Implementation Research: Embracing Practitioners' Views.

Purpose: This research explores practitioners' perspectives during the implementation of triadic gaze intervention (TGI), an evidence-based protocol for assessing and planning treatment targeting gaze as an early signal of intentional communication for young children with physical disabilities. Method: Using qualitative methods, 7 practitioners from 1 early intervention center reported their perceptions about (a) early intervention for young children with physical disabilities, (b) acceptability and feasibility in the use of the TGI protocol in routine practice, and (c) feasibility of the TGI training. Qualitative data were gathered from 2 semistructured group interviews, once before and once after TGI training and implementation. Results: Qualitative results documented the practitioners' reflections on recent changes to early intervention service delivery, the impact of such change on TGI adoption, and an overall strong enthusiasm for the TGI protocol, despite some need for adaptation. Conclusion: These results are discussed relative to adapting the TGI protocol and training, when considering how to best bring about change in practice. More broadly, results highlighted the critical role of researcher-practitioner collaboration in implementation research and the value of qualitative data for gaining a richer understanding of practitioners' perspectives about the implementation process.

Discovering indices of contingency awareness in adults with multiple profound disabilities.

We conducted two studies to examine parameters of social attention in contingency awareness training using switch activation with individuals who had multiple profound disabilities. In Study 1 we compared leisure devices and social attention as reinforcing stimuli with 5 individuals. Results indicated the reinforcing qualities of social attention over leisure devices with 2 individuals and documented the importance of session length in training. In Study 2 we investigated idiosyncratic behaviors as indicators of responsiveness with 3 of the 5 original participants as they activated switches. Behavior changes during switch activation versus nonactivation times in the leisure device and social attention conditions suggested volitional movement supporting contingency awareness and preference. Implications for clinical practice are discussed.

Moving Triadic Gaze Intervention Into Practice: Measuring Clinician Attitude and Implementation Fidelity.

Purpose: This research investigated a first step in implementing the dynamic assessment (DA) component of Triadic Gaze Intervention (Olswang, Feuerstein, Pinder, & Dowden, 2013; Olswang et al., 2014), an evidence-based protocol for teaching early signals of communication to young children with physical disabilities. Clinician attitudes about adopting external evidence into practice and implementation fidelity in DA protocol delivery were examined following training. Method: Seven early intervention clinicians from multiple disciplines were trained to deliver the four essential elements of the DA protocol: (a) provide communication opportunity, (b) recognize child's potentially communicative signal, (c) shape child's signal toward triadic gaze, and (d) reinforce with play. Clinician attitude regarding adopting evidence into practice was measured at baseline and follow-up, with the Evidence-Based Practice Attitude Scale (Aarons, 2004). Implementation fidelity in delivering the protocol was measured for adherence (accuracy) and competence (quality) during trial implementation. Results: Clinicians' attitudes about trying new evidence that at first was perceived as incongruent with their practice improved over the course of the research. Clinicians demonstrated strong adherence to the DA protocol; however, competence varied across clinicians and appeared related to child performance. Conclusions: The results provided insight into moving Triadic Gaze Intervention into practice and yielded valuable information regarding the implementation process, with implications for future research.

Survey of SLP caseloads in Washington State schools: implications and strategies for action.

PURPOSE: To document statewide and regional caseloads and to examine workload management strategies by surveying speech-language pathologists (SLPs) in Washington State public schools. METHOD: All school SLPs who were registered with the Office of the Superintendent of Public Instruction were mailed a detailed survey in May, 2001 and a brief follow-up survey 1 year later. RESULTS: Response rates were 43% (N=431) and 47% (N=464), respectively. Caseload findings showed a statewide mean of 59 students, with regional variation as high as 30%. IMPLICATIONS: There was no systematic evidence that caseloads were managed through state, district, or local limits or by distributing clients on the basis of the severity of impairment or SLP experience ortraining. There was significant evidence, however, that clinicians with larger caseloads were more likely to have assistants and to conduct a higher proportion of group sessions than were clinicians with smaller caseloads. The authors discuss the implication of these findings for and other states with no caseload limits and a shortage of SLPs. There is an appeal for more research using newly established measures of workload as well as a call to action to address the challenges that these findings represent.

Triadic gaze intervention for young children with physical disabilities.

PURPOSE: This randomized controlled study investigated whether a supplemental treatment designed to teach triadic gaze (TG) as a signal of coordinated joint attention would yield a significantly greater increase in TG in the experimental versus control group. METHOD: Eighteen 10- to 24-month-old children with severe motor impairments were randomly assigned to an experimental ( n = 9) or control group ( n = 9). For approximately 29 sessions over 17 weeks, experimental participants received TG treatment twice weekly with a speech-language pathologist in addition to standard practice. Control participants received only standard practice from birth-to-three therapists. Coders who were masked to group assignment coded TG productions with an unfamiliar speech-language pathologist at baseline, every 3 weeks during the experimental phase, and at the final measurement session. RESULTS: TG increased across groups from baseline to final measurement, with the experimental group showing slightly greater change. Performance trends were examined using experimental phase moving averages. Comparisons revealed significant differences between groups at 2 time points (at 12 weeks, r = .30, a medium effect, and at the end of the phase, r = .50, a large effect). CONCLUSION: The results suggest the promise of a short-term, focused treatment to teach TG as a behavioral manifestation of coordinated joint attention to children with severe physical disabilities.

Validating dynamic assessment of triadic gaze for young children with severe disabilities.

PURPOSE: This research investigated the use of a dynamic assessment (DA) to identify differences among young children with severe disabilities, which would predict progress in learning behaviors indicating coordinated joint attention (CJA). METHOD: Six children 10-24 months of age were enrolled in a 16-week treatment for behaviors indicating CJA, specifically triadic gaze (TG), which is a 3-point gaze shift between object and adult. An initial static assessment documented the children's eligibility for the study and their baseline performance of TG. DA procedures were then implemented to determine each child's performance with examiner support in producing behaviors suggesting joint attention (i.e., tracking, gaze toward an object or an adult, scanning between objects, scanning an object and adult, and TG). RESULTS: Results demonstrated differences among children during the DA via a DA score and a behavioral profile. These results were predictive of differences among children in subsequent learning of TG. CONCLUSION: These data support the validity of DA for describing heterogeneity among young children with severe disabilities who look similar on static assessment but appear differentially ready to learn behaviors associated with joint attention. This knowledge will assist clinicians in planning more efficacious services for young children who struggle to communicate and are at risk for extended therapeutic needs.

Development of the communication complexity scale.

PURPOSE: Accurate description of an individual's communication status is critical in both research and practice. Describing the communication status of individuals with severe intellectual and developmental disabilities is difficult because these individuals often communicate with presymbolic means that may not be readily recognized. Our goal was to design a communication scale and summary score for interpretation that could be applied across populations of children and adults with limited (often presymbolic) communication forms. METHOD: The Communication Complexity Scale (CCS) was developed by a team of researchers and tested with 178 participants with varying levels of presymbolic and early symbolic communication skills. Correlations between standardized and informant measures were completed, and expert opinions were obtained regarding the CCS. RESULTS: CCS scores were within expected ranges for the populations studied, and interrater reliability was high. Comparison across other measures indicated significant correlations with standardized tests of language. Scores on informant report measures tended to place children at higher levels of communication. Expert opinions generally favored the development of the CCS. CONCLUSIONS: The scale appears to be useful for describing a given individual's level of presymbolic or early symbolic communication. Further research is needed to determine whether it is sensitive to developmental growth in communication.