Gear Up for Lively Debates In a throwback to earlier times, sessions on controversial topics headline this year’s convention. Features
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Features  |   August 01, 2016
Gear Up for Lively Debates
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Hearing Disorders / Swallowing, Dysphagia & Feeding Disorders / Special Populations / Autism Spectrum / Professional Issues & Training / Features
Features   |   August 01, 2016
Gear Up for Lively Debates
The ASHA Leader, August 2016, Vol. 21, 54-62. doi:10.1044/leader.FTR3.21082016.54
The ASHA Leader, August 2016, Vol. 21, 54-62. doi:10.1044/leader.FTR3.21082016.54
Top-down or bottom-up treatment approaches for children with autism?
Treat an adolescent’s anxiety first and then his stutter—or vice versa?
Does reducing the risk of aspiration in people with dysphagia increase the possibility for other, more dangerous, conditions?
And where—if at all—do over-the-counter hearing devices fit into an audiologist’s practice?
Perhaps these questions make you uneasy. After all, some of the leading researchers and clinicians in communication sciences and disorders fervently argue in favor of opposite answers. The 2016 Convention will feature these four controversial topics in a series of debates and—in the case of personal sound amplification products (PSAPs)—a panel discussion.
Convention program planners designed these special sessions to resurrect a convention format common in years past. Characterized by vigorous discussion and thoughtful reflection, the sessions will provide a forum for panelists and audience members to explore theoretical and practical issues.
Will these colloquia lead to certainty? Probably not. But they will feature lively discussion and deliberation by professionals with expertise and insight into the topics at hand.
The ASHA Leader staff spoke with the session facilitators to get a pulse on the discussions.
Hold on to your hats, convention-goers. It’s going to be a wild ride.
From Silence to Effective Communication
Experts will debate behavioral versus naturalistic approaches to language learning in children with autism.
Which works better for teaching children with autism to speak: a naturalistic, child-directed approach or a more structured, clinician-directed approach? That question has been debated in the autism community since the 1960s—and this year the debate is coming to a meeting room near you at the ASHA Convention.
“Children with autism are as variable as neurotypical children, and we are beginning to understand that there are many types of autism,” says debate moderator Tina Veale, program director and professor of speech-language pathology at Midwestern University in Glendale, Arizona. This variation makes it important for speech-language pathologists to fully understand different treatment philosophies and methods, “and help families choose an approach that will work well for them and their child,” says Veale.
On the naturalistic side, used in programs like Floortime, children direct the treatment, choosing preferred activities while clinicians work alongside them on communication goals. The idea is that children best learn language as they interact within their natural environments.
On the behavioral side, represented notably by the Lovaas model of applied behavior analysis (ABA) and the Picture Exchange Communication System (PECS), clinicians direct treatment, focusing on developing targeted skills. The idea is to build communication block by block, in a highly structured way.
“While behavioral and naturalistic methods are vastly different, many approaches combine elements from each model,” says Veale. “A good example of this is TEACCH [a method developed at the University of North Carolina at Chapel Hill], which uses direct instruction within everyday routines. Many family-centered models also blend elements from many methods.”
Presenters at the convention session will describe the underlying language-learning theories—and the 20 years of intensive research—that support these approaches. “I want attendees to understand that there is more than one way to treat autism, and to walk out with respect for these different positions and more understanding of treatment options,” says Veale. “SLPs need to have lots of strategies to treat the many variants of autism.”
In brief, the presentations will feature:
  • ASHA Past President Patricia Prelock of the University of Vermont, on family-centered naturalistic treatment.

  • Erika Olmedo of CommuniKids, on Developmental Individual-difference Relationship-based (DIR)/Floortime.

  • Mareile Koenig of West Chester University, on ABA techniques.

  • Lori A. Frost of Pyramid Educational Consultants, on PECS.

The real crux of the debate, says Veale, is that although neurotypical children learn language effortlessly through incidental learning in their natural environments, many children with autism do not. So they need help.

“I want attendees to understand that there is more than one way to treat autism, and to walk out with respect for these different positions and more understanding of treatment options.”

“Therapists must decide whether to approach the language-learning task in a direct, bottom-up manner, as with ABA, or use a context-dependent, top-down naturalistic way,” Veale says. “It’s important to recognize that different children learn differently, whether they have autism or not.”
Intensity is also key. Research has shown that children with autism need 25 or more hours of language intervention per week to successfully acquire language. “No matter what technique is applied,” says Veale, “intensity is pivotal.”
Veale hopes that SLPs leave the session with fresh perspectives on what classic treatment models offer. “Making the best choice in language intervention is the first step along the long road from silence to effective communication,” says Veale. “It is a critical moment in the life of an individual with autism.”
—Bridget Murray Law, editor-in-chief, ASHA Leader bmurraylaw@asha.org
Are We Over-Modifying Diets?
Modifying the diet of a patient with dysphagia may not be the treatment of choice if it increases other risks.
If a speech-language pathologist prescribes a modified diet to reduce the aspiration risk for a patient with dysphagia, is the clinician increasing the risk of other—perhaps more serious—complications?
This question—and how to handle the possible implications of a modified diet—are at the heart of the dysphagia debate at this year’s convention, according to the debate’s moderator, James F. Naas. A private practitioner in Kentucky, Naas specializes in treatment for people with stroke, head injury, and head and neck cancer.
Clinical preparation and shared decision-making also are important issues to explore, he says.
“Some SLPs err on the side of what they think is ‘patient safety,’ because a patient may tend to aspirate liquids or foods,” says Naas, “and they choose to adhere to that position even when the patient or family members exercise patient autonomy and refuse modified foods and liquids.”
Naas contends that clinicians often don’t know what the consequences of aspiration might be. “But there is clear science about the consequences of dehydration, malnutrition, urinary tract infections and dental caries,” all of which may result from a person refusing to eat or drink what is offered. And “motility disorders may be exacerbated by a well-meaning clinician insistent on providing only thickened liquids.”
In addition, patients’ prescribed medicines may significantly affect their ability to ingest food or liquids, and increase their aspiration risk.

“We really don’t fully know what the consequences of aspiration are. Your tolerance of aspiration may be very different from mine.”

Academic programs tend to focus on teaching students to avoid aspiration, Naas says. “That’s what students hear, and we often don’t teach about the other issues. But we really don’t fully know what the consequences of aspiration are. Your tolerance of aspiration may be very different from mine.”
Some work environments, administrators, physicians and legal personnel—rather than the clinician’s best judgment—may also influence patient care and decision-making regarding modified diets, Naas explains.
One of the keys to this issue is refining dysphagia management education in training speech-language pathology graduate programs. “From a medical model, there’s a difference between training and education,” Naas says. “We have to refine our educational model for teaching about dysphagia. Students need to learn about dysphagia management in terms of treatment efforts that hold promise as opposed to just diet modification.”
Naas cites several research studies underway that demonstrate effective treatments for people with dysphagia—including those with dementia—and help people continue to eat and drink the foods they enjoy.
SLPs’ role in patient management and decision-making is also up for debate, Naas says. “We’re not very good at patient management,” he explains. “We’re unsure about who should take the lead in certain environments in making some dysphagia decisions.” Medical paternalism—an environment in which physicians make all the decisions, with the patient doing only what is directed—is not a model that works particularly well, he says, and clinicians need to be able to take an active role in dysphagia-related issues.
Naas looks forward to a “provocative discussion” with panelists Jacqueline Hind of Swallow Solutions, Joseph Murray of the VA Ann Arbor Healthcare System, Pamela Smith of Bloomsburg University and Debra Suiter of the University of Kentucky.
“I hope this discussion helps people move forward in this area,” he says, “and leads to a greater commitment to focused research and practice and changes in the educational preparation of clinicians.”
—Carol Polovoy, managing editor, ASHA Leader cpolovoy@asha.org
Finding the Right Words
A debate on approaching early and later fluency intervention will feature arguments, rebuttals and conclusions.
Four SLPs specializing in fluency will present two different perspectives on case studies examining earlier and later stuttering treatment at one of the convention’s debates.
Moderator Joseph Donaher, academic and research program director at the Children’s Hospital of Philadelphia’s Center for Childhood Communication, plans to make sure everyone sticks to their allotted time so that a variety of perspectives can be shared: They get 10 minutes for an opening argument, followed by six-minute rebuttal speeches and even shorter closing summaries. So the four presenters need to choose their words carefully.
Presenters for the first case study will discuss options for treating a preschooler with fluency issues. Marilyn Nippold from the University of Oregon and Nan Bernstein Ratner from the University of Maryland will offer perspectives on how they’d approach this case and why. Donaher expects them to talk about ways to determine if the student needs intervention, as well as what approach will provide the best results or change for such a child and the family.
Next, the University of Georgia’s Anne Bothe Marcotte and Marshall University’s Craig Coleman will share their viewpoints on an adolescent case study. Donaher anticipates this portion of the session to get a little more passionate. In addition to discussing intervention goals, he expects presenters to cover options for mitigating the negative impact of a fluency disorder.

“Some believe wholeheartedly in certain programs, while others feel evidence-based approaches won’t work for all cases, because treatment is so individualized that you can’t group results together.”

Older students who stutter tend to experience high levels of anxiety, for example. One point presenters might argue is whether the student’s fluency must improve in order to reduce anxiety or whether reducing anxiety first would help make fluency treatment more effective.
In addition to drawing on their experiences, presenters will offer evidence to support their perspectives. Research on stuttering treatment outcomes is limited, notes Donaher, and existing studies spur differing opinions.
“Some believe wholeheartedly in certain programs,” says Donaher, “while others feel evidence-based approaches won’t work for all cases, because treatment is so individualized that you can’t group results together.”
The presenters all share a common goal, of course—improve outcomes for people who stutter. Donaher expects this debate to produce much-needed discussion and understanding about fluency issues and approaches. The format offers several advantages over straightforward lecture or panel presentations, he explains.
First, timed speeches will keep everyone on topic and force presenters to share clear, concise highlights of their beliefs along with strong supporting evidence. Next, four topic experts will give their reactions and challenges to what the others say—in a civil manner. Finally, the audience gets to hear multiple informed approaches to treating stuttering.
“Getting to hear evidence and challenges from all presenters lets everyone in the audience take home what they like from all perspectives,” says Donaher. “It’s really similar to what each clinician goes through every time they work with a client who stutters, and this session should allow them to make better informed decisions for themselves.”
—Shelley D. Hutchins, content producer/editor, ASHA Leader shutchins@asha.org
Why the Controversy Over PSAPs?
A convention panel session tackles the hot, nationally debated topic of personal sound-amplification products and their role in audiology.
Most audiologists would probably agree that hearing health care should be more affordable and accessible for the large number of people with age-related hearing loss.
But how to make this happen is the root of a wide disagreement across the profession and its stakeholders, with two sides holding very different opinions. The panel “Use of PSAPs for Affordable Treatment of Age-Related Hearing Loss” aims to tackle this “polarizing topic,” says session chair and moderator Sherri Smith, audiologist at the Mountain Home Veterans Affairs Medical Center and associate professor of audiology at East Tennessee State University.
One side of the debate calls for easing Food and Drug Administration (FDA) guidelines to make personal sound-amplification products (PSAPs) more readily available to adult consumers with mild-to-moderate hearing loss. These PSAP supporters note that the devices are relatively inexpensive and easy to use compared with hearing aids.
The other side warns about possible dangers of the devices—such as the damaging output levels available in some models. These PSAP detractors also raise concerns that the devices de-emphasize audiologists’ expertise and professional medical advice regarding treatment of the serious, chronic health condition of hearing loss.
The hour-long session will include 10-minute presentations from three speakers: Neil DiSarno, ASHA chief staff officer for audiology; Ruth Bentler, University of Iowa professor and chair of the Department of Communication Sciences and Disorders; and Barbara E. Weinstein, professor and founding executive officer of the City University of New York Graduate Center’s AuD program.
Kicking off the session, DiSarno will introduce the topic and review background information, such as recent reports and recommendations from the President’s Council of Advisors on Science and Technology (PCAST) and the National Academy of Sciences (NAS). (In response to the PCAST and NAS reports and in presentations to the FDA, ASHA, while commending the groups’ attention to hearing health care, has been critical of their lack of focus on audiologist-provided counseling and aural rehabilitation in the reports’ recommendations regarding PSAPs and a newly proposed class of over-the-counter hearing devices.)
Bentler will then present current research evidence comparing outcomes of hearing aids versus PSAPs, followed by Weinstein’s examination of the pros and cons of incorporating PSAPs in clinical practice.
“I think hearing both sides of the argument will be very beneficial to those attending the session,” says Smith. Attendees will also be able to discuss PSAPs with the panel members in the remaining 30-minute Q&A session. “All questions related to this issue are fair game during the Q&A portion of the session, which I think will make for an interesting discussion.”
By the end of the session, Smith says, the information presented may help form attendees’ opinions “one way or the other, and may inform whether or not they’ll adopt PSAPs in their practice.”
—Haley Blum, writer/editor, ASHA Leader hblum@asha.org
3 Mini-Series Explore Hot Audiology Topics

Audiologists will be able to take a deep dive into topics covered in three mini-series at this year’s convention.

Presenters will discuss ototoxicity, development and testing of vestibular reflexes, and noise-induced hearing loss in separate mini-series, each with three one-hour presentations on the issue’s underlying science and clinical applications for children and adults.

“We wanted to put together a lineup of presentations that was current, exciting and novel, with a breadth that would be attractive to attendees, regardless of their practice setting,” says A. Tucker Gleason, convention audiology chair and associate professor in the Department of Otolaryngology–Head and Neck Surgery in the University of Virginia Health System.

Convention-goers can attend all three talks within a topic area, or they can pick and choose which individual sessions are most relevant to them, Gleason says.

1 Comment
August 18, 2016
Nikia Dower
Gear Up for Lively Debates: From Silence to Effective Communication
Could ASHA or Tina Veale post references to published studies showing that "Research has shown that children with autism need 25 or more hours of language intervention per week to successfully acquire language. 'No matter what technique is applied ... intensity is pivotal.' ?
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