having prioritized managing the perseverations, I took to the literature and found very little treatment research to guide me other than Helm-Estabrooks’s single article on Treating Aphasic Perseverations (TAP).  Feeling like that was not a good fit, I turned to the scientific literature to try to understand the nature of perseveration for clues as to what to do next.

While the specifics of the theory and method of RAP can be found in The Clinician’s Guide to Reducing Aphasic Perseveration, what I want to point out here is that one theory suggested that perseveration was due to the abnormally long time required to deactivate the response.  So in my next session with the patient, I decided to experiment using a picture naming task.  I increased the length of time between the presentation of each picture to evaluate the impact on the occurrence of the perseveration.  When I hit 20 seconds, the perseverations reliably disappeared.  I must admit that the effect was absolutely surprising and exciting.  From this attempt to help one patient, RAP was born; a treatment that aims to reduce the occurrence of the perseveration and strengthen the activation of the target response.  I have used it successfully with a number of patients, though the time required to eliminate the perseveration varies greatly (the longest has been about 60 seconds).

So, why does theory matter in speech-language therapy? In the absence of strong evidence, theory can help us develop treatment methods based on an understanding of the underlying speech-language-cognitive process. We can develop treatments with an internal logic that helps us identify how we can manipulate aspects of the treatment to make the task easier or harder based on the needs of the client.  The theory can help us identify cues and supports for particular aspects of the skills being targeted. Understanding the theory gives us the luxury of FLEXIBILITY because we can alter the treatment in predictable ways based on the needs of the client.  Most of all, understanding the theory gives us a treatment that we have with us always because it’s in our head.  I don’t need a book or specific pictures to do RAP, in a pinch I could gather things from a patient’s room and get to work using a treatment I understand through and through.

Why do you think theory matters?