Outcomes in social communication intervention: the case for … · case for mechanism...

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

of 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

observed 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 i a l 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 P r o g r a m m e 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 observational 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






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






Includes excess information

Referents are sometimes unclear

Talk is over-precise

Talks about things either not established or already known

Pragmatics






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






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 other don’t seem interested

Pragmatics






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 others


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


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


• 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

√


√

LP 1 Vocabulary and word knowledge

X

SUSI 2 Understanding emotion cues in interactions

√


√ 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

√


√

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

[email protected]

www.napierhillpress.co.uk

• @napierhillpress #SCIPManual

• @JacquelineGaile

• @Cathy_adams1

Laura Clitheroe

Jacqueline Gaile

http://www.scip2.bmh.manchester.ac.uk

mailto:[email protected]

https://www.napierhillpress.co.uk

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