ACQ Vol 10 No 2 2008

Work– l i f e balance : preserv i ng your soul

Clinical case Subject

commencement of work towards the goals, and a specific timeframe must be set for independent evaluation of progress, or rating, using the pre-set scale (Cardillo & Choate, 1994). The follow-up rater collates a “summary score” which is used to find a corresponding T-score (Cardillo, 1994). GAS has been found to have high inter-rater reliability (Stolee, Rockwood, Fox & Streiner, 1992) while reliability over time and between scales has not yet been shown (Caslyn & Davidson, 1978; Cardillo & Smith, 1994). The validity of GAS as an outcome measure has been criticised (e.g., Caslyn & Davidson, 1978); however, a number studies (e.g., Goodyear & Bitter; 1974; Williams & Stieg, 1987) found GAS to be a valid and reliable outcome measure in the rehabilitation setting (Hurn, Knee­ bone & Cropley, 2006). A review of research in this area has shown that while GAS has flaws in terms of a “general measure of outcome”, it is a strong measure of “treatment- induced change” (Smith & Cardillo, 1994, p. 272). It is recom­ mended that it be used in conjunction with other standardised forms of assessment for pre and post testing (Smith & Cardillo, 1994; Malec, 1999). GAS has been found to measure “clinically important change” (Rockwood, Stolee & Fox; 1993, Rockwood, Joyce & Stolee; 1997), including small changes which may not be detected in standardised assessments (Rockwood, Stolee & Fox; 1993; Malec 1999). PROMPT uses a structured format for a “System Analysis Observation” based on the stages of the Motor Speech Hierarchy (TPI, 2007) which forms the basis of assessment, and leads into the development of three main goals for therapy (TPI, 2007). GAS can be seen as a natural extension of this, allowing for systematic evaluation of the outcomes of these goals.

The client involved in this project, DB, was a 4-year-old boy. He was initially seen by a non-PROMPT trained therapist, and was found to be suitable for a trial of PROMPT therapy. He was then referred to a PROMPT trained therapist for on­ going therapy. The potential of GAS as an outcome measure for PROMPT therapy arose and was seen as an opportunity to explore the tool for this purpose. Much of the background information reported here was gleaned retrospectively from reports and progress notes from the initial therapist; therefore sufficient baseline measures desirable for the present study are lacking. An initial assessment of DB’s speech and language skills prior to commencement of PROMPT therapy indicated severe speech and language difficulties. His hearing was found to be within the normal range and gross and fine motor skills (except oromotor skills) were developing normally. He used mainly vowel sounds when speaking and was unable to be fully understood in social situations. DB had an expressive vocabulary of 4–10 recognisable words (e.g., Mum and “gar” for “car”), using four different consonant sounds (/g/, /h/, /m/, and /j/). He was unable to complete a formal articulation assessment due to his limited vocabulary. DB did not use any grammatical markers, and his mean length of utterance was 1–2 words. He also showed significant delays in receptive language including difficulty understanding questions and grammatical markers, and difficulty following multi-step directions. Social communication difficulties were also noted, including difficulty initiating communication (including non-

Table 1: Goal attainment follow-up guide; DB’s therapy goals Goal 1 Goal 2

Goal 3

Goal 4

Level of attainment

DB will count from 1-5 without PROMPT

DB will pronounce words with changing jaw gradient (4-1)

DB will produce CV words with rounded vowels

DB will produce alveolar consonants in the initial position of CV words DB will elevate his tongue to the alveolar ridge for /n/ with PROMPT <50%. DB will elevate his tongue to the alveolar ridge for /n/ /t/ and /d/ with PROMPT <50%. DB will achieve correct tongue placement for alveolar sounds 2 on 50% of attempts with PROMPT. DB will produce alveolar sounds in isolation with PROMPT

Much less than expected –2

DB will need surface PROMPTs to produce an approximation 1 of each number. DB will produce one number without surface PROMPTs, yet will need PROMPT for other numbers. DB will produce two numbers without surface PROMPTs. (may need visual/auditory cues) DB will produce three numbers without surface PROMPTs. (may need visual/auditory cues) DB will produce all

DB will need parameter PROMPT for jaw gradient on all target words DB will need parameter PROMPT for 80-90% of target words. DB will need parameter PROMPT for 60-70% of target words. (may need visual/auditory cues) DB will need parameter PROMPT for 50% of target words. (may need visual/auditory cues)

DB will produce 50% of target words with surface PROMPT. DB will produce 70% of target words with surface PROMPT.

Somewhat less than expected –1 Expected level of outcome 0 Somewhat more than expected +1

DB will produce 70% of target words with verbal cue to round lips.

DB will produce 90% of target words with verbal cue to round lips.

DB will produce alveolar sounds at the beginning of CV words with PROMPT.

Much more than expected +2

DB will need parameter PROMPT for less than 50% of target words.

DB will produce 70% of target words without verbal cue or PROMPT.

numbers without surface PROMPTs.

1 Expected pronunciation of numbers: one- ‘ooah’, two- ‘oo’, three- ‘ee’, four- ‘for’, five- ‘fah’ or ‘fy’ (as in ‘my’). 2 Tongue placement without production of sound (ie. no airflow) acceptable.

57

ACQ uiring knowledge in speech , language and hearing , Volume 10, Number 2 2008