Surprise! Science says more therapy isn’t always better…

This is a transcript from our podcast episode published October 3rd, 2022. The podcast episode is offered for .1 ASHA CEU (introductory level, related area). This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime.

A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible.

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[00:00:00] Kate Grandbois: Welcome to SLP nerd cast, the number one professional resource for evidence based practice in speech language pathology. I'm Kate Grandbois 

[00:00:09] Amy Wonkka: and I'm Amy Wonka. We are both speech language pathologists working in the field and co-founders of SLP nerdcast. 

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[00:01:44] Kate Grandbois:Welcome to today's episode everyone. We are so, so, so excited for today's conversation. We're so excited. In fact that we got very sidetracked before we hit the record button and had to stop ourselves from going down a rabbit, a million different rabbit holes. We're here today to discuss [00:02:00] dosage and frequency of treatment and we are, we have the great pleasure of welcoming Dr. Mary Beth Schmidt onto our show. She is a researcher who is an expert in this area. Welcome Mary Beth.

[00:02:12] Mary Beth Schmitt: Thank you. Thanks for having me.

[00:02:18] Amy Wonkka: All right, Dr. Schmidt, you're here to discuss a very, very exciting topic. Um, how much therapy do children need to make progress and what we know and don't yet know about prescribing speech language therapy in schools. I'm really excited to have this conversation, but before we get started, can you please tell us and our listeners a little bit about yourself?

[00:02:40] Mary Beth Schmitt: Sure. So I am a speech language pathologist. That's um, that's my background. I work, have worked with children and families, um, for a lot of years now. uh, but I've worked in the schools. I've worked in university settings. Um, both as a supervisor, as an instructor, went back [00:03:00] later in life to get my PhD focused on clinical research, um, with a specific goal of supporting SLPs, um, specifically in the schools, right.

Trying to equip them with, what do we know, um, about what works, um, and what doesn't work for children with language disorders, um, in a very kind of naturalistic setting. And so I am currently, um, a assistant professor at the University of Texas at Austin, where, um, I do some teaching and mentorship and get to partner with SLP and school districts.

Um, around the country to promote what we know about kids with DLD, um, from a research perspective, 

[00:03:44] Kate Grandbois: we're so excited to have you here. I cannot wait to read our learning objectives and disclosures so that we can have this conversation. Okay. So learning objective number one, describe the role of dose and frequency on children's outcomes.

Learning objective [00:04:00] number two, describe how student engagement relates to learning outcomes. Learning objective number three, identify at least three strategies for implementing the key findings from dosage and frequency research in your current practice disclosures, Mary Beth Schmitz financial disclosures. Mary Beth receives salary support from NIH for a current study related to treatment intensity. She receives compensation for her role as EBP brief editor, Mary Beth is employed and receives a salary from University of Texas Austin.

Mary Beth also received an honorarium for participating in this course, Mary Beth's non-financial disclosures. Mary Beth is an ASHA member. Kate Grandbois financial disclosures. That's me. I am the owner and founder of grand wa therapy and consulting LLC. And co-founder of SLP nerd cast. My non-financial disclosures.

I'm a member of ASHA SIG 12, and serve on the AAC advisory group for Massachusetts advocates for children. I'm also a member of the Berkshire association for behavior analysis and therapy and the association for behavior [00:05:00] analysis international and the corresponding speech pathology and applied behavior analysis, special interest group.

[00:05:04] Amy Wonkka: Amy's financial disclosures. That's me. I'm an employee of a public school system and co-founder of SLP nerd cast. And my non-financial disclosures are that I'm a member of ASHA. Um, I'm a member of special interest group 12, and I serve on the AAC advisory group for Massachusetts advocates for children.

All right, Dr. Schmitt, why don't you start us off by telling us a bit about our first learning objective. Tell us a little bit more about the role of dose and frequency on children's outcomes because that seems like something we should know a bit about. 

[00:05:39] Kate Grandbois: Wait, tell me everything. 

[00:05:43] Mary Beth Schmitt: right. How long do we have?

So, um, okay, so to nerd out a little bit, it, I think the relevance of what we're gonna talk about is really grounded in where these data came from. So if I might let me give a little bit of background. [00:06:00] And so this study was funded by the department of education, um, institutes of educational science, um, and included 300 kids approximately just shy like 294 kids with language impairment who had already been diagnosed in the public schools and were being served by school based SLPs.

And why that is really, really important is well, and then one other piece, we, we went in with the intent of, of really kind of capturing business as usual treatment, meaning we didn't ask the SLPs to do anything different. Nothing at all. Um, because we wanted to capture out of the hundreds of decisions that LPs are making for their students, which ones are driving outcomes for their kids.

So we're gonna call that like an active ingredient, like which decisions are actually really important for us to be thinking about. And then maybe which other decisions we don't find any [00:07:00] connection to their outcomes. And so it was really important that, that we kind start with, well, what are you already doing?

Like before we go in and say, Hey, SLP, do this different, do this different. We need to know like, what are you already doing that we can capitalize on? Um, in a way that advances outcomes for our kids. 

[00:07:21] Kate Grandbois: I just wanna pause right there and soak up how important this question is. How important is it for us as clinicians to pause and or for you as researchers to ask this question?

What is it that we are doing that is working? What is it? That's our whole jobs. Our whole jobs are to do things that work. Yeah. And I, I can't wait to hear the answer to the question. I just, I just wanted to take a minute to talk to just to important this question is. So, and thank you for doing the research, but keep going, keep going.

[00:07:52] Mary Beth Schmitt: Absolutely. Absolutely. We had a running joke with our team that like, what is at the end of the day, the thing that [00:08:00] matters is like flannel boards, right?

FLA not really. That was

it captured, I think the true openness, right. Of we're gonna go in and gather as much data as we can, um, across all of these metrics. And so, um, what we asked then the SLPs to do and like, Kudos to these SLPs. So there were 75 school based SLPs that signed up for this. And we will, as a field, like never get over thanking them because here's what they did.

Right? Like they agreed to follow up to five kids on their caseload, who again were already diagnosed with language impairment. And so within this, it also captured the great heterogeneity of kids on our caseload, right? Because we relied on them. Who on your caseload, have [00:09:00] you already determined to have a language impairment?

It wasn't our definition. Right? These were school based kids. And so they were already diagnosed. So then every week they filled out a log that captured what days the kids came to therapy, how long they were there. So a literal start time. And end time, this wasn't what the IEP said. This was the actual, this week.

How often did I see the kid, whether or not they, um, were absent that day, we had to cancel therapy. How many kids were in the therapy session, um, where the therapy session was, whether the kids involved were typical peers, um, or if they, uh, were other kids that had an IEP, a ton of information, right. About their therapy sessions every week.

And then in addition, the SLPs videotaped five therapy sessions over the academic year. And again, it was literally like set the camera up and press record and do your [00:10:00] awesomeness, um, without any finangling of what we just asked them to capture kind of a representative day. And so from that data, then we were able to capture literal dose and frequency.

So for this, and I've learned this talking with different groups across the country, I think sometimes our definitions are different. Um, Amy you're nodding. Yeah. 

[00:10:25] Amy Wonkka: Maybe if you could just give us and, and our listeners, I guess would give me sort of an idea of what, what your definitions are for those terms.

That would be helpful. 

[00:10:33] Mary Beth Schmitt: Yeah. And our definitions, um, came from the research, but you guys let me know if we need to be using different terms that would align better to what school-based SLPs are doing day in and day out. Or if this varies across districts like this is I think an kinda an interesting semantic question, right?

Um, dose. Well, let's start with frequency. Frequency is literally like how often do the kids show up? [00:11:00] So are you seeing them once a week, three times a week? Like what, how literally, how many times are they in your presence and you are in their presence dosage then can be defined a couple of different ways.

Sometimes you'll see dosage in the, um, in the literature referred to as like numbers of opportunities, like how many opportunities did they have to work on a specific goal or that type of thing? Um, the way we coded our therapy videos, we were actually able to capture time, not time in the session, but time where language goals were being actively targeted and we know this to be true.

Right. 

[00:11:48] Amy Wonkka: So I was gonna say as a school based person, and particularly earlier on in my career, I did a lot of groups and sometimes you have this really eclectic mix of students in your group, and you may [00:12:00] have four or five students who have really different IEP goals, but that's how the schedule worked out.

Um, so yeah, saying that they have a 30 minute session is maybe not exactly fully capturing the amount of time on task. So very cool.

[00:12:16] Mary Beth Schmitt: Yeah, absolutely. And the way we did it for this study is we, we didn't parcel out for every child, but just looking at the session as a whole, how much time was spent on a language goal, defined as you know, if they were working on grammar, they were working on vocabulary, narratives, literacy, um, phonological awareness type things, just kind of literacy.

Um, like how much of it was language, how much was spent on articulation and then coding, how much was spent on somebody had to go to the bathroom, you're having to manage conflict. You're switching out activities. Maybe you're reading a book, but the kids are not really being asked to do [00:13:00] anything right now, except for listening.

And so we separated out all those components of the therapy session, regardless of how long, and then extracted out of all of that, how much of that time was spent on language and for this study, that represented dose. 

[00:13:21] Kate Grandbois: So to say that back to you. The active participation a time that was spent in active intervention, where goals were being actively addressed.

Cause I'm think I'm just reflecting on my own treatment session. You know, my clients under the table running around the room, avoiding work, 

Mary Beth Schmitt: absolutely 

telling jokes with me, telling me about their weekend. I mean, there's a lot. I wanna call it fluff or like stuff it's rapport building.

It's important, but it's not necessarily active intervention. Right. So what you're talking about is time spent during active intervention. 

[00:13:56]: Mary Beth Schmitt That's right. Okay. That's right. Um, [00:14:00] and so with that, then you can tell, like we kind of ignored what the length of the actual session was. Cause the theory was that, well, it's not just being in the speech room that, oh, you know, language is part comes down upon the child, you know, but it's, it is that active back and forth.

And so we captured how much time was spent in that. And so from our research, what we found is that on average, on average, there was about 11 minutes, again, not per child, but per group. Right. So 11 minutes spent on language therapy. The average session length was about 22 minutes long. So about half is what we found on average.

About half of these therapy sessions for kids with language impairment were actually spent on language goals. And we could probably pause there just for that take home. 

[00:15:02] Amy Wonkka: And I think, sorry, go [00:15:00] ahead. Nope. You go ahead. I, I think I, it raises questions for me about did you get, this is just me being nosy, potentially get details about what those groups were working on.

Like, was that a group where half the kids had articulation goals and half the kids had language goals? Um, it's, it's always because every group is unique, right? It, it must have been very hard to get a good feel for. Why that amount of time was that amount of time? Was that the amount of time? Because it was a group who just had a lot of challenging behavior as a group in their dynamic was a lot of redirection.

Did you get any of that information or was that a two?

[00:15:40] Mary Beth Schmitt: Yes. Yes. Great question. It varied. Right. As you might imagine, there were some where you know, that 11 minutes was the average, so it could have been a lot less than that. I think it was like zero up to like 22 minutes. Um, some of the, so then you're looking at, well, what [00:16:00] were the other 11 minutes?

Right? And sometimes it was articulation. Um, sometimes it was what we called management. So a lot of redirection, whether it was somebody off task or just somebody chatty, right. Wanting to talk about whatever, you know, their experience with grandma over the weekend or what they're seeing outside the window, or, you know, whatever the case may be.

And then other times what we call null where. It literally was quiet for a minute in the therapy room and the SLPs were changing out materials or they were, um, you know, needing to reference their lesson plan or whatever the case may be. And we go back to the original goal of the whole study, right?

Where there wasn't any judgment, right? Like, is this good? Is this bad? Is this irrelevance? Why that half of the therapy session, for kids with language impairment is focused on language. We don't know whether or not that mattered 

[00:16:59] Amy Wonkka: [00:17:00] because we also aren't robots and children aren't robots so it also, would've been surprising, you know, to consistently see, yes, all 22 minutes, we are just, boom, boom, boom.

And nobody ever tells us a story about grandma and we never look outside the window, you know? So, so yes, I think if you work with children, that's. That also makes sense because children are people and other people are people and, and we are not on task all the time. 

[00:17:23] Kate Grandbois: And some of those softer non-active intervention minutes are also really important for developing a flow of a session or, you know, making a connection with a student because maybe grandma just passed away or maybe it was a, a super fun weekend and they wanna share it with you.

I mean, there are so many softer things that go into relationship building to create safe spaces and get work done. But anyway, keep going, right. Keep telling us what's happening. I, now I can feel myself going another rabbit hole 

[00:17:51] Mary Beth Schmitt: right. Well, and I, and I think a different rabbit hole for a different day.

But part of like, when we think about to our last learning objective and like, what does this matter? [00:18:00] And I'm trying not to give the ultimate spoiler alert here, but right. But I think as a profession, we need to be thinking about like how, how we're talking about the therapy we're providing. So if we're saying we're gonna see kids for 20 minutes, Twice a week.

There's kind of that assumption that 20 minutes are spent on goals. And what, what we found is that that's not an accurate reflection. Right? And so again, maybe that mix is what's supporting kids. Maybe it's not that, that we really need to be thoughtful of how are we talking about this when we're talking about how much therapy kids need or don't need just, just that, right?

Like maybe, maybe we need to be thinking about it in a little bit of a different way and so that, okay. So frequency, literally how many sessions dose the time spent on goals, not the session and then duration. So for how long are we gonna look at [00:19:00] this to kind of get a snapshot? And for us, we followed an academic year.

And so for most kids that meant about 36 weeks worth of those therapy logs that the SLPs filled out. And what that means is that not only did we get frequency every week. We got the sum total, literally how many sessions did each individual child receive over the entire academic year and how much dose was represented in all five of those videos?

And so this is another important methods point. We looked at the, the therapy videos that we coded, cuz we only coded three of them. One at the very beginning of the year, one in the middle one at the end and the, the correlation. So when we looked at the statistics, the dose was crazy related to each other.

And so what we found in that is like, it seems to be pretty representative of what the groups are. We didn't see vast variation. We [00:20:00] saw a lot of variation between kids. We didn't see a lot of variation for each individual child's experience. Does that make sense? So like the dose captured in the first video, the dose captured in the middle video and then the dose captured at the end was pretty similar. And so we felt pretty confident then making that assumption of like, okay, then each child's experience is pretty similar. And so we can use that as a representation then of how much dose did they get throughout that academic year. 

[00:20:32] Amy Wonkka: That's interesting too. Right. I think as a clinician, that's interesting.

And back to my sort of side question about, well, what were they doing in that other time? It's interesting to think about. All right. Well, maybe part of that was because it was a, it was a mixed group and part of your time was intended to be spent on articulation. And part of your time was intended to be spent on language.

Or perhaps we, we just have a real chatty group of friends,[00:21:00] 

And we’re just doing lot of grandma chats. So that's, that's interesting. That's interesting to hear. 

[00:21:10] Mary Beth Schmitt: So we were curious then to know, does any of that matter, does. Frequency or dose matter, or is there a relationship between the two, cuz there's a little bit of research really from education more than we hadn't seen it done yet in speech pathology that looked at the interaction between the two, meaning there's been tons of research in speech pathology, looking just at dose or just at frequency, but very little looking at what they call the cumulative intervention intensity, looking at the, kind of the multiplication of both dose and frequency.

Um, and so that's what we did in this research and we controlled for their language at the fall. And what that means is that we, we controlled for any possibility [00:22:00] that our findings were related to severity, right? Like maybe kids who had more severe language had a different frequency and dose than kids with more mild, um, language impairments.

We took that into consideration. And so we're looking at all areas of language. So looking, um, across, um, content form, mostly content inform and, um, and looking at that both at the fall and the spring, so that we were able to see children's language change over that academic year, and then looking at dose frequency in the combination of the two in respect to their outcomes.

[00:22:40] Kate Grandbois: So I'm gonna say respect to you and sort of, and sort of paint this picture of where we are in this story, right? Yeah. Cause so much like this is, is storytelling. Yeah. You took a boatload of data. I mean, it sounds to me like you had so much information at your fingertips to analyze and [00:23:00] look at to see what variables again, going back to this original question, what are we doing?

That makes a difference. What are we doing that is working? And you looked at all these variables sounds like I am not a researcher by any stretch of the imagination, but to sort of reflect back something that you mentioned before we hit the record button, it sounds like this is very sound science. Like the science of this is, is very good in terms of what you controlled for is that, I mean, I feel like that's an important piece of this story.

[00:23:28] Mary Beth Schmitt: Absolutely. Um, Jessica Logan was our methodologist in this study and, um, she just does phenomenal work. And so we had this team of researchers who bring kind of the more content knowledge. So those of us with experience in the schools and understanding language and understanding the dynamics they're in and then, um, methodologists and statisticians that can really oversee the, um, both the design as well as the, the numbers.

Right. And the, the mathematical component of it. And then it's all done [00:24:00] in teams, right. We're we're talking about it, we're wrestling with the data, um, and making sure it, it all aligns and then it makes sense. So, yeah. 

[00:24:11] Kate Grandbois: So not only is this an incredibly important question, but what you are about to tell us these findings was done in a way that we is valid and reliable and we can trust it.

Yes. Excellent. Okay. Don't tell us this

[00:24:25] Mary Beth Schmitt:. are you ready? And I'll tell you that too. We're it out? Just one more, more when we first ran these's analysis, right. And found what I'm about to share. We did not believe it. We were like, we did something wrong. There was a glitch in the data, like, go again. So that, and like more to your point, Kate, like we, we were doubtful.

We interrogated the heck out of this data, out of the analyses because [00:25:00] what we found was that dose mattered frequency mattered. When we looked at the combination of the two, they mattered differentially. Meaning when children had more dose and more frequency. So the high, remember I said that there was a lot of variability and that's awesome because where we see variability, we can explain something.

Some kids with number of sessions received 15 therapy sessions over the academic year, which translates to about one session every other week. Some kids received upwards of 90 or more sessions over the academic year, which translates to about three sessions on average per week. And everything in between some kids dose was as little as like zero to two minutes.

We'll talk about the two minutes, right? Two minutes per session. Some had that [00:26:00] average of 11 minutes and some had dose up to like 22 minutes on average, across those therapy videos. When we look at the outcomes, kids who receive like using all my hands, right? I'm like visual. I think the, the graph when kids received the higher number of frequency. So they were coming to therapy three times a week. And every time they came, the dose was towards 22 minutes. Their outcomes were quite poor, 

Kate Grandbois: poor? 

Mary Beth Schmittpoor, their, their outcomes were,, 

[00:26:41] Kate Grandbois: is this the moment where you had, no this is wrong. We have to do this differently. Is this the moment?

Do, what is this the moment where you looked at the data and said, this is, this is wrong. Something is wrong.

[00:26:50] Mary Beth Schmitt: Yes. Yes. Like our scales wrong. Like, did we flip the, the graph? Like what, what happened happened? [00:27:00] Kids were receiving more therapy relative to their peers did worse than so here are the two groups that did better.

Okay. Kids who either got high frequency. So they were towards that three times a week over the course of the academic year. But when they came, they got these short bursts, right. Their dose was like two minutes. They rocked it in terms of outcomes,

Kate Grandbois: joking. You’re a research researcher, you don't joke. There's no joking here with data. 

Mary Beth Schmitt:We don't have humor. 

[00:27:43] Kate Grandbois:Right.  uh, I, okay. Okay. Keep going. I mean, there's a million thing, more things. I, more questions. I know. 

[00:27:48] Mary Beth Schmitt: And like, I wish I wish so much that I could like paint a picture for your listeners. Right? So,

so it's dose in frequency working in opposite directions. So kids with high [00:28:00] frequency, three times a week, but low dose, these little spurts, like two minutes, they did great. Um, and by great, like let's define that, like let's. Let's be a little bit more specific they, they gained more in terms of their language growth or language change over the academic year than the kind of the average average amount.

Cause overall here's another take home, sorry, I'm going a little bit overall kids who get therapy do better than kids that don't get therapy. Like our therapy overall is effective. What we're trying to figure out is what pushes kids a lot more than just kind of the average. This is in general, what we expect to see in terms of language change for our kids, with language impairment.

There are some kids that are gaining a lot more over this academic year, and this is one piece of it that we are associated with or, or found associated with those changes, [00:29:00] high frequency, low dose, or, or the other split. The other side of that coin. Low frequency. So they were only coming once every other week, but when they came, their dose was high, their dose was more that 22 minutes of therapy, those two kind of profiles of kids, for lack of a better word.

Those, those two experiences for kids with language impairment was related to more gain over the academic year than the other two extremes kids who got low frequency and low dose. And that's intuitive, right. If they only came once every other week and they only got about two minutes of therapy, shocker alert, like they didn't do very well by the end of the year.

But, but the real big story though, is the other extreme. When they got more of both high frequency, high [00:30:00] dose, their outcomes were equally poor. 

[00:30:03] Kate Grandbois: This is insane. I have brain explosion, emojis, right? 

[00:30:06] Mary Beth Schmitt: Adjust. I still have brain explosion. And we've been talking about this for a while now. So, so to say the brain explosion back, yeah.

[00:30:15] Amy Wonkka: In general, receiving therapy helps school, age children. That's good thing. You have language disorders. It's good. But when you pull apart the progress that those different students are making the patterns that you see, the associations that you see are surprising because the students who are getting the most frequent longest amount of concentrated therapy are not the ones who are making the best progress that is being seen by either frequent, shorter duration or infrequent, relatively infrequent, longer duration.

[00:30:53] Mary Beth Schmitt: That dose dose dose. Yep. Yeah. And dose meaning not about [00:31:00] session length, right? Yes. I know. That's hard. Do, yeah. 

[00:31:03] Amy Wonkka: So it's not about what the session length is on paper. It's about the amount of time in that session spent on the language targets. You got it. That does kind of blow my mind little bit. Right

[00:31:14] Kate Grandbois:.Well, and I know I, what I'm about to say sort of touches a little bit on our third learning objective, and I don't wanna go there yet, but it's, I'm reflecting on myself as a clinician. And I know that if I only have five minutes, uh, if, if my, if I have a short, if, if I have a short dosage of time, that's allotted and, and I, I have to be more efficient.

Right, right. I have to spend more of my concentrated time, actively engaged in intervention. And I might not, I might not have an elongated chat about grandma. I don't know. I, I just, there are so many practical and I know we haven't gotten to the practical applications here yet, and I'm really jumping the gun, but this is just mind blowing.

It's making me think of so many additional things, 

[00:32:01] Amy Wonkka: but there are other places I remember reading about, you know, the idea that these short bursts of articulation therapy can be really effective. Right, right. Or that, you know, if you are working with somebody on motor speech goals, you might be better off doing frequent, shorter duration.

So as, as a school based person, I wish that there was more of this research out there because it would really help me in thinking about recommending service delivery. Right. But it's, it's it like blows my mind, but then also kinda makes sense. Cause I feel like we've. Things sort of like this about other areas.

[00:32:37] Mary Beth Schmitt: Absolutely. And you know what, that's what we went back to. So we reran the data. No, the science was sound. The analyses were sound. Um, we went back to prior literature and cognitive scientists have been saying this literally for decades. Like since the [00:33:00] 1960s, maybe even earlier, if memory serves across all content areas with reading, right?

The, they call it spaced versus mass. So spaced when you're spacing out, you're learning opportunities versus massed it's the idea of cramming for a test, right? Like we all had that experience in college. You can do it. Your brain will show up. Usually you cram the night before you get as much in as you, can you go take the test, you pass likelihood that you're retaining that information.

Slim to none, right? It's like cram, take the test done with that. I'm moving on in life versus when you spend time in it a little bit at a time over and over again, across they're showing it in math. They're showing it in reading. They're showing it in the arts, learning a musical instrument. I was sharing this before we hit record.

Like I'm working with a physical trainer right now on my wrist and ankles. And she said it the other day, she was like right up [00:34:00] doing 10 reps, five different times throughout the day is better for your muscles and really retraining than, than doing one set of 50. Right. That's spaced learning. That's dose across multiple frequency, right?

Low dose high frequency. That's exactly what she was prescribing of me too. And so it's. When we go back to then other disciplines and we really rely on like cognitive science, who's been studying the brain forever. We are just learning. We know this to be true about learning, whatever it is you're learning our brains do better with space opportunities rather than mass.

And what our study suggests is that kids with language impairment follow the same pattern. 

[00:34:53] Kate Grandbois: So before I, I, I, the application of this, again, the, the brain explosion emoji. But before we start [00:35:00] talking about that, I wonder if you can talk to us a little bit about how engagement factors into all of this. 

[00:35:06] Mary Beth Schmitt: Yeah.

Great question. So in a separate study, not related to this actual paper and these analyses, we looked at some of the videos of kids and specifically we narrowed in on how actively engaged are the kids during therapy. So we took those language, you know, how looking at their language goals and the dose of language.

And we went in and coded in 15 second intervals. Are the kids off task, meaning they're talking about, you know, grandma and the squirrel outside the window, or they're doing circles in their chair, or they're running around the room or they're underneath the table, or like they are literally doing something other than related to the task.

Are they passively engaged? 

 Meaning that when we look at the kids. Right. Um, from what we can tell, cuz we [00:36:00] can't see inside what's going on, but they're sitting still, they're looking towards the activity and or the speech therapist or the peer that's talking like the outward, um, appearance is somebody who's focused and attending to the task capacity, but they're not actively participating.

Right. They're just, they're there they're present. They seem to be attending and then actively engaged, meaning that they are either verbally or non-verbally responding to a prompt so that maybe, maybe they're answering the question or maybe they're following a direction, right. That can be nonverbal. Um, maybe their, um, whatever the, the goal or the prompt was, they're responding to it.

And so that was actively engaged. And so again, then we looked at, okay, does the, if we were able then to, to summarize. Or sum rather, how many intervals across a [00:37:00] therapy session were kids off task, passively engaged or actively engaged? We did have a fourth one that was kind of a mix, right? So like over 15 seconds, it was a little bit of this and a little bit of that.

And what we found was that it was active engagement that related to outcomes. And there was a wide range. We had some kids who were actively engaged zero during their therapy session. We had some kids who were actively engaged for the majority of their therapy session. And so what we found is that the more actively engaged the kids were the better their outcomes and the better their outcomes to quite a significant, um, degree in terms of changing their, um, the gain, the overall improvement of their language from the beginning of the year, to the end of the year, compared to kind of on average, what kids are, are receiving or benefiting from.

[00:37:57] Kate Grandbois: So to say this back to you [00:38:00] encompassing all of this, I I'm thinking about myself, any of our listeners, our jobs, what we want is to do things that work, that move the needle yeah. That have a positive impact for our clients. When we're making decisions about service delivery or planning our sessions. We wanna think about this intersection between dose and frequency.

Right. So either having a high frequency with a low dose or a low dose with a high frequency. Yeah. But also thinking, considering those idiosyncratic variables in our clients to try and get them as actively engaged as possible within that combination of dose and frequency. Is that an accurate summation?

[00:38:47] Mary Beth Schmitt:Yes. Yes. And again, like I heard this analogy once I didn't come up with this. Right. But. They liken active engagements to riding a bike. Like if you're learning to [00:39:00] ride a bike, you gotta get on the bike and balance and learn how to coordinate with pedaling and all the things like you have to be on the bike and try, you can sit on the side and you can have somebody narrate to you.

Okay. Here's how you ride a bike. You're gonna sit and you're gonna balance your body and you're gonna hold your hands on the handle. Like you could listen to that all day long, but guess what? You're not learning how to ride the bike until you actually get on and try. I think it makes sense for us when we think about articulation, right?

Like we need kids to actually attempt these sounds to get better at producing the sounds themselves. And yet when we think about it with language, you know, we've gotten feedback from SLPs before too, of like, but I was trained that they need good lo good language models first. Right. They need to listen to a lot of input first, before they get a turn.

And the [00:40:00] data suggests that that's not actually the case. 

[00:40:05] Amy Wonkka: There are so many interesting pieces here. So many my mind is getting so blown. I have a long commute. I listen to a lot of audio books and the theme this summer has been attention and I can't help, but make a connection between the findings of both of the studies that you're talking about.

Right? Yeah, because there, I believe is a fair amount of research also out there showing that our attention is better. All of us kids, grownups when we are actively interested in the activity. Absolutely. Right. So when we are able to have those higher rates of engagement, those kids are probably paying more atten like your operational definition of engagement is you know, you're seeing those things probably more often. And if I reflect on my therapy sessions, I'm seeing those things more often when I'm able to pick an activity that's motivating or meaningful for the student on my caseload. Right. I, if I were to try and collect that data, you collected myself [00:41:00] and code those interactions.

I think that I could definitely pick out some patterns yeah. With current and previous students about, oh yes. These activities are way more likely to get me that active engagement, um, as defined, you know, in your study. 

And then also our attention span. Isn't infinite as adults or children, and we're always switching back and forth with our attention.

Um, so I feel like another takeaway for me, kind of specific to the engagement is for us as clinicians to be really thoughtful. If we think we're going to maybe take that frequent, but low dosage approach to also really be thoughtful about making those low dosage amounts, high engagement, promoting activities, if we can, um, I know you didn't really do that study and I'm sort of extrapolating it, but, um, you know, that's, that's a question that it's raising for me is like, is there some intersection there too?[00:42:00] 

[00:42:01] Mary Beth Schmitt: Yeah, it's a good question. Right. And we haven't done that study. But again, the theory behind it all kind of makes sense. Right? And you, you know, we keep talking about the art, the comparison with articulation, it's that idea of short bursts where the kids are getting a lot of repetitions. I think it was Lynn Williams study that showed like upwards of 75 opportunities is what kids really need to change.

Amy Wonkka: It's super high number

Mary Beth Schmitt: and it's so, yeah, super high, but it's achievable if, and forgive me, cuz I'm talking to myself, if we'll stop talking, right. Totally kids can get those opportunities if we kind of take ourselves out and, and do some interesting things in therapy, 

[00:42:47] Kate Grandbois: what is making me think of, again, there's so many, this touches so much of what we do.

Yeah. I'm thinking about the planning and organizing to try to [00:43:00] actually make this happen. Right. And how much of this. Comes in contact with the infrastructural expectations of our workplace. So I have worked in places where I was told we do two times 30 here. Yeah. This is, this is the service delivery that we give as like a blanket, right?

Yeah, yeah. Or the conversations I've had with parents where let's say the service delivery is two times 30, but they want five times 60 . Yeah. You know, or, or the, or the contentious conversations with other providers who are giving a service delivery. And, you know, if you ask, well, why. Um, well, I, I don't know why now we have a why.

Well, because we know that I know that my student needs 10 minutes of a, of warmup to be actively engaged. I know that my student needs X, Y, Z sensory activity to be actively engaged. And it takes this much time. And, and based on this [00:44:00] research, we can also say most effective outcomes will be a combination of all of these variables.

This is, this is it. This is, this is everything. I can't believe that I've been practicing for 15 years. And I am just learning this today. I was today years old until all of these critically important pieces came together to form a picture of what I am supposed to be doing as a clinician. It's it's insane.

[00:44:29] Amy Wonkka: It's really hard though. I mean, you raised such a great point, Kate. I mean, I, I have received many outside reports that recommend a very high, um, not dosage, but duration and frequency of services. And so if we map onto it, the findings of Dr. Schitz research, we, we really have more than just kind of our gut and the idea, you know, I mean the time comes from somewhere.

It, the time that we spend in [00:45:00] speech at school is coming from some other activity that the student could be participating in. There's a, there's a lot of pieces that go into determining service delivery. Yeah. Um, And I, I hope that this message also gets out to other providers also gets out to, you know, other allied health professionals who may be making recommendations around dose and frequency, believing that to be in the best interest of the shared client.

Um, when in fact the research is suggesting maybe not,

[00:45:29] Mary Beth Schmitt: maybe not, maybe not. Yeah. And this is where, um, the type of research done matters, right? Because it absolutely has policy implications, but the, the design of this study that makes it so relevant to SLPs also brings with it some limitations on how far we can use it to make specific recommendations.

And so for instance, we don't get an actual [00:46:00] number, right. Like we can't, we don't know at this point that okay, if I actually do schedule my client for 90 sessions over a 40 week period and see them for two minute dose that will improve their lang-. We don't have that data. What we did with this study is called correlational data and it means that we, you know, we just took a lot of information and we looked at patterns.

There was a pattern between, um, the inverse relationship between dose and frequency. So high frequency, low dose, low frequency wait, or then high, high dose, low frequency. Uh, I have to give it straight too, um, and children's outcomes and it's, you know, the science would sound it corroborates what cognitive sciences has, has been saying forever.

It corroborates what we know from other disciplines, education, motor learning, all of it. But, what my team and I are doing now is [00:47:00] we have funding from NIH to literally test just that. Um, and this is where I really could use the help of your listeners. You know, our study is online, it's across the country, it's even in Canada.

Um, and we're looking at what is that, that magic combination and not just how much the, like how much dose versus frequency kids need, but at what point does our therapy stop being effective? 

Amy Wonkka: This is so exciting. 

Kate Grandbois:This is the biggest question of all time. 

Mary Beth Schmitt:It's huge. It, it really is huge. And we're hearing from more and more both.

Yes. Like I never felt good about the two times a week for 20 minutes, but I didn't have anything else to go on. 

Kate Grandbois: Yes, exactly. 

Mary Beth Schmitt:And just the, like, let, please tell me, like, please give us more information. And we've also heard from SLP who are finding creative. Solutions within the current constraints while we're waiting.

Cuz science is slow. Y'all like, oh my [00:48:00] sorry, my Texas came through. Um, it's y'all science is so slow. And so it's like, what can we learn from the data that we have and how can we, you know, kind of using an evidence based practice model, how can we take this external research, use our current, um, constraints and barriers and directives from where we're working.

Some of our kind of internal pieces collect our own data, um, to really, really decipher ourselves. Like, can we go ahead and optimize this in ways? And. We have some thoughts. 

[00:48:40] Kate Grandbois: Uh, I wanna just quickly, Amy, I know you have words in your mouth. Hold on one second. I just wanna, I just wanna make sure that we give our listeners a link or some information for how we can help you.

So is there a link that you can give us that we can put in the show notes just to make sure people if they're listening yes. And they wanna contribute to this [00:49:00] research for a way for them to connect, get connected with you? 

[00:49:03] Mary Beth Schmitt: Yeah, absolutely. Absolutely. Um, and, and I should add to, from the SLPs perspective, we really don't need anything of you.

We'll do all the work. We just need to help find these find kids. So we're looking for kids who, same as before, like they are already on your caseload, right? They're they have a diagnosed language impairment. For right now we're trying to keep it just like the language impairment is their primary diagnosis.

So they don't also have comorbid diagnoses, um, that might explain the language impairment. Um, and, and then we'll, we'll. We'll do all of it. Like we'll so this is not a burden on you just help us find these kids. And the other interesting thing about this research, I think is that we're using, um, a vocabulary intervention.

That's already been proven effective through their research in all the kids get it. So no one's in a control group. All kids are gonna get this supplemental vocabulary intervention for [00:50:00] participating, um, plus some other incentives. And so we're, we're excited about this design. We're excited about the offering that we're able to give kids the fact that, you know, silver lining of the pandemic, it forces us online and kids are responding well to it.

Families are enjoying it. Um, and so we can get into more homes that way. And then for our profession, we're really hoping to have some actual policy guidance. Um, For that. And so absolutely Kate, like, I'll give you the links, but I also want your listeners to know too, like we have on the website, the, um, UT Austin's children's language literacy and learning lab CL3, go alliteration and acronym.

Um, we have, there's a PDF of this article and we are self, self archiving in the way that is legal and following all the rules of how you can do that, so that, um, so that you can get access to it because this one is not [00:51:00] in the ASHA journals. That's a whole nother story, but the, the, but we have a copy of the article itself, but we also have a PDF.

That highlights the outcomes of this data so that you can take this PDF into your IEP meetings. With that family that's asking for more and more and more, and you can show them right now. It's not a matter of, I don't have time. It's a matter of actually the data suggests that that would put your child at a disadvantage.

And that, that we're so excited to be able to really empower SLPs with data, without having to like read through the article and pull it out. We've given it to you in just this one, snapshot, take it to your administration, take it to your principles, take it to your lead SLPs, um, and really start a conversation about what could this look like for us.

[00:51:55] Amy Wonkka: And it's, it's so exciting because I think often, especially [00:52:00] school based SLPs, can be very bound into the schedule. Well, this is how we do our blocks and we don't do anything other than 30 or 15 minutes. And we need you to do a duty at this specific time. Yeah. Um, so I think. Even just having that conversation with your administration could allow more flexible thinking.

I mean, I'm just thinking about evidence based practice and I'm thinking about the evidence based practice triangle. Yeah. And this is sort of that external evidence piece that might lead a clinician. To gather some internal evidence about their client in with a, with a variable change that we probably wouldn't.

I, I wouldn't have even thought of. Right. Yeah. Often if something's not working and I'm looking to external evidence, I'm looking specifically at a treatment approach, right. So what I'm doing during therapy, I'm not thinking about things like how enga, I mean, it's more fun for everybody when everyone's engaged in its fun activity, but not necessarily thinking about [00:53:00] that explicitly as a variable to change and see if it made a difference, not necessarily looking at, or feeling empowered, to suggest a change in frequency or dosage to see if that makes a difference.

So it, I think it also just really widens. It, it widens the, the world of things that might actually make a difference for one of our students. Right. And maybe we can, while we're waiting for the slow slog of research to, you know, get us the answers. Yeah. External evidence wise, it's something that we might be able to look at internal evidence for our own clients.

So just asking yourself some different questions and being curious to, to steal one, a few words, but being curious about, well, actually, maybe it's not my activity at all. 

[00:53:47] Mary Beth Schmitt: Absolutely. Maybe these other things. Absolutely. And, you know, remember that we gathered these data from SLP, like we didn't know that this was gonna be a thing.

Right? So these SLPs were doing [00:54:00] their business as usual. So most of them were in those same constraints of, you know, a couple times a week for 20 minute sessions. But remember it wasn't the length of the therapy session. It was the dose. And so what that does for SLPs listening, is it, it gives you some power while, while you're having conversations with administration and talking about the policies.

And can we look at our prescribed therapy in a different way when it comes to the actual IEPs, while you're having that conversation, you could go ahead and experiment with this. For instance, maybe, you know, maybe you have a, um, a client who has a narrative goal and some grammar goals, right. And maybe you do something like a cycles approach, right?

Maybe you work on grammar kind of as a drill, the first five minutes of your therapy session. Right. And [00:55:00] then the last 20 minutes or 15 minutes or however long it is, you focus on narrative and then you don't touch narrative again for at least another week. If not two weeks. Right. And then maybe the next day you hit grammar again.

Right? So you're doing higher frequency, low dose do a quick burst of grammar, but then maybe you do a longer on, on vocabulary. Right? Find the goals that they need a little bit more. Like you gotta take a little bit more time to get into the depth of them. Then use that like restructure your 20 minutes in such a way that you're intentionally doing some high dose and low dose, if you're not able to be flexible.

But you know, then that said, I worked with districts before that they used a minutes per month model. Right. So rather than two times a week for 20 minutes, each it was, we're gonna get in 260 minutes or 240 minutes over the month. That's permission then to experiment with this. [00:56:00] Right. And maybe you don't try it with all of your kids.

Maybe there's one group or a couple kids that are not making anticipated yearly progress. Start there. Right and gather your data. And then you've got now both external evidence from our research, plus your own internal data to take to families, to the it meetings, to your administration, to whomever and say, look, look at what we're noticing.

Look at what we're seeing here. Um, and so I don't want SLP feeling like, oh my gosh, we're sitting on this goal mine, and now we have to wait for us to do more research. No, no. Use this at, you know, to the extent that it's meaningful and relevant to your caseload, don't feel constrained by your situation.

Think about how to creatively use the data. The data had nothing to do with the time of the session. It was all about the dose of the language. 

[00:56:56] Kate Grandbois: And I, I can't help as I'm listening to you talk, I can't help but [00:57:00] thinking about, think about the difficult conversations that you might a listener or a speech pathologist might have to happen have with their administration or with their infrastructure.

That is just very used to doing a certain things a certain way. I also think in terms of making effective change and tailoring your message to your audience, there are likely some creative ways that you can apply this to be more efficient. So thinking about a kid on your caseload, gosh, I really don't need to see this kid five times a week.

I could probably make even more effective progress by reducing the amount of time that the student is spending outside the classroom or reducing the amount of time to be a more efficient worker. And that's like, those are the kinds of things that your administration might also want to hear, because again, tailoring our message to our audience.

And I think that this applies to outpatient centers. I think this, I know your research is about the schools, but when you're [00:58:00] having these conversations with your administration, consider it the budget implications, consider your, your productivity implications consider. And you know, it may be caseload to caseload.

This might not be true for every SLP in terms of improving efficiency, but those are also really important variables for how we can be effective in our jobs. Again, going back to this, what's the point, to be effective at our jobs and your administration might care a lot about efficiency and productivity, depending on your caseload and all of these very specific variables.

But I think it's definitely something to consider. 

[00:58:34] Mary Beth Schmitt: I think that's a really important point, you know, and, and again, you're not making this up now. Like it's, data and,

[00:58:41] Kate Grandbois: and it's really good data as you already established. This is one of the most, this is good. Good science. 

[00:58:48] Mary Beth Schmitt: Yeah. Yeah. So that, you know, and then you think about the engagement piece.

I was working with a, a school district and some SLPs that were, were really looking at it. And the first place that [00:59:00] we started was just take data on yourself. Like some SLPs, literally turn their video camera on. And they watched themselves to see, okay, out of my 20 minute session, how many opportunities do my kids have to attempt their goals?

And some who brought in like a trusted peer. Right. Of just like, here's what I, I want you to track, like how, how often, or, you know, time it or what, however they wanted to do it, them talking versus the kids talking versus, you know, off task. And so some of them, it was an eye opener. It was like, oh my gosh, like I'm not doing very much active engagement or my kids don't have opportunity.

Great. That's great data start there. Right? Like that's a, that's a toggle that you can make and just make that switch. Maybe you take your own data and you're like, actually I'm doing pretty good. Right. Then that's equally important because you can talk about that in the IEP meetings and with your, um, administration annual reviews, that kind [01:00:00] of thing of look there's data to suggest this matters.

And the PDF for this is also on our website. There's there's data to suggest that engagement matters. I took my own data. I'm doing this, right? Like my practice in this regard is aligned to the research. Now there's this other piece of talk, thinking about like the dose and frequency of that active engagement.

That's what I'm gonna attempt next. Right? So like, you can really use the external data, not just to inform change to your practice, but then also use it to affirm what you're already doing. Right? Like, look at it. You might already be doing low dose, high frequency or low frequency, high dose. Like some of the SLPs in our study were, and you just didn't realize that's what you were doing.

And you didn't realize that that mattered. Awesome. Figure out who you're doing that with and then do try doing more of it and see if that doesn't have [01:01:00] cross implications for all. 

[01:01:02] Amy Wonkka: I want this study to be replicated with all sorts of school population groups. I just selfishly often say that. Um, I think, I think these are such good questions and although the groups I work with most often are not represented in, in your work.

I think, you know, as, as somebody moving forward, I'm definitely going to think about these variables in ways that I haven't before, um, as potentially agents of changed for student progress, 

[01:01:31] Mary Beth Schmitt: right. And Amy, I think that's such an important point, right? Of just because different populations weren't represented in the data doesn't necessarily mean it's irrelevant.

That's where your internal data comes. Real becomes really important. Try it. Right because the theory behind it and cognitive science data for decades would suggest that it likely does have implications for other populations, but you don't have the same external data yet [01:02:00] to rely on. You can do your own, do your own trial, your own comparison, gather your data and see, and then you've got, you've got that, um, information to help lead you to 

[01:02:11] Kate Grandbois: In our last couple of minutes, I wonder if you have any additional recommendations for SLPs listening, for how to apply this research. I mean, we've, we've gone over a bunch of talking to your administration, bringing the PDFs that you have available on your website, into the conversations to show the data, to show the research. Um, we've even all of that will be linked in the show notes for anyone listening. We've also talked about structured planning. So taking a look at your own caseload, you know, looking for inefficiencies, planning per student, based on what they need for engagement, what do, what combination of dosage and frequency is maybe most relevant to their clinical presentation, those kinds of things.

Are there any other words of wisdom or any other really good takeaways that you would like to share? [01:03:00] 

[01:03:01] Mary Beth Schmitt: Yeah, I think maybe two main ones first. Like I would just encourage your listeners to kind of be reflective of themselves. Right. Of cuz we've heard from lots of SLP, some hear this and they're empowered.

Right. And it's like, this is what I have known in my bones and I just didn't have the data. And so if that is you like go ye fourth, right? Like use the resources we have, reach out to me if you have questions, get a buddy or two. Right. Who are also wanting to think about this within the constraints of whatever your setting is and yeah.

Try it out. But if you are on the other side and you're like, this is still blowing my brain, like I still need a minute to just think about what this means. And this sounds like a lot because I have a huge caseload and I'm super constrained in the, [01:04:00] the frequency and dose that, or at least the frequency of how often I can schedule, then it's okay to start slow.

Right. I would encourage you to take a look at our PDFs that are the one pagers. And I would encourage you to take data on what you're already doing. See if there are groups and or sessions where you were already doing this and you just didn't have language for it. Because what that'll do is I think that will give you some encouragement and motivation to be like, oh, This actually isn't completely changing everything I know to be true about service delivery, it's giving language to it.

And so I just would encourage people to figure out where they are on that continuum of hearing new information and figuring out how it applies, not dismiss it, but it's okay to be on that continuum. It's okay to just be at the processing side and it's okay to be like ready to dive in and [01:05:00] like have IEP meetings for all of your kids, change every change everybody's schedule. That's okay, too. 

[01:05:08] Kate Grandbois: This has been so incredibly helpful. Thank you so, so much for sharing all of this wisdom and research and great, amazing science that is going to change our field one day. Once we continue to move the needle, we're so grateful for your time. You again, so much for being here.

[01:05:27] Mary Beth Schmitt: You're welcome. Thank you for having me. This is, this is always fun to talk about this. Thank you so much.

[01:05:34]Kate Grandbois: Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study, please check in with your governing bodies or you can go to our website, www.slpnerdcast.com. All of the references and information listed throughout the course [01:06:00] of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info@slpnerdcast.com