Efficacy of the SATPAC Approach for remediating

persistent /s/ errors

Stephen Sacks, M.A., CCC-SLP SATPAC Speech, Fresno, CA

& Peter Flipsen Jr., Ph.D., S-LP(C), CCC-SLP Pacific University, Forest Grove,

OR

Disclosure-Stephen Sacks

Financial: • Owner and Developer of SATPAC Speech and receives royalty payments. • Receives royalty payments from Marshalla Speech & Language.• Consultant for the Bureau of Education & Research and receives

honorarium compensation.Nonfinancial:• Board Member of the Oral Motor Institute

Disclosure – Peter Flipsen Jr.

• No financial or non-financial conflicts to report

Outline

• What are persistent speech errors?• Current approaches to treatment• The SATPAC Approach• Study design and results• Discussion• Questions

Persistent Speech Errors• Frequently encountered on school caseloads• Mild distortions of /s, z, r, l/.• Hard to justify more than limited treatment.• Minimal impact on intelligibility?• Usually little impact on academics?

• Have proven difficult to correct with traditional methods• Ingrained bad habits?

Management Options?

• Traditional therapy but more Tx time? • Unlikely; no more time available

• Ignore? • Probably not a good idea.• Negative peer reactions • See Crowe Hall (1991), Madison & Gerlitz (1991), & Silverman & Paulus (1989).

• Reduced adult expectations• See Overby et al. (2007) & Lass et al. (1988)

• Possible increased risk of emotional and behavioral problems• See Beitchman et al. (1986)

Management Options?

• Modify the therapy sequence?• Concurrent task sequencing (Skelton, 2004).• Relatively unstudied so far.

• Modify feedback?• Electropalatography? • Still somewhat expensive and requires considerable training

• Spectrograms? Ultrasound? Speech Buddies?• All relatively unstudied.

The SATPAC Approach• Systematic Articulation Training Program Accessing Computers.

• www.satpac.com

• Combines the use of:• 1. Non-words based on facilitating contexts (with transition to real words)

• Helps get around ingrained bad habits, and• Takes advantage of coarticulation

• 2. Computer generated stimulus lists • Progressively move through ever more challenging contexts, and • Avoid other error sounds that may interfere or are not in the student’s repertoire.

• 3. Practice at normal (or near-normal) speaking rate• Avoids odd prosody, and• Promotes normal motor planning, and• Promotes generalization from an early stage

Multimodality Approach

to /s/ Remediation

Use of /t/ Sound (and other unusual things)

• /s/ is not mentioned

• Mouth is open which is not normal for /t/ (but only temporarily)

Use of an Auditory Visual Model to Contrast

Correct/Incorrect “EET”Production

Use an Applicator Stick for Visual Tactile

Feedback(EE-point)

Tongue Tip Pointing forVisual, Tactile-Kinesthetic

Feedback

page 33

Tongue Pops forVisual, Tactile-Kinesthetic

Feedback

EE Point Tip forVisual, Tactile-Kinesthetic

Feedback

Tongue, Lips and Jaw Differentiation

EET for Auditory, Tactile-Kinesthetic

Feedback

KF Second Session

EETS for Auditory, Tactile-Kinesthetic

Feedback

The French/t/

page35

Systematic Articulation Training Program Accessing Computers

SATPAC Procedure Checklist-Establishment Phase

Practice Phase-Criteria for Completion80%+ accuracy on the first 4 lists @ 140 BPM

80%+ accuracy on List 5 at a normal conversational rate with no slowing down on the target sound

Practice Phase-Lists 1 and 2Practice Phase Lists 1 and

2

Practice Phase-Lists 3 and 4Practice Phase Lists 3 and

4

Practice Phase-List 5

Practice Phase List 5Contrastive Stress

Generalization/Transfer PhaseGeneralization/Transfer Phase

TALLY COUNTER

Generalization/Transfer Phase Phrases

Generalization/Transfer Phase Short Sentences

Generalization/Transfer Phase Sentences

Generalization/Transfer Phase Short Contrasts

Generalization/Transfer Phase Contrasts

Current Study

• Sacks, Flipsen, & Neils-Strunjas (in press) revealed significant improvement in persistent /s/ with the SATPAC approach when administered by the first author (who is also the program designer).• Attempting to replicate using other clinicians trained in the approach.

• Between groups alternating treatments design• Measure baseline performance, treat group 1 while group 2 waits.• Then measure performance on both and treat group 2 while group 1 waits• Measure both groups again and re-measure after an additional 12 weeks to

check for maintenance.

Participants• 13 children recruited from two public schools.• 7 males; 6 females – initial age 6;11 to 8;8 (Mean = 7;11)• No previous speech or language treatment rec’d.• 8/13 monolingual English speakers; 5/13 bilingual but English

dominant.• All presented with either dentalized or interdental versions of /s,z/• Dentalized = sounds distorted • Interdental = may or may not sound distorted but looks atypical

Progress Measures

• Measured production accuracy of /s/ in: • 1. CPAC /s/ probe (words and sentences; Secord & Shine), and • 2. conversational speech

• Allowed for measurement of performance in the structured context of therapy and to monitor generalization.

CPAC /s/ Probe

Treatment Plan

• Participants randomly assigned to two groups• Group 1 (n=7) included 5M; 2 F; ranged in age from 6;11 to 8;8• Group 2 (n=6) included 2M; 4 F; ranged in age from 7;5 to 8;3• No significant age difference

• Individual treatment sessions by 2 clinicians who were trained on the approach• Focus only on /s/• Each clinician saw about half the children in each group• 12 weeks of treatment; 1 X 15 minute session per week = 180 minutes of total treatment.

• 180 total minutes of therapy.

Observations about Treatment

• Variation between SLPs• One SLP administered the program more faithfully than the other and

consequently showed significantly better results (7/8 90%+ in conversation vs. 2/5 90%+ when study was completed).

• All completed Tx but 3 (2 from Group 1) moved at the end of the school year and were no longer available at follow-up. • Net result: missing any follow-up data for 1 participant.

Group Results (CPAC probe)

Time periodTx Group

432121212121

90

80

70

60

50

40

30

20

10

0

CPAC

Mn

%

12

Tx Group

Change in CPAC / s/ Accuracy over Time

Group Results (Conversational Speech)

Time periodTx Group

432121212121

70

60

50

40

30

20

10

0

Conv

Mn

%12

Tx Group

Change in Conversational / s/ Accuracy over Time

Individual Results• Not all participants achieved the same results• 6/12 (3 from each group) followed an “ideal” pattern.• Saw change on both measures immediately after therapy and it was

maintained at follow-up.

time

Y-Da

ta

% Correct / s/ over TimeParticipant = AG

time

Y-Da

ta

% Correct / s/ over TimeParticipant = JH

Individual Results• “Delayed” generalization?• 1/12 showed immediate change after treatment on CPAC probe but no generalization to

conversation until follow-up.• 1/12 showed gradual change over time on CPAC probe but no change in conversation until 24

weeks post-treatment.

time

Y-Da

ta

% Correct / s/ over TimeParticipant = PJ

time

Y-Da

ta

% Correct / s/ over TimeParticipant = AS

Individual Results• At least one participant showed gradual improvement to

acceptable levels by initial follow-up but regressed at 24 week follow-up

time

Y-Da

ta

% Correct / s/ over TimeParticipant = TT

Individual Results• 3/12 participants showed little or no change in one or both

measures.

time

Y-Da

ta

% Correct / s/ over TimeParticipant = EL

time

Y-Da

ta

% Correct / s/ over TimeParticipant = SL

time

Y-Da

ta

% Correct / s/ over TimeParticipant = EP

Overall Results and Conclusions• Group results show obvious effects for both the CPAC probe and

conversational speech.• Individual results showed obvious signs of improvement for 8/12

participants to acceptable levels of performance on both measures.• Doesn’t work for everyone.

• With a relatively short treatment period (12 weeks) and relatively brief sessions (15 minutes per week), the SATPAC Approach appeared to be effective at correcting persistent /s/ errors.

Future Directions• Need to determine efficacy with other errors (/r/, /l/).• Need to evaluate whether each component is absolutely

necessary.• E.g., are the specific “establishment” procedures necessary or can any

technique to establish good /s/ work?• E.g., how crucial are the nonsense stimuli?

• Need to determine why some don’t respond to the therapy.

Questions?