PRAXIS SPEECH-LANGUAGE
PATHOLOGY EXAM

Scope of Practice

ASHA's Scope of Practice (2016) defines the breadth of SLP services across the lifespan: prevention, screening, diagnosis, treatment, and advocacy. Areas include speech sound production, resonance, voice, fluency, language (spoken and written), cognition, feeding and swallowing, social communication, and AAC. SLPs work in hospitals, schools, private practice, rehabilitation centers, and skilled nursing facilities. The Scope is not static — it expands as evidence base grows (e.g., gender-affirming voice, transgender communication).

ASHA Code of Ethics — All Four Principles

• Principle I: Responsibility to persons served and to research participants. Includes welfare, non-discrimination, informed consent, and confidentiality.
• Principle II: Responsibility to achieve and maintain highest professional competence. Includes practicing only within areas of competence, pursuing CE, and providing accurate clinical info.
• Principle III: Responsibility to the public. Prohibits misrepresentation of credentials, services, or outcomes. Includes honest marketing.
• Principle IV: Responsibility to professional relationships. Includes ethical conduct with colleagues, referral obligations, and reporting ethical violations.

Evidence-Based Practice (EBP)

• Three pillars: (1) Best available external evidence, (2) Clinical expertise and judgment, (3) Client/patient values and preferences
• Evidence hierarchy: Systematic reviews/meta-analyses → RCTs → non-randomized controlled studies → cohort/case-control → case reports → expert opinion
• PICO: Population, Intervention, Comparison, Outcome — used to form searchable clinical questions
• Databases: PubMed/MEDLINE, ASHA Wire, CINAHL, Cochrane Library
• Key concepts: Efficacy (lab conditions), Effectiveness (real-world), Efficiency (resources). NNT (number needed to treat), ARR (absolute risk reduction).

HIPAA, Confidentiality & Informed Consent

• PHI (Protected Health Information): Any individually identifiable health data. Must be protected in all forms (written, electronic, verbal).
• HIPAA Privacy Rule: Governs disclosure of PHI. SLPs may share with treatment team without explicit consent. External disclosure requires signed authorization.
• Informed Consent: Client must understand: nature of services, risks/benefits, alternatives, and right to withdraw. Must be obtained in accessible language.
• FERPA vs. HIPAA: Schools use FERPA (Family Educational Rights and Privacy Act), not HIPAA. FERPA protects student education records.
• Mandatory Reporting: SLPs are mandated reporters of suspected child abuse, neglect, or elder abuse regardless of client confidentiality.

Cultural & Linguistic Diversity (CLD)

• Disorder vs. Difference: A disorder impairs communication relative to the individual's OWN community norms. A difference is a linguistic or cultural variation (e.g., AAE, Spanish-influenced English).
• African American English (AAE): Rule-governed dialect. Key features: habitual be, copula deletion, zero possessive, consonant cluster reduction, zero plural. NEVER pathologized as disorder.
• Assessment: Use trained interpreters (not family), collect language samples in all languages, use culturally/linguistically appropriate tools (BESA, DORA). Dynamic assessment is essential for CLD populations.
• Bilingualism: Bilingual children may code-switch — this is normal and not a sign of disorder. Assess in both languages. DLD exists in both languages simultaneously.
• Cultural humility: Ongoing self-reflection, power sharing with clients, institutional accountability. Goes beyond cultural competence.

IDEA: IEP & IFSP Requirements

• IDEA Part C (Birth–3): Early intervention, IFSP, services in natural environments. Family-centered. Team includes family as full members. Transition planning at age 2.5 to Part B.
• IDEA Part B (Ages 3–21): IEP in least restrictive environment (LRE). FAPE (Free Appropriate Public Education) is guaranteed.
• IEP Components: Present Levels of Academic Achievement and Functional Performance (PLAAFP), measurable annual goals, special education/related services, accommodations/modifications, transition plan (age 16+), LRE statement.
• IFSP Components: Child and family strengths, outcomes (not goals), early intervention services, natural environments, service coordinator, transition plan.
• Related Services: SLP services are "related services" under IDEA when necessary to benefit from special education.
• Eligibility: Under IDEA, eligibility for SLP services requires an educational impact — the disorder must affect academic or functional performance.

Section 504 vs. IDEA vs. ADA

• IDEA: Special education law. Provides FAPE with IEP. Requires educational impact for eligibility. Only in schools.
• Section 504: Civil rights law. Broader eligibility than IDEA. Provides accommodations (504 Plan) but not specialized instruction. No educational impact required — only disability that substantially limits major life activity.
• ADA: Civil rights law for employment and public life. Applies post-secondary, workplace. Requires "reasonable accommodations." Does not mandate FAPE.
• Clinical distinction: A student who doesn't qualify for IDEA may still receive a 504 plan (e.g., student with mild articulation disorder with no academic impact).

ICF Framework (WHO)

• Body Functions & Structures: Physiological and psychological functions; anatomical parts (e.g., impaired vocal fold function, absent tongue movement).
• Activity: Execution of a task (e.g., difficulty producing intelligible speech in conversation).
• Participation: Involvement in life situations (e.g., avoidance of social events due to stuttering).
• Contextual Factors — Environmental: Physical, social, and attitudinal factors (e.g., noisy classrooms, supportive communication partners).
• Contextual Factors — Personal: Individual characteristics (age, coping style, motivation, cultural background).
• SLP Application: Goals should address all ICF levels, not just impairment. Participation-level goals reflect real-world functional outcomes.

Professional Documentation & Service Delivery

• SOAP Notes: Subjective, Objective, Assessment, Plan — structured clinical documentation format.
• DAP Notes: Description, Assessment, Plan — alternative format used in some settings.
• Progress notes must link to IEP/IFSP goals and document measurable client performance.
• Service delivery models: Direct (individual, group), indirect (consultation, collaboration, coaching), pull-out vs. push-in, telepractice (synchronous, asynchronous).
• Response to Intervention (RTI/MTSS): Three-tier model. SLPs serve in Tier 1 (classroom-wide), Tier 2 (small group), Tier 3 (intensive individualized). Data-driven decision making.
• Supervision: Clinical Fellows (CFs) must complete 1,260 hours under ASHA-certified SLP. 36-week minimum. Supervisor must hold CCC-SLP.

Standardized Testing: Psychometrics

• Standard Scores: Mean=100, SD=15. Normal range: 85–115 (±1 SD).
• Percentile to SD: 50th = mean; 16th = -1 SD; 2nd = -2 SD; 84th = +1 SD.
• Reliability: Test-retest (stability over time), inter-rater (consistency between examiners), internal consistency (Cronbach's alpha).
• Validity: Content (covers the domain), Construct (measures the theoretical construct), Criterion (correlates with gold standard).
• SEM (Standard Error of Measurement): Confidence interval around score. Used to determine if two scores are meaningfully different.
• Sensitivity vs. Specificity: Sensitivity = detects true cases (high = few false negatives). Specificity = correctly rejects non-cases (high = few false positives).
• Norm-referenced: Compares to peers. Criterion-referenced: compares to established mastery criterion. Curriculum-based: compares to classroom curriculum.

Speech Sound Assessment — Key Tests & Concepts

• GFTA-3 (Goldman-Fristoe-3): Articulation test, ages 2–21. Assesses consonants in word-initial, medial, and final positions. Single-word format only.
• DEAP (Diagnostic Evaluation of Articulation and Phonology): Ages 3–8;11. Distinguishes phonological processes from articulatory errors. Provides phonological process analysis.
• KLPA-3 (Khan-Lewis Phonological Analysis-3): Used alongside GFTA-3 to analyze phonological processes from the same stimulus items.
• Stimulability: Ability to correctly produce error sounds when given a model. High stimulability = positive prognosis; may indicate sound is emerging.
• PCC (Percent Consonants Correct): From connected speech sample. >90% = mild; 65–90% = mild-moderate; 50–65% = moderate-severe; <50% = severe.
• Intelligibility norms: Age 1 = 25%; Age 2 = 50–75%; Age 3 = 75–100% to familiar listener; Age 4 = 100% to unfamiliar listener.
• Single-word vs. connected speech: Always supplement single-word tests with connected speech sample — discrepancy can indicate motor planning issues (CAS).

Phonological Process Norms

• Final Consonant Deletion: Eliminated by age 3;0
• Cluster Reduction: Eliminated by age 4;0
• Syllable Reduction/Weak Syllable Deletion: Eliminated by age 4;0
• Stopping /f, s, z/ → stop: Eliminated by age 3;0–3;6
• Stopping /v, ʃ, ʒ, tʃ, dʒ/: Eliminated by age 3;6–4;6
• Fronting (velar → alveolar): Eliminated by age 3;6
• Gliding (liquids → glides): Eliminated by age 5;0–6;0
• Deaffrication: Eliminated by age 4;0
• Assimilation: Eliminated by age 3;0

Language Assessment — Tests by Age/Population

• PLS-5 (Preschool Language Scales-5): Birth–7;11. Auditory comprehension + expressive communication. Available in English and Spanish.
• CELF-5 (Clinical Evaluation of Language Fundamentals-5): Ages 5–21. Core language score, receptive, expressive, language content, memory/language structure. Gold standard for school-age.
• CELF Preschool-3: Ages 3;0–6;11.
• TOLD-P:4 (Test of Language Development Primary-4): Ages 4;0–8;11.
• BESA (Bilingual English-Spanish Assessment): Spanish-English bilingual children. Assesses morphosyntax and phonology in both languages simultaneously.
• PPVT-5: Receptive vocabulary, ages 2;6–90+. Not a language battery — cannot diagnose language disorder alone.
• EVT-3 (Expressive Vocabulary Test-3): Expressive vocabulary. Used with PPVT-5 as a vocabulary pair.
• ROWPVT/EOWPVT: Receptive/Expressive One-Word Picture Vocabulary Tests. Available in English and Spanish.

Language Sample Analysis (LSA)

• MLU (Mean Length of Utterance): Count morphemes per utterance. Brown's Stages: Stage I (1.0–1.99), Stage II (2.0–2.49), Stage III (2.5–2.99), Stage IV (3.0–3.74), Stage V (3.75–4.5+).
• Age–MLU correlation: Age 1.5 = 1.0–1.99 morphemes; Age 2 = 2.0; Age 3 = 3.0; Age 4 = 4.0+
• TTR (Type-Token Ratio): Types (different words) / Tokens (total words). Low TTR = limited vocabulary diversity.
• Bound morphemes to track: -ing, plural -s, possessive -s, regular past -ed, irregular past (came), third person singular -s, articles (a, the), copula (is), auxiliary (is).
• Narrative structure (story grammar): Setting, initiating event, internal response, attempt, consequence, reaction. Hildebrand's High Point Narrative Analysis.
• SALT (Systematic Analysis of Language Transcripts): Software for standardized LSA. Uses reference databases for comparison.
• Discourse types: Conversation, narrative, expository, procedural, persuasive.

Fluency Assessment

• SSI-4 (Stuttering Severity Instrument-4): Frequency (% syllables stuttered), duration (longest 3 moments), physical concomitants (distracting sounds, facial grimacing, head movement, limb movement). Scaled total: very mild to very severe.
• Typical vs. stuttered disfluencies: Typical = phrase repetitions, revisions, interjections (um, uh). Stuttered = sound/syllable repetitions, prolongations, blocks (tense pauses).
• Percent Stuttered Syllables (%SS): 1–5% = borderline/mild; 6–10% = mild-moderate; 11–17% = moderate; 18%+ = severe.
• Cluttering: Fast rate, irregular rate, reduced intelligibility, telescoping (omitting syllables), poor awareness. Often co-occurs with stuttering.
• Attitude assessments: CAT (Communication Attitude Test, ages 7–13), A-19 scale (school-age), OASES (Overall Assessment of Speaker's Experience, teens/adults). Captures impact beyond frequency.
• Neurogenic stuttering: Acquired post-stroke or TBI. Does not improve with adaptation effect. Disfluencies more consistent across speaking contexts.

Voice Assessment — Perceptual & Instrumental

• GRBAS Scale: G=Grade (overall), R=Rough, B=Breathy, A=Asthenic (weak), S=Strained. Rated 0–3 (0=normal, 3=severe). Widely used perceptual rating scale.
• CAPE-V (Consensus Auditory-Perceptual Evaluation of Voice): ASHA-recommended perceptual tool. Rates overall severity, roughness, breathiness, strain, pitch, loudness on 100mm visual analog scale.
• MPT (Maximum Phonation Time): Normal adults: males ~20–25 sec, females ~15–20 sec. Reduced MPT suggests insufficient respiratory support or vocal fold pathology.
• S/Z Ratio: /s/ (voiceless airflow) divided by /z/ (voiced phonation). Normal ≥1.0. Below 1.0 = possible vocal fold pathology (nodules, polyps). Ratio of <0.8 is clinically significant.
• Acoustic measures: Jitter (cycle-to-cycle pitch perturbation), Shimmer (cycle-to-cycle amplitude perturbation), HNR (Harmonic-to-Noise Ratio — higher = cleaner signal), Cepstral Peak Prominence (CPP). Measured via PRAAT or CSL.
• Laryngoscopy: Rigid (oral) or flexible (transnasal/FEES). Stroboscopy adds slow-motion view of mucosal wave — essential for diagnosing subtle vocal fold lesions.
• Aerodynamic measures: Subglottic pressure, glottal airflow rate, laryngeal airway resistance. Measured via Phonatory Aerodynamic System (PAS).

Dysphagia Assessment

• Four phases of swallowing: Oral preparatory (chewing, bolus formation) → Oral transit (posterior tongue propulsion) → Pharyngeal (airway protection, peristalsis, UES opening) → Esophageal (peristalsis to stomach — not in SLP scope but SLP refers).
• Clinical Bedside Evaluation (CBE/BSE): Screens for aspiration risk via clinical signs: wet/gurgly voice, cough during/after swallow, drooling, reduced laryngeal elevation, oral/pharyngeal residue. CANNOT detect silent aspiration.
• MBSS/VFSS (Modified Barium Swallow Study): Fluoroscopic real-time imaging. Views oral and pharyngeal phases. Allows bolus modification trials. SLP co-administers with radiologist. Best for detecting penetration/aspiration and testing compensatory strategies.
• FEES (Flexible Endoscopic Evaluation of Swallowing): Nasolaryngoscope passed transnasally. Direct view of pharynx/larynx. No radiation — can be repeated. Limited view during pharyngeal phase (whiteout). Best for secretion management, prolonged assessment, bedside/ICU.
• Penetration vs. Aspiration: Penetration = material enters larynx but stays above vocal folds. Aspiration = material passes below vocal folds. PAS (Penetration-Aspiration Scale): 1 = no penetration, 8 = silent aspiration.
• Silent aspiration: Aspiration without cough reflex. Common in elderly, neurological patients. Only detected instrumentally.
• DOSS (Dysphagia Outcome and Severity Scale): 7-level functional scale: 1=nothing by mouth, 7=normal diet/no restrictions.

Cognitive-Communication Assessment

• Domains: Attention (sustained, selective, alternating, divided), memory (working, short-term, long-term), executive function (planning, inhibition, flexibility), language, and social communication.
• TBI scales: GCS (Glasgow Coma Scale): 3–8=severe, 9–12=moderate, 13–15=mild. Rancho Los Amigos (I–X): I=No response, IV=Confused-Agitated, VI=Confused-Appropriate, VIII=Purposeful-Appropriate, X=Purposeful-Appropriate (modified independence).
• RBANS (Repeatable Battery for Neuropsychological Status): Assesses immediate/delayed memory, attention, language, visuospatial. Used in TBI, dementia.
• ASHA FACS: Functional Assessment of Communication Skills for Adults. Rates communication in daily life across 43 behaviors in 4 domains.
• Right Hemisphere Damage (RHD): Affects pragmatics (humor, sarcasm, indirect requests), discourse (main idea, inference, narrative coherence), prosody (comprehension and production), and attentional deficits. Language structure intact.
• Primary Progressive Aphasia (PPA): Three variants: Nonfluent/agrammatic (Broca's-like, motor speech involvement), Semantic (profound anomia + single-word comprehension loss), Logopenic (word retrieval + repetition deficits, Alzheimer's pathology common).

Aphasia Assessment — Classification & Tests

• Broca's: Non-fluent, agrammatic, telegraphic. Relatively preserved comprehension. Impaired repetition. Lesion: posterior inferior frontal gyrus (Broca's area, Brodmann 44/45).
• Wernicke's: Fluent, jargon, paraphasias (semantic + phonemic). Severely impaired comprehension. Poor repetition. Lesion: posterior superior temporal gyrus (Brodmann 22).
• Conduction: Fluent, good comprehension, severely impaired repetition. Frequent phonemic paraphasias, self-corrections. Lesion: arcuate fasciculus.
• Global: Severely impaired fluency, comprehension, repetition, and naming. Largest lesion (perisylvian).
• Transcortical Motor: Non-fluent, intact repetition, intact comprehension. Lesion: anterior/superior to Broca's.
• Transcortical Sensory: Fluent, intact repetition, impaired comprehension. Lesion: posterior/inferior to Wernicke's.
• Anomic: Fluent, intact comprehension and repetition. Primary deficit = word finding. Least severe type.
• Tests: WAB-R (Western Aphasia Battery-Revised), Boston Diagnostic Aphasia Examination (BDAE-3), BNT (Boston Naming Test), ASHA FACS.

AAC Assessment — Comprehensive

• No prerequisites: AAC has no cognitive, linguistic, or motor prerequisites. Anyone who cannot meet daily communication needs through speech alone is a candidate.
• Feature Matching: Match device/system features to individual's motor access, sensory/perceptual abilities, cognitive-linguistic level, literacy skills, and environmental needs.
• SETT Framework: Student (abilities, needs, preferences), Environment (settings, partners, demands), Tasks (activities the student must accomplish), Tools (strategies and devices matched to above).
• Access methods: Direct selection (pointing, touch, eye gaze), scanning (automatic, step), partner-assisted scanning. Consider position, range of motion, fatigue.
• PECS (Picture Exchange Communication System): Phase I (physical exchange) → Phase II (distance) → Phase III (discrimination) → Phase IV (sentence structure) → Phase V (responding to 'what do you want?') → Phase VI (commenting). Based on ABA/verbal behavior.
• Light tech: Communication boards, alphabet boards, PODD books. No power required.
• High tech: SGDs (Speech-Generating Devices), dynamic display, robust vocabulary systems (LAMP, Unity, Proloquo2Go, NOVA Chat).
• Partner training: Essential. Communication partners must model AAC use (aided language stimulation), respond to all communication attempts, and provide opportunity.

Hearing Screening & Audiological Concepts

• SLP screening protocol: Pure-tone screening at 1000, 2000, 4000 Hz at 25 dBHL. Fail = referral to audiologist.
• Audiogram axes: X-axis = frequency (Hz, low to high). Y-axis = intensity (dB, quiet to loud — reversed, louder downward).
• Degree of HL: 0–25 dBHL = normal; 26–40 = mild; 41–55 = moderate; 56–70 = moderately severe; 71–90 = severe; 91+ = profound.
• Conductive HL: Outer/middle ear. Air-bone gap present. Bone conduction normal. Often treatable medically.
• Sensorineural HL (SNHL): Cochlea or auditory nerve. No air-bone gap. Usually permanent. Managed with hearing aids or cochlear implants.
• Tympanometry: Type A = normal. Type B = flat (effusion or perforation). Type C = negative pressure (ETD). As = shallow peak (ossicular fixation). Ad = deep peak (TM hypermobility).
• CI candidacy: Severe-to-profound SNHL bilaterally, limited benefit from amplification, post-lingual or pre-lingual, medical clearance, motivated family/patient, access to aural rehabilitation.

Dysarthria Assessment

• Flaccid: LMN damage. Breathy, nasal voice, weakness. ALS (early), Bell's palsy, myasthenia gravis.
• Spastic: Bilateral UMN damage. Harsh/strained voice, slow rate, hypernasality. Stroke, TBI, MS.
• Hypokinetic: Basal ganglia (PD). Monopitch, monoloudness, reduced stress, festinating rate, hypophonia.
• Hyperkinetic: Basal ganglia (Huntington's, dystonia). Irregular rhythm, voice arrest, distorted vowels.
• Ataxic: Cerebellar damage. Excess equal stress, irregular breakdowns, drunken-sounding.
• Unilateral UMN (UUMN): Stroke affecting one side. Mild dysarthria, imprecise consonants, slight hypernasality.
• Mixed: Multiple systems involved. ALS = flaccid + spastic. Multiple sclerosis = ataxic + spastic.
• Assessment tools: FDA-2 (Frenchay Dysarthria Assessment), Robertson Profile, intelligibility measures (SPIN, SIT), acoustic analysis.

Dynamic Assessment & Response to Intervention

• Dynamic Assessment: Evaluates learning potential through mediated learning (scaffolding). Measures: (1) baseline performance, (2) modifiability with cues, (3) maintenance. Test-Teach-Retest paradigm.
• Clinical value: Distinguishes disorder from difference in bilingual/CLD children. Shows "zone of proximal development." Less biased than static tests for diverse populations.
• RTI/MTSS: Multi-Tiered System of Support. Tier 1 = universal instruction + screening. Tier 2 = targeted small-group intervention. Tier 3 = intensive, individualized, data-driven services.
• SLP role in RTI: Prevention, early identification, collaborative consultation, progress monitoring, data collection. SLPs are NOT gatekeepers — RTI does not replace evaluation.
• Progress monitoring tools: Curriculum-based measures (CBM), maze, DIBELS (literacy), behavior frequency counts, probe data.

Motor Learning Principles for Speech

• Practice schedules: Blocked (same task repeated) = faster acquisition but poor retention. Variable/random (different tasks mixed) = slower acquisition but better retention and generalization. Use blocked early, shift to random for consolidation.
• Feedback types: Knowledge of Results (KR) = outcome feedback. Knowledge of Performance (KP) = feedback on movement process. KP is often more useful in speech motor learning.
• Feedback frequency: 100% feedback inhibits long-term learning. Fading feedback (every 3rd–5th trial) promotes self-monitoring and retention.
• Specificity of practice: Practice conditions should resemble target conditions. Functional generalization requires varied contexts.
• Mental practice: Imagery of correct movement sequences can supplement physical practice, especially in CAS.

Articulation Therapy Approaches

• Traditional approach (Van Riper): Establishment → Transfer → Maintenance. Sequence: isolation → syllable → word → phrase → sentence → conversation.
• Phonological approach: Targets error patterns, not individual sounds. Minimal pairs, maximal oppositions, empty set, multiple oppositions, Cycles.
• Cycles Approach (Hodson): For highly unintelligible children. Auditory bombardment + pattern practice. Cycles through each target pattern for 2–6 hours before moving on. Does NOT require mastery before cycling.
• Minimal Pairs: Contrast word pairs differing by one phoneme (e.g., bat/pat). Child's error creates communication breakdown — motivates phonological learning.
• Maximal Oppositions: Contrast maximally different phonemes to maximize learning (e.g., /s/ vs. /m/). Bigger contrast = faster system reorganization.
• Multiple Oppositions: Targets phoneme collapse (one sound replacing many). Simultaneously introduces multiple contrasting targets.
• Naturalistic Speech Sound Intervention (NSSI): Targets speech in functional, play-based, conversational contexts.

CAS Intervention — Comprehensive

• DTTC (Dynamic Temporal and Tactile Cueing): Simultaneous production → direct imitation → imitation with delay → spontaneous. Tactile cues to jaw, lips, tongue. Variable practice. Reduced feedback frequency for maintenance.
• ReST (Rapid Syllable Transition Treatment): Targets coarticulatory transition between syllables in novel pseudowords. Evidence-based for school-age CAS.
• Nuffield Dyspraxia Programme (NDP3): Hierarchical approach from phoneme to multisyllabic words. Structured cue hierarchy.
• K-SLP (Kaufman): Simplified word shapes and motor movement sequences. Bridges babbling/jargon to meaningful speech.
• Key CAS therapy principles: High repetition in variable practice, frequent sessions (3–5x/week), multimodal cueing (auditory + tactile + visual), meaningful stimuli, family involvement, no auditory discrimination tasks (motor-based problem).
• CAS vs. Dysarthria vs. Phonological disorder: CAS = inconsistent, motor planning. Dysarthria = consistent, weakness-based. Phonological = patterned, linguistic-level.

Language Intervention — Evidence-Based Approaches

• Enhanced Milieu Teaching (EMT): Naturalistic prompting strategies (incidental teaching, mand-model, time delay) embedded in daily routines. Caregiver training essential.
• Focused Stimulation: High-density input of a specific target in naturalistic context. No response required from child.
• Recasting: Repeat child's utterance in corrected/expanded form without directly correcting. "Ball falled" → "Yes, the ball fell."
• Expansion + Extension: Add grammatical elements (expansion) or semantic content (extension) to child's utterance.
• Narrative Intervention: Story grammar elements: setting, character, problem, attempt, outcome. Increases complex language production.
• Fast Mapping vs. Extended Mapping: Fast = initial word learning from minimal exposure. Extended = refining word knowledge over time. Children with DLD have deficits in both.
• Discrete Trial Training (DTT): Behavioral, structured, massed trials with reinforcement. Effective for ASD. SD → Response → Reinforcement cycle.
• Prelinguistic Communication targets: Joint attention (responding + initiating), intentional communication, means-ends, imitation, object permanence.

Stuttering Intervention — Children

• Lidcombe Program: Parent-delivered operant treatment for children under 6. Stage 1: daily structured conversations + verbal contingencies (praise fluency, gently note stutters). Stage 2: maintenance. Targets %SS reduction to <1%.
• Palin PCI (Parent-Child Interaction): Family-centered for ages 2–7. Addresses interaction style, family demands, and child factors. No direct fluency targets initially. Indirect approach.
• RESTART-DCM (Demands and Capacities Model): Address imbalance between fluency demands (linguistic, environmental, emotional, motoric) and the child's fluency capacities.
• School-age stuttering: Integrated approach — fluency shaping + modification + attitudes/teasing/bullying. Involve teachers, peers. Desensitization to speaking situations.
• Natural recovery: ~75% of preschool children who stutter will recover naturally, most within 1–2 years. Risk factors for persistence: male, family history of persistent stuttering, time since onset >12 months, co-occurring speech/language disorder.

Stuttering Intervention — Adults

• Fluency Shaping: Establishes fluent speech using: slow rate, gentle onset (easy voice initiation), light articulatory contacts, continuous airflow, continuous voicing, gradual rate increase. Goal: zero stuttering. Targets the behavior itself.
• Stuttering Modification (Van Riper): Four stages: Identification → Desensitization → Modification → Stabilization. Modification techniques: cancellation (after stutter, pause, repeat fluently), pull-out (during stutter, ease through), preparatory set (before stutter, plan easier production).
• Acceptance and Commitment Therapy (ACT): Third-wave CBT. Targets avoidance reduction, acceptance of stuttering, psychological flexibility, value-based action. Goal: reduce impact, not necessarily frequency.
• Avoidance Reduction Therapy (ART): Sheehan's iceberg model. Most disability below surface (avoidance, shame, fear). Address the "hidden" part of stuttering through desensitization and voluntary stuttering.
• Voluntary stuttering: Intentionally stutter openly to reduce shame and avoidance. Used in modification and desensitization phases.

Voice Therapy Approaches

• Vocal Hygiene: Hydration (8 glasses water/day), humidification, voice rest, eliminate throat clearing (replace with silent swallow or water sip), reduce caffeine/alcohol, avoid shouting/whispering.
• Resonant Voice Therapy (RVT): Targets "forward" easy phonation with oral resonance sensations. Uses /m/ humming as foundation. Evidence-based for vocal nodules and hyperfunctional disorders.
• Vocal Function Exercises (VFE/Stemple): Four-exercise protocol: sustain /i/ at comfortable pitch, glide from lowest → highest pitch on /o/, glide from highest → lowest pitch on /o/, sustain /o/ at musical notes. Targets intrinsic laryngeal muscle strength/balance/coordination.
• LSVT LOUD: 16 sessions over 4 weeks. Intensive. Targets maximum effort in loudness. Recalibrates proprioceptive awareness of loudness level. Evidence base for Parkinson's disease and other hypokinetic conditions.
• Laryngeal manipulation: Manual therapy for musculoskeletal tension dysphonia (MTD). Digital pressure to lower laryngeal position and reduce extrinsic muscle tension.
• Confidential voice: Easy, breathy, soft phonation. Used acutely for vocal fold trauma, laryngitis, post-surgical voice rest.
• Spasmodic dysphonia: Botox injection into thyroarytenoid (adductor SD) or posterior cricoarytenoid (abductor SD). Voice therapy adjunct, not primary treatment.
• Vocal fold paralysis: Unilateral: compensatory therapy (pushing techniques discouraged; target adduction without hyperfuction). Medialization via surgery or injection augmentation.

Dysphagia Intervention — Comprehensive

• IDDSI Framework Levels: 0=Thin, 1=Slightly Thick, 2=Mildly Thick, 3=Liquidised, 4=Pureed, 5=Minced & Moist, 6=Soft & Bite-Sized, 7=Regular. Standardized globally. Replaced NDD (National Dysphagia Diet).
• Compensatory strategies (modify task/environment, not physiology):
  • Chin tuck: delayed trigger or reduced laryngeal closure. Narrows laryngeal entrance.
  • Head rotation (to weak side): closes weaker pyriform sinus, directs bolus to stronger side.
  • Head tilt (to stronger side): gravity assists bolus to stronger side.
  • Alternating liquids/solids: clears pharyngeal residue.
  • Small sip/bite size: reduces bolus volume.
• Rehabilitative techniques (change physiology):
  • Mendelsohn Maneuver: prolong laryngeal elevation, increases UES opening.
  • Effortful Swallow: increases tongue base retraction, reduces valleculae residue.
  • Supraglottic Swallow: voluntary airway closure before/during swallow.
  • Super-Supraglottic: adds Valsalva to tilt arytenoids for greater airway closure.
  • Shaker Exercise: strengthens suprahyoid muscles, improves laryngeal elevation and UES opening.
  • EMST (Expiratory Muscle Strength Training): pressure-threshold device for expiratory force. Improves cough and swallowing in neurological populations.
  • McNeill Dysphagia Therapy Program (MDTP): exercise-based, functional eating, progressive resistive exercises.
  • Tongue resistance training: Iowa Oral Performance Instrument (IOPI) for tongue strength.
• Non-oral feeding: NG tube (naso-gastric), PEG (percutaneous endoscopic gastrostomy). SLP coordinates with medical team. Ethical considerations: patient autonomy, quality of life, goals of care.

Aphasia Intervention — Evidence-Based

• Semantic Feature Analysis (SFA): Anomia treatment. Activate semantic network by systematically naming features of target words (category, action, association, location, properties). Strengthens semantic self-cueing.
• VNeST (Verb Network Strengthening Treatment): Targets verb retrieval and thematic roles (who does it, with what, to whom, where). Improves sentence production in connected speech.
• CILT (Constraint-Induced Language Therapy): Intensive verbal communication with constraint (no gestures or AAC). Massed practice, 3 hrs/day for 10 days. Applies neural plasticity principles.
• PACE (Promoting Aphasics' Communicative Effectiveness): Functional communication. Any modality (speech, gesture, drawing, AAC). New information each exchange. Clinician and client take turns conveying hidden pictures. Natural conversation simulation.
• Melodic Intonation Therapy (MIT): Non-fluent Broca's with good comprehension. Exaggerated melody + left-hand tapping. 3 levels: syllable humming → unison → independent. Leverages intact right hemisphere melodic processing.
• Script Training: Repeated practice of personally relevant utterances/conversations. Builds automaticity for functional communication needs.
• Supported Conversation for Adults with Aphasia (SCA): Partner training. Techniques: writing, drawing, gesturing, providing multiple choice, acknowledging competence.
• Aphasia and AAC: Multi-modal communication. Alphabet boards, visual scene displays (VSDs), high-tech SGDs. All aphasia types may benefit. No prerequisite literacy level for AAC.

Social Communication & Pragmatics Intervention

• SCERTS Model: Social Communication (joint attention, symbol use), Emotional Regulation (self-regulation, mutual regulation), Transactional Supports (interpersonal, learning). Framework, not program — individualized. Evidence-based for ASD.
• Social Thinking (Michelle Garcia Winner): Teaches perspective-taking, expected vs. unexpected behaviors, "social thinking vocabulary" (social memory, thinkable thoughts). For ages 4 to adult with social-cognitive challenges.
• PEERS Program: UCLA program for teens and young adults with ASD, ADHD. Ecologically valid social skills (entering conversations, electronic communication, handling arguments, dating). Involves parent co-therapists.
• Theory of Mind (ToM): Understanding others have different beliefs, intentions, and knowledge than oneself. False belief tasks (Sally-Anne) test Level 1 ToM. Deficits common in ASD.
• Joint attention: Triadic (person-object-person) shared focus. Responding to JA (following gaze, point) precedes initiating JA (pointing to share interest). Critical prelinguistic skill.
• Conversational repair: Detecting and fixing communication breakdowns. Request for clarification, revision, repetition. Targets: recognizing breakdowns, signal partner, use repair strategies.
• Grice's Maxims: Quantity (say enough), Quality (be truthful), Relation (be relevant), Manner (be clear). Violations underlie pragmatic disorders.

Early Intervention — Evidence-Based Practice

• Prelinguistic targets: Joint attention (responding to and initiating), intentionality, means-ends understanding, imitation, object permanence, communicative gestures (reaching, giving, showing, pointing).
• JASPER (Joint Attention Symbolic Play Engagement and Regulation): Evidence-based for toddlers with ASD. Targets joint engagement, joint attention, and symbolic play as foundations for communication.
• Routines-Based Intervention (RBI): McWilliam. SLP embeds communication targets in family's natural daily routines. Maximizes learning opportunities beyond therapy sessions.
• Coaching model: Coach primary caregiver rather than directly treating child. SLP demonstrates, observes, provides feedback. Increases intervention intensity through caregiver-mediated practice.
• Late talkers: Children 18–24 months with fewer than 50 words or no word combinations. ~75% catch up by age 3 ("late bloomers"). Risk factors for persistent delay: family history, male, co-occurring deficits, fewer consonants in inventory.
• Late language emergence (LLE): Broad term for children 18–36 months with significantly below-average expressive language. May/may not have receptive delay.
• Watchful waiting vs. early intervention: EI is recommended even with uncertain prognosis — benefits outweigh risks, and early periods are critical for neural plasticity.

Literacy & Reading — SLP Role

• Five pillars of reading (NRP): Phonemic awareness, Phonics (decoding), Fluency, Vocabulary, Comprehension.
• Simple View of Reading: RC = D × LC. Both decoding AND language comprehension are necessary. Dyslexia = decoding deficit. Developmental Language Disorder (DLD) = language comprehension deficit. Hyperlexia = strong decoding, poor comprehension.
• Phonological awareness (PA) hierarchy: Word level → Syllable → Onset-rime → Phoneme segmentation → Phoneme manipulation (most complex).
• Phonemic awareness vs. phonics: PA = sound-only, no print. Phonics = sound-symbol (grapheme-phoneme) correspondence.
• Orthographic knowledge: Understanding of spelling patterns, morphology, and how print represents language. SLPs target morphological awareness (prefixes, suffixes, roots) to build vocabulary and spelling.
• Dyslexia: Neurobiological origin. Core deficit: phonological processing (segmentation, blending, phonological memory). Unexpected given IQ. Evidence-based interventions: Orton-Gillingham, Wilson Reading, RAVE-O, Lindamood-Bell.
• SLP's role: Prevention (PA instruction in preschool), early identification, intervention (PA, phonics, vocabulary, comprehension strategies, morphological awareness), collaboration with reading specialists and teachers.

Dysarthria Treatment

• LSVT LOUD: Hypokinetic dysarthria/Parkinson's. Intensive (16 sessions/4 weeks). Targets maximum effort in loudness. Evidence-base: improved intelligibility, articulation, and voice quality.
• SPEAK OUT! + LOUD Crowd: Alternative to LSVT for PD. Group maintenance phase (LOUD Crowd). Intent-to-communicate approach.
• Rate control: Used in ataxic dysarthria (unpredictable rate), ALS (preserves intelligibility as function declines). Techniques: pacing board, alphabet board (point to first letter), metronomic pacing.
• Augmentation for intelligibility: When dysarthria progresses, transition to AAC support. Alphabet supplementation (point to first letter) slows rate and provides listener context.
• Palatal lift/obturator: For VPI in flaccid dysarthria. Prosthetic device elevates velum or obstructs velopharyngeal port.
• Biofeedback: Acoustic (real-time pitch/loudness display), electromyographic (muscle activity), nasometer (nasalance). Enhances motor learning through visual feedback.

Autism Spectrum Disorder (ASD)

• DSM-5 criteria: (A) Persistent deficits in social communication and interaction across contexts AND (B) Restricted, repetitive patterns of behavior, interests, or activities. Present from early developmental period.
• Communication profiles: Highly variable. May be non-speaking, minimally verbal, or hyperfluent (but pragmatically impaired). Echolalia (immediate or delayed) may be functional or non-functional.
• Early red flags: No babbling by 12 months, no single words by 16 months, no two-word phrases by 24 months, any loss of previously acquired skills. Lack of joint attention, pointing, and social smile by 12 months.
• Evidence-based treatments: SCERTS, JASPER, PECS, ESDM (Early Start Denver Model), Pivotal Response Treatment (PRT), DTT, AAC, Social Thinking.
• Echolalia types: Immediate, delayed (hours/days/years later), mitigated (modified echoes), interactional, non-interactional. Functional echolalia = communicative intent (use it, don't eliminate it).

Developmental Language Disorder (DLD)

• Definition: Significant language impairment with no known biomedical cause (not due to ASD, intellectual disability, hearing loss, neurological damage). Most common communication disorder in children (approx. 1 in 14).
• Profile: Deficits in morphosyntax (particularly grammatical morpheme use), vocabulary, sentence repetition, and narrative. Receptive and/or expressive. Persistent across lifespan.
• Clinical markers in English: Difficulty with English morphology (-ed past tense, 3rd person -s, auxiliaries). Sentence repetition is a highly sensitive task.
• DLD in bilingual children: Exists in BOTH languages — deficit relative to bilingual peers, not monolingual norms. Assess in both languages.
• Long-term: Increased risk for reading disorders, academic challenges, social-emotional difficulties, and mental health problems.

Cleft Palate, VPI & Craniofacial Conditions

• VPI (Velopharyngeal Insufficiency/Incompetence): Failure of velopharyngeal mechanism to close completely. Results in: hypernasality, nasal air emission (audible or turbulent), weak pressure consonants, compensatory articulations.
• Compensatory articulations: Learned in response to insufficient intraoral pressure. Include glottal stops (replacing oral plosives), pharyngeal fricatives, nasal fricatives, mid-dorsum palatal stops. Require targeted articulation therapy AFTER structural management.
• SLP role with cleft: Newborn feeding (specialized bottles/nipples), post-palatoplasty articulation therapy, VPI assessment, resonance management, speech/language development monitoring.
• Surgical timing: Palate repair typically 9–18 months. SLP does NOT treat compensatory articulations before palate repair — premature therapy may reinforce compensatory patterns.
• Syndromes associated: Pierre Robin sequence, Treacher Collins, 22q11.2 deletion (velocardiofacial syndrome/DiGeorge) — high VPI prevalence.
• VPI assessment: Nasometry, pressure-flow (PERCI), videofluoroscopy (lateral view), nasopharyngoscopy (direct view of VP closure).

Traumatic Brain Injury (TBI)

• Classification: Mild (GCS 13–15), Moderate (GCS 9–12), Severe (GCS 3–8). Penetrating vs. closed head. Focal vs. diffuse axonal injury.
• Rancho Los Amigos Levels (I–X): I=No response, II=Generalized response, III=Localized, IV=Confused-agitated, V=Confused-inappropriate, VI=Confused-appropriate, VII=Automatic-appropriate, VIII=Purposeful-appropriate, IX=Purposeful-appropriate (standby assist), X=Purposeful-appropriate (modified independence).
• Cognitive-linguistic sequelae: Attention, memory, executive function, word retrieval, discourse, pragmatics (impulsivity, topic maintenance, perspective-taking).
• Post-Traumatic Amnesia (PTA): Period of disorientation and inability to form new memories. Duration correlates with severity and predicts outcomes.
• SLP interventions: Memory compensation strategies (planners, apps), attention training, metacognitive strategy training, social communication, discourse-level language, supported employment/school re-entry.

Dementia Across the Continuum

• Alzheimer's disease: Most common (~60–80%). Gradual onset, progressive memory loss, anomia (circumlocution, empty speech), ultimately global decline. Language: anomia → fluent jargon → mutism.
• Vascular dementia: Step-wise decline. Follows strokes/TIAs. Focal deficits depending on stroke location.
• Frontotemporal Dementia (FTD): Behavioral variant (disinhibition, apathy, early behavioral changes, preserved memory). Primary Progressive Aphasia variants (see PPA above). Younger onset (50–65).
• Lewy Body Dementia: Fluctuating cognition, visual hallucinations, Parkinsonism. Hypersensitivity to antipsychotics.
• SLP interventions: Spaced retrieval therapy, Montessori-based activities, memory books/external aids, caregiver training, supported conversation, communication partner training, dysphagia management as disease progresses.
• Goals shift: Early stages: compensatory strategies, independence. Middle stages: supported communication, safety. Late stages: comfort, quality of life, palliative care.

Voice Disorders — Comprehensive Classification

• Organic — structural: Nodules (bilateral, at anterior-middle third junction, hyperfunctional use), polyps (unilateral, hemorrhagic, abrupt onset), cysts (submucosal, may be retention or epidermoid), papilloma (HPV, most common benign laryngeal tumor in children), leukoplakia (white lesion, precancerous potential).
• Organic — neurogenic: Unilateral vocal fold paralysis (UVFP — breathy, reduced loudness, diplophonia, aspiration risk), bilateral VFP (adductor = aphonia, abductor = stridor + dyspnea), spasmodic dysphonia (adductor = strained-strangled, abductor = breathy-whispered voice breaks), essential tremor, paradoxical vocal fold motion (PVFM — exercise-induced, inspiratory stridor, often misdiagnosed as asthma).
• Functional — hyperfunctional: Muscle Tension Dysphonia (MTD) = excess laryngeal and perilaryngeal tension without lesion. Primary (no organic pathology) or secondary (overlying organic pathology). Ventricular phonation = false fold use.
• Functional — hypofunctional: Puberphonia/mutational falsetto = young males using high pitch after voice change. Treatment: pitch lowering techniques.
• Presbyphonia: Age-related vocal fold bowing/atrophy. Breathy, weak voice, reduced MPT. Treated with voice therapy or medialization (injection augmentation, thyroplasty).

Fluency Disorders — Full Picture

• Stuttering etiology: Multifactorial. Genetic component (chromosome 12q, GNPTAB, GNPTG, NAGPA genes). Neurological differences in motor planning circuits (cortico-striato-thalamo-cortical loop).
• Normal disfluency: Phrase/whole-word repetitions, revisions, interjections. Normal rate: <10% of utterances. No tension or struggle.
• Stuttered disfluency: Sound/syllable repetitions (tense), prolongations, blocks (airflow/voicing cessation). Often accompanied by secondary behaviors (eye blinks, head jerks, circumlocution, avoidance).
• Onset: Typically 2–5 years. Boys more likely to persist (4:1 adult ratio). Girls more likely to recover. Most natural recovery by age 7.
• Neurogenic stuttering: Acquired after stroke, TBI, degenerative disease. No adaptation effect, no fear/avoidance, more consistent across speaking contexts. May co-occur with aphasia.
• Psychogenic stuttering: Sudden onset following psychological trauma. May remit spontaneously. Requires interdisciplinary management.
• Cluttering vs. stuttering: Cluttering = fast rate, telescoping, poor awareness. Stuttering = awareness, tension, secondary behaviors. May co-occur (clutterer who stutters).

Neurological & Developmental Populations

• Cerebral Palsy (CP): Non-progressive UMN disorder from early brain damage. Spastic (most common, ~70%: increased tone, hyperreflexia), Dyskinetic/Athetoid (basal ganglia damage, involuntary movements), Ataxic (cerebellar, coordination), Mixed. SLP addresses dysarthria, dysphagia (positioning, texture modification), AAC, feeding in NICU.
• Down Syndrome (Trisomy 21): High prevalence of hearing loss (conductive + SNHL), otitis media, hypotonia affecting articulation, resonance (hypernasality due to enlarged adenoids and hypotonia), relative strength in social communication vs. expressive language. Vocabulary stronger than morphosyntax.
• Fragile X Syndrome: Most common inherited intellectual disability. Males more affected. Perseverative speech, tangential language, social anxiety, cluttering-like speech. Motor planning deficits.
• Williams Syndrome: Cocktail party speech — hyperfluent, sociable, superficially elaborate but semantically impoverished. Strong prosodic and social drive. Significant visuospatial and numerical deficits.
• Prader-Willi Syndrome: Hypotonia, feeding difficulties in infancy, hyperphagia, articulation/language delays, often require AAC initially.
• Selective Mutism: Failure to speak in specific social situations despite ability to speak in others. Anxiety-based. NOT elective silence. SLP + mental health collaboration. Stimulus fading, systematic desensitization.

Feeding Disorders — Pediatric

• Etiology: Medical (GERD, cardiac, respiratory), anatomical (cleft, laryngomalacia), neurological (CP, prematurity), sensory (hypersensitivity, hyposensitivity), behavioral (learned food refusal).
• NICU feeding: Non-nutritive sucking (NNS) for breast-stimulation and pacifier use. Nutritive sucking (NS) transitions to oral feeding. SLP assesses suck-swallow-breathe coordination.
• Avoidant/Restrictive Food Intake Disorder (ARFID): Limited variety/volume of food intake not explained by body image concerns (as in anorexia). Often sensory-based. Interdisciplinary: SLP + OT + behavioral feeding + GI + nutrition.
• Sequential Oral Sensory (SOS) approach: Structured, hierarchy-based approach to food exploration. Begins with tolerance/exposure before expectation of eating.
• Premature infants: Suck-swallow-breathe coordination typically matures by 34 weeks gestational age. SLP/feeding specialists guide transitioning from tube to oral feeding.

Levels of Evidence

• Level I: Systematic reviews and meta-analyses of RCTs (highest)
• Level II: Individual RCTs (randomized, controlled, blinded)
• Level III: Non-randomized controlled trials, quasi-experimental
• Level IV: Cohort studies, case-control studies
• Level V: Case series, case reports
• Level VI: Expert opinion, consensus statements (lowest)
• Single-Subject Experimental Design (SSED): Widely used in SLP. A=Baseline, B=Intervention. Designs: A-B, A-B-A (withdrawal), A-B-A-B (reversal), Multiple Baseline (across subjects, behaviors, or settings), Alternating Treatments. Provides causal inference with small N.

Research Design Concepts

• Internal validity: Confidence that the IV (intervention) caused the change in DV (outcome). Threats: history, maturation, testing effects, regression to mean, selection bias, attrition.
• External validity: Generalizability to other populations, settings, and time periods.
• Randomization: Random assignment to groups eliminates selection bias, the primary threat to internal validity in group designs.
• Control group: Allows comparison — treatment vs. no treatment or treatment vs. alternative treatment. Waitlist control, active control (attention control), treatment-as-usual control.
• Blinding: Single-blind = participant unaware of group assignment. Double-blind = participant AND researcher unaware. Reduces expectation bias and measurement bias.
• Placebo effect: Improvement due to expectation of treatment, not treatment itself. Controlled through blinding and placebo conditions.
• Hawthorne effect: Behavior change due to awareness of being observed. Independent of treatment.

Statistical Concepts for SLPs

• p-value: Probability of obtaining results as extreme as observed, assuming null hypothesis is true. p<0.05 = statistically significant. Does NOT indicate clinical significance.
• Effect size: Magnitude of treatment effect, independent of sample size. Cohen's d: 0.2=small, 0.5=medium, 0.8=large. Pearson's r: 0.1=small, 0.3=medium, 0.5=large.
• Confidence Interval (CI): Range within which true population value likely falls. 95% CI = 95% confidence the true value is in this range. If CI does not cross 0, effect is significant.
• Type I error (alpha): False positive. Incorrectly reject null (find effect that doesn't exist). Controlled by p-value threshold.
• Type II error (beta): False negative. Fail to reject null when effect exists. Controlled by statistical power.
• Statistical power: Probability of detecting a true effect. Increases with larger sample size, larger effect size, lower alpha threshold.
• NNT (Number Needed to Treat): = 1/ARR. How many must be treated for one additional person to benefit. Lower NNT = more effective treatment.

Sensitivity & Specificity — Applied to SLP

• Sensitivity: TP / (TP + FN). Proportion of people with the disorder who test positive. High sensitivity = few false negatives. Good screening tool.
• Specificity: TN / (TN + FP). Proportion of people without disorder who test negative. High specificity = few false positives. Good diagnostic tool.
• Mnemonic SnOut: High Sensitivity + Negative result → rules OUT the disorder.
• Mnemonic SpPin: High Specificity + Positive result → rules IN the disorder.
• PPV (Positive Predictive Value): Probability that a positive test means the person has the disorder. Affected by prevalence.
• NPV (Negative Predictive Value): Probability that a negative test means the person does NOT have the disorder.
• Clinical application: Use high-sensitivity measures for broad screening (don't miss cases). Use high-specificity measures for diagnosis (don't falsely label).

PICO & Literature Searching

• PICO: P=Population, I=Intervention, C=Comparison, O=Outcome. Structures the clinical question for efficient searching.
• Background questions: General knowledge (What is X? How does Y work?). Answered by textbooks, clinical guidelines.
• Foreground questions: Specific clinical decisions (In a child with X, does treatment Y compared to Z result in better outcome O?). Answered by primary research using PICO.
• Search databases: PubMed/MEDLINE (medical literature), CINAHL (nursing and allied health), Cochrane Library (systematic reviews), ASHA Wire (SLP-specific), PsycINFO (psychological literature).
• MeSH terms: Medical Subject Headings — controlled vocabulary for PubMed searches. Use for more precise results.
• Critical appraisal: Evaluate study quality: Was randomization used? Was there a control group? Were outcome measures valid and reliable? Was there blinding? Was there an ITT (intention-to-treat) analysis?

Outcome Measurement in SLP

• ASHA NOMS (National Outcomes Measurement System): 7-point FCM (Functional Communication Measure). 1=Least functional, 7=Most functional. Available for multiple SLP service areas. Used for clinical benchmarking.
• ASHA FACS: 43 functional communication behaviors across 4 domains: Social Communication, Communication of Basic Needs, Reading/Writing/Number Concepts, Daily Planning. For adults with neurogenic disorders.
• FIM (Functional Independence Measure): Used in rehabilitation settings. 18 items (13 motor, 5 cognitive). SLP contributes to cognitive subscores. 7-point scale.
• ICF-based measures: Target activity and participation (not just impairment). Align with real-world functional goals.
• Efficacy vs. Effectiveness vs. Efficiency: Efficacy = does it work under ideal conditions? Effectiveness = does it work in real clinical settings? Efficiency = does it work at acceptable cost?
• Treatment fidelity: Degree to which intervention was delivered as intended. Essential for replication and valid outcome interpretation.
• Progress monitoring: Frequent, brief measures of target skills to track response to intervention and make data-based decisions. Essential in RTI/MTSS Tier 3.