What is Meant by Success in Intervention?
By Barbara Jane Cunningham, Winner of the 2015 Isabel Richard Student Paper Award (Doctoral Category)
Please note that this paper appears in its original form, in the language in which it was submitted; we have not edited it for style or grammar.
Introduction. The 21st century has seen significant changes in thinking about what makes an intervention successful (Rosenbaum & Stewart, 2007; Whyte & Hart, 2003). Following the World Health Organization’s publications of the International Classification of Functioning, Disability and Health (ICF) (World Health Organization, 2001) and ICF-Children and Youth (ICF-CY) (World Health Organization, 2007), speech-language pathologists have been increasingly challenged to consider their interventions and the impact of those interventions on the everyday lives of people with communication disorders and their families. This represents a real shift from the traditional biomedical approach to intervention planning and delivery in which clinicians intervened to address a functional problem that needed to be ‘fixed’, without considering the real-world issues that impacted people’s ability to engage in life. Using the ICF as a framework, we can reconceptualise the way we set goals and evaluate outcomes in speech-language pathology to ensure we are successful in making a meaningful difference, and improving quality of life for people with communication disorders and their families.
This paper first presents a summary of the ICF framework. The framework is then used to describe the traditional biomedical approach to intervention, and the ways in which we can now use the ICF framework to expand the scope of our interventions, making them more relevant for the people we serve. New ways of measuring success in interventions are also presented.
The ICF Framework. There are two parts to the ICF framework: functioning and disability, and contextual factors.
The first component, functioning and disability, is made up of three sub-components: body structures and functions, activities, and participation (see Figure 1). For communication, body structures and functions include the anatomical parts of the body involved in the production of voice and speech (Threats, 2006). Activities refer to the execution of tasks or actions by an individual, for example attending; articulating; and understanding (Threats, 2006). Participation refers to how an individual uses communication to engage in life situations, for example ordering food in a restaurant; making an appointment over the telephone; and engaging in conversation with peers (O’Halloran & Larkins, 2008; Threats, 2003; World Health Organization, 2001). The activity and participation sub-components of the ICF are further modified by capacity and performance qualifiers. The capacity qualifier describes how the person performs a task under ideal circumstances, such as in a standardized environment like a therapy room. The performance qualifier describes how the person performs that same task in the real world (Threats, 2003).
The second part of the ICF framework, contextual factors, includes both environmental and personal factors that affect a person’s functioning (see Figure 1). Environmental factors relate to the physical, social, and attitudinal environments in which people live. Personal factors include factors like age, gender, and race (World Health Organization, 2001).
Figure 1. The International Classification of Functioning, Disability, and Health, World Health Organization (2001).
The traditional biomedical approach to intervention. Speech-language therapy has traditionally been delivered using thinking informed by a biomedical approach. For example, under this approach, a treatment goal for the speech-language pathologist working with an adult with aphasia might be to increase naming of pictures, while a goal for the therapist working with a preschooler with a phonological delay might be to reduce fronting of velar sounds. Within a traditional approach, we might use informal assessment methods such as counting the correct production of target sounds and words, or formal measures like standardized tests, to measure change and evaluate the effectiveness of the intervention. In this way, a successful outcome for the adult with aphasia would be an increase in the number of pictures named correctly, while a successful outcome for the child with phonological delay would be increased accuracy in the production of /k/ and /g/ sounds.
Applying the ICF framework, it becomes clear that traditional approaches to intervention encourage the setting of goals and evaluation of outcomes that target skills at the level of body structure, function, and perhaps activity. Traditional approaches also target a person’s capacity for communication (Threats, 2003), that is how they communicate in a structured environment. These traditional approaches to intervention have a narrow focus, and do not address skills or outcomes related to performance, or how the person uses communication to engage in their own ‘real world’ (Threats, 2003). For example, at the conclusion of a biomedically-based intervention, a client with aphasia may perform well on a capacity-based assessment of expressive vocabulary like the Boston Naming Test (Kaplan, Goodglass & Weintraub, 2000), but they may still struggle to find the words necessary to engage in conversation with friends. Similarly, for the preschooler with phonological delay, we may observe a reduction in the fronting of /k/ at the beginning of single words, but that child may still be unable to say the name of a sibling or the family pet. In summary, these traditional ways of providing intervention and evaluating outcomes too easily overlook important participation-based skills that contribute to overall health and quality of life (Threats, 2006; Washington, 2007), the skills and outcomes that are ultimately most meaningful for patients and families.
Moving beyond the biomedical approach. As in other areas of clinical work, there is a compelling need to move beyond the traditional biomedical approach to treating impairments in individuals with communication disorders, towards a more holistic approach that considers other factors (e.g., physical, mental, and social) that impact an individual’s functioning as they would like it to happen (World Health Organization, 2001). Viewed from the lens of the ICF, we can move beyond the focused but narrow view that a successful therapy leads to improvements in body structures, functions, and capacity-based skills, towards the broader, and perhaps more meaningful idea that a successful intervention facilitates a person’s performance, or their ability to use communication to participate in life (Rosenbaum & Gorter, 2012; Washington, 2007; Thomas-Stonell, Oddson, Robinson & Rosenbaum, 2009a; Thomas-Stonell, Washington, Oddson, Robertson & Rosenbaum, 2013).
One important participation-level skill that should be included in intervention goals and evaluation of outcomes for speech-language therapies is communicative participation. This refers to “an individual’s communication and interaction in real world situations such as the home, school, or community” (Eadie et al., 2006).
By including goals like improving communicative participation in our interventions, we can work towards improving a person’s performance at the level of participation, and in turn, we can evaluate meaningful real-world changes (or successes) that result from our interventions. More specifically, we can target and evaluate skills that relate directly to how that person is able to use his or her communication to engage in life. Under this approach, goals for the adult with aphasia might include increasing their ability to name common objects around the home, or their ability to sign their own name. Goals for the child with phonological delay might include increasing their ability to use /k/ sounds so that they can understandably use words that are meaningful to them (e.g., a sibling’s name). A successful outcome for both the adult with aphasia and the child with phonological delay would be demonstrably improved communicative participation skills, or an improved ability to use their communication to interact and engage in their world.
New ways of measuring successes in intervention. We have a plethora of standardized and informal methods for measuring changes in capacity for communication skills. Standardized measurement tools such as the Boston Diagnostic Aphasia Examination (Goodglass, Kaplan & Barresi, 2000) and the Clinical Evaluation of Language Fundamentals – Preschool-2 (Semel, Wiig & Secord, 2004) serve an important role in clinical practice, allowing us to evaluate a person’s capacity to perform certain tasks, facilitating goal setting, and helping us to describe a person’s skills relative to the ‘norm’. They do not, however, tell us whether our interventions have successfully improved an individual’s performance of communication-related tasks, or about their ability to use communication to engage and participate in everyday life. In addition to these traditional impairment-based measures, we need tools to evaluate the meaningful participation-level changes that we hope will take place as a result of our interventions.
Two new standardized self-report measures evaluate communicative participation outcomes for individuals with communication disorders. The Communicative Participation Item Bank (CPIB) is a standardized disorder-generic self-report tool designed for use with adults with various communication challenges (Baylor, Yorkston, Eadie, Miller & Amtmann, 2011; Baylor, Yorkston, Eadie, Kim, Chung & Dagmar, 2013; Eadie et al., 2006). The tool provides insights into how much an individual’s condition interferes with participation in a range of speaking situations (Baylor et al., 2013). The Focus on Communication Outcomes Under Six (FOCUS©) is a standardized parent-report measure that was developed to capture and evaluate ‘real world’ changes in the communication skills of preschoolers receiving speech-language therapy (Thomas-Stonell et al., 2009a; Thomas-Stonell, Oddson, Robertson & Rosenbaum, 2009b; Thomas-Stonell et al., 2013; Washington et al., 2013a; Washington, Oddson, Robertson, Rosenbaum & Thomas-Stonell, 2013b). This tool has been validated for use with preschoolers with a variety of communication difficulties, and it accounts for many of the important social changes associated with speech-language interventions (Thomas-Stonell et al., 2013). The CPIB was designed for use with adults who interact in speaking situations, and the FOCUS© was designed for use with preschool-aged children. To date, there are no tools available for the evaluation of communicative participation outcomes for school-aged children or adults who are non-verbal. The development of tools for use with these populations would be beneficial.
The CPIB and the FOCUS© can be used to augment findings from our capacity-based measurement tools, as they can provide a richer, more concrete, and more relevant conceptualization of the impact our therapies have on the performance and participation of individuals with communication disorders in their everyday lives. They can also enable us to explore the strength (or not) of the relationship between changes in a person’s capacity for communication and changes in a person’s communicative performance.
Conclusion. In the past we have worked to improve skills at the level of body structure, function, and activity for individuals with communication disorders, and we have evaluated the successes of our interventions using capacity-based measurement tools. This traditional approach does not consider important therapy goals related to life engagement and participation and does not evaluate a person’s communicative performance or participation in everyday life. The World Health Organization’s International Classification of Functioning (ICF) helps us to conceptualize this gap in our practice. Using the ICF, we can see that what makes our interventions successful is ultimately gains in participation, specifically (in the examples used in this essay) gains in communicative participation. Working to improve one’s ability to engage in their world will have the most significant impact on quality of life for those living with communication disorders.
References
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About the author:
Barbara Jane Cunningham, M.Sc., SLP(C), Reg. CASLPO
Winner of the 2015 Isabel Richard Student Paper Award (Doctoral Category)
McMaster University
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