Deconstructing Interventions

A throwaway remark by my Audiology lecturer caught me by surprise. She said that she sits behind children when training them after they receive a cochlear implant in order that they not rely on visual cues when learning to discriminate speech sounds.

Cochlear_implant2Children and adults with hearing loss cannot simply be fitted with an aid or an implant and then walk away ready to hear. They need specific (and in some cases a lot of) training in perceiving speech sounds (as do hearing people, who do this as babies). However, there is a divide between deaf educators/audiologists about the best way to train listening in this population:

  • Auditory-Verbal: No sign language, no visual-cues (i.e. lip-reading) – the child must learn to listen solely through the use of the acoustic signal.
  • Auditory-Oral: Children can use lip-reading and contextual cues as well as listening to crack the speech signal.

Of course there are many shades between these two approaches, and countless other approaches to deaf education. Perhaps I’ll just link to the ASHA Evidence Map

On the other side of the SP range of practice…

I thought it was interesting, because it conflicted with how we do phonological therapy in Speech Pathology, where children who cannot distinguish phonemes are encouraged to perceive both the articulatory and acoustic differences in the sounds. It also is a similar ‘debate’ in Aphasia rehabilitation. One approach is Constraint-Induced Language Therapy (CILT), where clients are restricted to verbal output (no gesture, writing or drawing) through the use of physical screens. A review [1] found large effect sizes, but since the therapy was intense, it remains unknown whether ‘constraint’ is an important aspect of the treatment.

However, there is another school of thought which claims clients should be able to draw on any residual communication in any form. Such an approach is found in Multi-Modal Aphasia Treatment (MMAT), which a pilot study found to be equally efficacious as CILT. A RCT is in the works.

The danger of single-treatment studies

When your study has only one treatment, even if it has a control, it is impossible to say whether it is a treatment that should be used. If clinicians are to choose the best treatments (which we are not presently required to do, all we are required to do is to use evidence-based treatments), we need more studies like [2] and less like [1]. Two other examples spring to mind:

  • Literacy: Is Reading Recovery more efficacious than a Systematic Phonics program?
  • Fluency: Is Demands and Capacities Therapy more efficacious than the Lidcombe Program?

(There is research on the second question [3] finding equal efficacy, but the Lidcombe program was only administered for 12 weeks, in defiance of best-practice and proscribed standards for its implementation).


When we do therapy, we cannot point to research that proves that every component of the intervention (like constraint) is directly related to a result. Perhaps if we removed it, the treatment would still work. This is where a solid theoretical framework helps. If what I’m doing is reasonable given what I know about the body and the brain, I think I’m a lot more comfortable, even if a small aspect of my intervention hasn’t been checked by an RCT.

  1. Cherney, L. R., Patterson, J. P., Raymer, A., Frymark, T., & Schooling, T. (2008). Evidence-based systematic review: Effects of intensity of treatment and constraint-induced language therapy for individuals with stroke-induced aphasia. Journal of Speech, Language, and Hearing Research, 51, 1282–1299.
  2. Rose, M. L., Attard, M. C., et al. (2013). Multi-Modality Aphasia Therapy Is as Efficacious as a Constraint-Induced Aphasia Therapy for Chronic Aphasia: A Phase 1 Study. Aphasiology, 27(8), 938-971.
  3. Franken, M. C., Kielstra-Van der Schalk, C. J., Boelens H. (2005). Experimental treatment of early stuttering: a preliminary study. Journal of Fluency Disorders, 30(3), 189-99.

One comment

  1. Roman

    I was told to always sit behind a child in auditory verbal therapy sessions to ensure they are hearing and not seeing my speech. For assessment I think this is necessary in order to ascertain what the child truly can hear, but for training, I disagree. Normal conversation will not take place from behind the child; dialogue most commonly occurs between two people facing each other. I think we miss teaching children other aspects of conversation (eye contact, timing of turn taking, body language)if we only provide therapy from behind or even from beside and slightly back as I have heard some therapists recommend.


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