Outcomes in social communication intervention: the case for - - PowerPoint PPT Presentation

Outcomes in social communication intervention: the case for mechanism identification and individualization

• f therapy

Dr Catherine Adams University of Limerick 3 May 2017

Outline

• Social Communication Intervention

programme and project

• Individualization of intervention
• Outcomes within complex intervention

evaluations

• Outcome and process evaluation in our new

research

• Mechanism evaluation in the context of

evidence generation

Main pragmatic and language impairment features

• bserved in Social Communication Disorcer

From Adams C (2013) Pragmatic language impairment in F. Volkmar (Ed.) Encyclopedia of Autism, Springer: New York.

Pragmatics

Responsivity Initiations Turn-taking Verbosity Topic Presupposition Reference

Language impairment

Non-literal language Inference Word meaning Narrative

+ Mild autism features

S o c ia l C o mmunicatio n I nte r ve ntio n Pro gra mme

a s p e c i a l i s t c o m m u n i c a t i o n i n t e r v e n t i o n

Jacqueline Gaile Catherine Adams

Aimed at children aged 6-12 years

Assessment Process (2-3 hours) Intervention Mapping (1-2 hours) Phase 1 Intervention (4-6 hours) Phase 2 Intervention (11-14 hours) Finish SCIP Intervention

• Standardised formal tests
• Non-standard observation
• Carer and teacher checklists
• Identification of core skills Phase 1 needs
• Identification of Phase 2 needs: SUSI,

PRAG, LP

• Direct Phase 1 intervention (core skills)
• Phase 2 individualised planning
• Direct Phase 2 intervention (main

intervention phase)

• Carer / teacher training
• Phase 3 planning
• Personalisation and generalisation of

therapy

• Carer / teacher further liaison and

training

• Agree: monitoring schedule and further

SCIP intervention Phase 3 Intervention (11-14 hours)

Assessment (2-3 hours) Functional measures:

• Carer checklist
• Teacher checklist
• Standardised assessments
• Non-standardised formal and
• bservational measures
• Extract gaps in knowledge, performance and impressions of functioning
• Extract concerns with peer relationships, play and social situations and priorities

for intervention

• Evaluate the problematic situation to extract key skills required to meet

‘desirable outcomes’ ASSESSMENT SUMMARY

• Write a summary of strengths / needs
• Begin to identify priority areas for intervention

Individualised intervention objectives for Phase 2

Phase 1 Intervention Assessment to Intervention Mapping

CM Comprehension Monitoring USC Introduction to Understanding Social Context MPA Basic Metapragmatic Awareness BN Basic Narrative EM Introduction to Emotions in Context FR Introduction to Friendship

• SCIP has established route to Phase 2 intervention

assessment intervention goals

• Prescribed manual of intervention activities

all specified in the manual

Phase 2 intervention

Assessment to Intervention Mapping

PHASE 2 Intervention Components

SUSI PRAG LP Pragmatics

PRAG 1: Conversation and metapragmatic skills PRAG 2: Understanding information requirements PRAG 3: Improving turn- talking skills PRAG 4: Understanding and managing topic in conversation PRAG 5: Understanding and improving discourse style

Pragmatics PRAG 1: Conversation and

metapragmatic skills PRAG 2: Understanding information requirements PRAG 3: Improving turn- talking skills PRAG 4: Understanding and managing topic in conversation PRAG 5: Understanding and improving discourse style

• Conversational flow is problematic with frequent

clashes or misinterpretations

• Shows lack of reciprocity in conversation
• Ignores speaker and / or does not look at person he

is speaking to

• CCC-2: Ignores conversation overtures from others

Pragmatics PRAG 1: Conversation and

metapragmatic skills PRAG 2: Understanding information requirements PRAG 3: Improving turn- talking skills PRAG 4: Understanding and managing topic in conversation PRAG 5: Understanding and improving discourse style

• Includes excess information
• Referents are sometimes unclear
• Talk is over-precise
• Talks about things either not established or already

known

Pragmatics

PRAG 1: Conversation and metapragmatic skills PRAG 2: Understanding information requirements PRAG 3: Improving turn- talking skills PRAG 4: Understanding and managing topic in conversation PRAG 5: Understanding and improving discourse style

• Lack of reciprocity in conversation
• Frequent clashes during conversation
• Does not take up his turn in conversation
• Difficult to interrupt the child’s flow of talk in

conversation Pragmatics PRAG 1: Conversation and

metapragmatic skills PRAG 2: Understanding information requirements PRAG 3: Improving turn- talking skills PRAG 4: Understanding and managing topic in conversation PRAG 5: Understanding and improving discourse style

• Frequently changes topic in conversation
• Does not signal topic change
• Dominates conversation
• CCC-2: talks repetitively about things no-one is

interested in

• Talks about lists of things he has memorised; Moves

the conversation to a favourite topic even though

• ther don’t seem interested

Pragmatics PRAG 1: Conversation and

metapragmatic skills PRAG 2: Understanding information requirements PRAG 3: Improving turn- talking skills PRAG 4: Understanding and managing topic in conversation PRAG 5: Understanding and improving discourse style

• Can appear overly familiar in conversation
• Talks to unfamiliar people too readily
• Cannot change style to match different types of

interactions

• CCC-2: Stands too close to people when talking to them

PHASE 3

Uses real-life problematic situations reported by

• parents / carers
• teachers

Unlike Phase 1 and Phase 2 (where all activities are available and prescribed), Phase 3 has no prescribed therapy content Creates the context for personalised intervention Phase 3: Transfer knowledge & skills to everyday experiences

Individualization of therapy via Assessment to Intervention Mapping

Heterogeneous presentation Comprehensive set of therapy targets and activities

• Case study Joe
• Examples of assessment triggers
• Examples of prioritisation influences
• Examples of parent priority
• Completed Phase 2 plan

Assessment to intervention mapping

Assessment at baseline – Joe

• 10 years 4 months
• Year 5 mainstream school
• TA support 5 hours / week
• Lives at home with parents and two older

sisters

• Autism spectrum disorder preschool

Overview

SCIP pre-screening checklist 4/5 features of PLI/SCD Children’s Communication Checklist CCC-2 score Cut-off for DLD ≤55 GCC = 31 SIDC = -16 Ravens CPM centile midpoint 75 Test for Reception of Grammar TROG-2 standard score 88 Social Communication Questionnaire Autism spectrum disorder CELF Core Language Score 91

Joe’s language scores (1)

CELF-4 Standard scores

Time 1 Concepts & Following Directions 7 Word Classes Receptive 8 Receptive Language Score 85 Recalling sentences 10 Formulated Sentences 10 Word Classes Expressive 7 Expressive Language Score 95

Understanding spoken paragraphs

8 Core Language Score 91

• Clip 1 and 3

SCIP PHASE 2 PLANNING SUMMARY AND PRIORITIES Joe

SUSI PRAG

LP SUSI 1

Understanding social context cues in interactions

PRAG 1

Conversation and metapragmatic skills

LP 1

Vocabulary and word knowledge

? SUSI 2

Understanding emotion cues in interactions

PRAG 2

Understanding information requirements

LP 2

Improving narrative construction

√ SUSI 3

Understanding and practising flexibility

PRAG 3

Improving turn-taking skills

LP 3

Non-literal language

SUSI 4

Understanding thoughts and intentions of others

PRAG 4

Understanding and managing topic in conversation

LP 4

Discourse comprehension

√ SUSI 5

Understanding friendship

PRAG 5

Understanding and improving discourse style

LP 5

Enhanced comprehension monitoring

√

Mapping CCC2 to SCIP Phase 2 content To carry out this aspect of mapping you would need:

• A SCIP Form
• CCC2 data for Joe
• CCC2 to intervention mapping guidance (in

manual)

• A knowledge of the therapy content of the

manual to identify potential SCIP Sections for inclusion in Phase 2 intervention

CCC-2 to PRAG intervention mapping

Items identified by parents on CCC-2 PRAGMATICS Sections

• 31. Ignores conversational overtures from
• thers

PRAG 1 Conversation and metapragmatic skills

• 37. Tells people things they already know
• 42. Includes over-precise information
• 48. Doesn’t explain what he is talking about to

someone who doesn’t share his experiences PRAG 2 Understanding information requirements

• 5. Talks repetitively about things no-one is

interested in (2)

• 26. Moves the conversation to a favourite topic

even though others don’t seem interested

• 35. It’s difficult to stop him from talking

PRAG 4 Managing topic in conversation

• 23. Pronounces words in over-precise manner
• 25. Can be hard to tell if he is talking about

fantasy or reality

• 49. Uses unusual words, or more adult-sounding

phrases PRAG 5 Understanding and improving discourse style

• Reciprocity/Turn-taking

– Is responsive but does not initiate; minimal answers given, conversation is ‘hard work’

• Taking account of listener knowledge

– Too much and too little information

• Verbosity

– stereotyped or learned phrases – you don’t want anybody to be sick

• Topic Management

– difficulties with topic maintenance

• Discourse Style

– Possibly unaware of intonation - yeah, of course

• Response problems

– overly literal comprehension – it comes from the kitchen

TOPICC to intervention mapping

PRAG 1 PRAG 5 LP 3 PRAG 4 PRAG 2 LP 2 LP 1

SCIP PHASE 2 PLANNING SUMMARY AND PRIORITIES Joe

SUSI PRAG

LP SUSI 1

Understanding social context cues in interactions

√ PRAG 1

Conversation and metapragmatic skills

√ LP 1

Vocabulary and word knowledge

X SUSI 2

Understanding emotion cues in interactions

√ PRAG 2

Understanding information requirements

√ LP 2

Improving narrative construction

√ SUSI 3

Understanding and practising flexibility

√ PRAG 3

Improving turn-taking skills

X LP 3

Non-literal language

√ SUSI 4

Understanding thoughts and intentions of others

√ PRAG 4

Understanding and managing topic in conversation

√ LP 4

Discourse comprehension

√ SUSI 5

Understanding friendship

√ PRAG 5

Understanding and improving discourse style

√ LP 5

Enhanced comprehension monitoring

√

The Social Communication Intervention Programme (SCIP) Trial

A randomised control trial of intervention for children with pragmatic language impairment Catherine Adams and Elaine Lockton Funded by the Nuffield Foundation RCT (N=88) of effectiveness of SLT for children with PLI /SCD (aged 6-11) International Journal of Language and Communication Disorders: Vol 47:3 (2012) & Vol 48:1 (2013)

Outstanding issues from school- based trial Heterogeneous population Application in real practice Complex intervention Development of clinical trial?

Complex intervention definition

Number of interacting components within the experimental and control interventions Degree of flexibility or tailoring of the intervention permitted A single primary outcome may not make best use of the data; a range of measures will be needed The intervention may work better if a specified degree of adaptation to local settings is allowed for in the protocol

Craig et al (2008) BMJ 337

SCIP 2 NIHR Research for Patient Benefit feasibility study: Aims*

study and refine aspects of the intervention procedure and outcome measurement refine the characteristics of the proposed modified goal attainment scale (GAS) primary outcome measure for effective use with the target population explore practitioner views on training needs and acceptance of novel techniques explore acceptability of the intervention (including training/support) to participants and their families *Co-investigators: Richard Emsley, Janet Baxendale, Hazel Roddam

RfPB feasibility study work schedule

Work package 1 Survey Work package 2 N of 1 parallel studies Work package 3 Qualitative study plus Delphi consensus study

• Practitioner survey

(England) N = 73

• NHS respondents (78%)
• non-NHS practitioners

(22%)

Number of resources used for children with Social Communication Disorder = 64 Number of different outcome measures used for capturing progress in social communication > 35 Large variation in service delivery

Work package 2

24 cases with NHS/independent or school-based speech and language therapists Receive manual and training Map assessment findings to individualized treatment programme with research speech and language therapist (Jacqueline Gaile) Set goals based on parent targets Goal attainment scales set at time 1 Secondary outcomes: SLDT, TOPICC, Parent questionnaire Revisited and rated by parent and therapist at time 2 (within-subject design)

Development of evidence in RfPB study

Outcome evaluation method Process evaluation method Mechanism of intervention

Process evaluation Implementing therapy in real practice

Practitioner engagement: Monitoring adaptations and responses via audio diaries Interviews with purposive sample of practitioners/service managers and parents/carers Structured picture – based therapy discussion with children at end of intervention Exploratory qualitative approach

Mechanisms of intervention?

A mechanism of change shows a causal relation between an intervention and an outcome The study of mechanisms requires the investigators to propose the specific basis for change (Kazdin et al 2008)

Mechanisms of intervention? Future steps

In order to ensure that therapy is individualised according to a child’s needs, it is essential to have a clear understanding of how therapy proposes to work How intermediate outcomes are currently measured in practice and how they are selected - based on the underlying mechanisms of change associated with an intervention Improving knowledge of intervention effects Improving guidelines for intervention

SCIP 2

Additional information

www.scip2.bmh.manchester.ac.uk catherine.adams@manchester.ac.uk www.napierhillpress.co.uk

• @napierhillpress #SCIPManual
• @JacquelineGaile
• @Cathy_adams1

Laura Clitheroe Jacqueline Gaile