International Journal of Speech-Language Pathology

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Optimal intervention intensity

Elise Baker

To cite this article: Elise Baker (2012) Optimal intervention intensity, International Journal of
Speech-Language Pathology, 14:5, 401-409, DOI: 10.3109/17549507.2012.700323

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International Journal of Speech-Language Pathology, 2012; 14(5): 401–409

SCIENTIFIC FORUM: LEAD ARTICLE

Optimal intervention intensity

ELISE BAKER

The University of Sydney, Australia

Abstract
Empirical evidence exists for many of the different interventions in speech-language pathology. However, relatively little is
known about the optimal intensity of those interventions. In order for speech-language pathology services to be both effec-
tive and efficient speech-language pathologists need to know how to faithfully administer ideal doses of the active ingredients
of interventions, in what forms, how often and for how long. This is the lead paper to a scientific forum on this fundamental
yet under-studied issue of clinical practice. Borrowing from the work of Warren, Fey, and Yoder, the concept of intervention
intensity is described. Issues involved in establishing the optimal intensity of interventions are identified, including what
and how intervention goals are targeted. Given that speech-language pathology interventions can involve the delivery of
therapeutic inputs (e.g., conversational recasts, questions) and/or clients carrying out an act (e.g., speech production, voice
production, comprehending, naming, swallowing), a framework is proposed for measuring all potential inputs and acts that
might contribute to the calculation of an intervention intensity. Client-, clinician-, condition-, and service-related variables
that could influence the investigation and practical application of an optimal intervention intensity are also discussed.

Keywords: Intensity, dose, treatment, intervention, speech-language pathology.

Introduction
A number of stakeholders, including speech-language
The question of how much intervention is enough is pathologists (SLPs), clinical researchers, clients, and
fundamental to effective and efficient speech-language third-party payers have a vested interest in knowing
pathology practice. An inaccurate dose, whether it is the optimal intensity of speech-language pathology
too much or too little, squanders resource. Too high a interventions. Surprisingly, relatively little is known
dose offered too frequently could be of no added ben- about this fundamental issue of SLP’s practice. Despite
efit (McGinty, Breit-Smith, Fan, Justice, & Kaderavek, the increase in publication of evidence-based reviews
2011), while too little could mean that intervention is and clinical practice guidelines (e.g., American Speech-
not effective enough, or worse still equivalent to no Language-Hearing Association, 2006; Kennedy, Coelho,
intervention (Glogowska, Roulstone, Enderby, & Turkstra, Ylvisaker, Sohlberg, Kan, et al., 2008; Law,
Peters, 2000; Lincoln, McGuirk, Mulley, Lendrem, Garrett, & Nye, 2004; Myers & Johnson, 2007;
Jones, & Mitchell, 1984). An inaccurate dose could Wambaugh, Duffy, McNeil, Robin, & Rogers, 2006),
also do more harm than good. This is evident in the there is a dearth of literature on optimal intervention
field of pharmacology where dosage is paramount. For intensities across a number of areas of speech-language
example, under-dosing of penicillin was thought to be pathology practice. This situation is in stark contrast to
more dangerous than over-dosing because an under- fields such as pharmacology and sports medicine where
dose was believed to expose microbes to non-lethal recommendations exist regarding optimal dose of a
quantities of penicillin, making them resistant (Flem- drug for a particular disease (e.g., Walton, Dovey,
ing, 1945). By contrast, over-dosing has been associ- Harvey, & Freemantle, 1999) or optimal exercise inten-
ated with serious health problems, such as sensory sity, frequency, and duration for a particular health con-
neuropathy in response to excessive vitamin B6 sup- dition (e.g., Goble & Worcester, 1999; Haskell, Lee,
plementation (Schaumburg, Kaplan, Windebank, Vick, Pate, Powell, Blair, Franklin, et al., 2007).
Rasmus, Pleasure, et al., 1983). What do we know The purpose of this scientific forum is to raise
about the dose or optimal intensity of speech-language readers’ awareness and understanding of the complex
pathology interventions? Is it possible to define, study, issue of intervention intensity in the field of speech-
and measure speech-language pathology interventions language pathology. The forum is divided into three
in discrete doses? If so, how much intervention is parts. In this paper, I describe the concept of inter-
needed to achieve a particular outcome? vention intensity based on the work of Warren, Fey,

Correspondence: Elise Baker, PhD, Discipline of Speech Pathology, Faculty of Health Sciences, The University of Sydney, Australia. PO Box 170, Lidcombe,
1825, NSW Australia. Tel: ⫹61-2-93519121. Fax: ⫹61-2-93519173. E-mail: [email protected]
ISSN 1754-9507 print/ISSN 1754-9515 online © 2012 The Speech Pathology Association of Australia Limited
Published by Informa UK, Ltd.
DOI: 10.3109/17549507.2012.700323
402 E. Baker

and Yoder (2007) and discuss issues involved in capsule, tablet, liquid, or topically via oint-
establishing the optimal intensity of an intervention. ment (Warren et al., 2007). Teaching episodes
Client-, clinician-, condition-, and service-related occur during a task or activity and contain the
variables that could influence the investigation and important active ingredients of intervention,
practical application of an optimal intervention similar to the pharmaceutical inside a capsule,
intensity are also considered. In part two, scholars liquid, or ointment. For example, recast of an
from around the world offer their insights on the utterance (active ingredient) during child-
intensity of interventions relevant to their area of directed play (dose form).
expertise. They consider the state of the empirical (2) Dose: the number of times an active ingredient
evidence, and reflect on issues unique to their spe- or a teaching episode containing a unique com-
cialty. Part three (Baker, 2012) is a reflection on the bination of active ingredients occurs per ses-
themes raised by the authors with respect to what is sion (e.g., 100 production practice trials during
known about intervention intensity, why the study of a 50-minute session; 60 perception trials in a
intervention intensity is complicated, and how 45-minute session). To determine the dosage
researchers and clinicians might move forward in rate, session duration would also need to be
their understanding and practical application of this specified. For example, 0.5 recasts per minute
fundamental clinical issue. (Proctor-Williams & Fey, 2007), or one teach-
ing episode per minute (Warren et al., 2007).
(3) Dose frequency: the number of intervention
What is intervention intensity? sessions per unit of time, such as per day, per
week, or per month (e.g., 2 ⫻ day, 3 ⫻ week,
Across speech-language pathology, intensity has
1 ⫻ month).
been studied and defined in a variety of ways (War-
(4) Total intervention duration: the total period of
ren et al., 2007). For example, intensity has been
time in which a particular intervention is pro-
considered analogous to the number and duration
vided (e.g., 10 weeks; 3 months; 1 year).
of sessions per week (e.g., Brandel & Loeb, 2011:
(5) Cumulative intervention intensity: the product
20–30 minute sessions 2–3 times a week), hours of
of dose ⫻ dose frequency ⫻ total intervention
therapy per week for a period of weeks (e.g., Bhogal,
duration (e.g., 100 production practice tri-
Teasell, & Speechley, 2003: 7.8 hours of therapy
als ⫻ 3-times per week ⫻ 10 weeks ⫽ 3000 trials;
per week for 18 weeks), the density or number of
50 recasts ⫻ 2-times per week ⫻ 12 weeks ⫽
teaching episodes per minute or per session (e.g.,
1200 recasts).
Proctor-Williams & Fey, 2007: 0.5 recasts per min-
ute; 5 recasts of each verb per session), and the The relationship between dose forms, dose, ses-
number of client responses per session per week sion duration, session frequency, total intervention
(e.g., Ukraintetz, Ross, & Harm, 2009: 20 client- time, and cumulative intervention intensity is shown
responses in a 30 minute session once or 3-times in Figure 1. Session duration, a term included by
per week). Warren et al. (2007) within dose, is shown separately
Many of these descriptions of intensity have one
thing in common—the concept of repeated, spaced
episodes of intervention over a period of time. In this
way, the intensity of speech-language pathology
interventions would seem similar to a prescribed
dose of a pharmaceutical such as 40 mg/kg/day
of penicillin 3-times daily for 10 days (Murph,
Dusdieker, Booth, & Murph, 1993). However, as
Warren et al. (2007) point out, the conceptualization
and measurement of speech-language pathology
intervention intensity is more complex than merely
quantifying intervention session occurrence. We need
to consider both the quality and quantity of the
learning experiences within and across sessions. In
an attempt to capture the many issues involved in
the study and provision of intervention intensity,
Warren et al. (2007) proposed that the concept
encompass five main terms:
(1) Dose form: “the typical task or activity within
which the teaching episodes are delivered”
(Warren et al., 2007, p. 71). Dose forms are
analogous to the ways in which medicines Figure 1. Parameters involved in determining the optimal intensity
are delivered, such as via injection, orally via of intervention, based on Warren et al. (2007).
 Optimal intervention intensity 403

in Figure 1 because of the possibility of manipulating fundamental clinical questions—what needs to be

dose independent of session duration (e.g., dose of learned, and how intervention goals are addressed.
50 or 100 trials in a 30-minute session, dose of 100
trials in a 30- or 60-minute session). Of the six terms
depicted in Figure 1, dose form represents the task What needs to be learned?
or activity in which active ingredients of intervention
The goal or desired end-point of an intervention
occur, while dose, session duration, session frequency,
program specifies what behaviours, perceptual,
and total intervention duration capture a unit of
motor, or cognitive-linguistic abilities are to be
measurement about how much, how often, and for
learned. Some goals might involve the acquisition,
how long intervention is delivered. Cumulative inter-
re-learning, or retention of a skilled vocal, swallow-
vention intensity is simply “the product of dose ⫻ dose
ing, or speech motor movement (e.g., Ramig, Sapir,
frequency ⫻ total intervention duration” (Warren et al.,
Fox & Countryman, 2001; Robbins, Bulter, Daniels,
2007, p. 72). The four terms requiring measurement
Gross, Langmore, Lazarus, et al., 2008). The acqui-
are shown on a separate line given that each term
sition of specific motor skills is thought to be the
can be manipulated independent of the other. Each
product of both practice-dependent (i.e., online) and
line also shows a possible degree of the measure, with
practice-independent (i.e., offline) learning (Yan,
reduced or less intensity towards the left and increased
Abernethy, & Li, 2010). Practice-dependent learning
intensity towards the right. The circles on the four
occurs when an individual repeatedly uses a motor
lines show the specific measure for each term, such
skill to induce lasting neural change (Robbins et al.,
as a dose of 100 during a 60-minute session, 3 ⫻ week
2008; Yan et al., 2010). Practice-independent learn-
for 12 weeks, resulting in a cumulative intervention
ing is thought to occur between practice-based ses-
intensity equivalent to 3600 doses.
sions via memory consolidation processes (Yan et al.,
2010). The timing of intervention in addition to the
repetitive nature and intensity of online practice are
Establishing the optimal intensity of an
considered critical when learning a motor skill
intervention: Issues to be considered
(Kleim & Jones, 2008). Exactly how much practice,
Of the terms described by Warren et al. (2007), dose and the ideal conditions of practice needed to learn
frequency, session duration, and total intervention particular types of skilled motor movements, is still
duration would seem to be relatively simple to quan- not well understood (Maas, Robin, Austermann
tify, study, and report. For example, Denes, Paraz- Hula, Freedman, Wulf, Ballard, et al., 2008; Robbins
zolo, Piani, and Piccione (1996) compared the et al., 2008). What is known is that repetitive and
relative benefits of intensive 45–60 minute group frequent practice is beneficial (e.g., Spielman, Ramig,
intervention sessions for people with global aphasia Mahler, Halpern, & Gavin, 2007).
scheduled 6–7 ⫻ week with a less intense dose fre- What about goals other than or not limited to
quency of 3 ⫻ week, over a mean of 6 months inter- skilled motor movements, such as improved cogni-
vention duration. Denes et al. (1996, p. 385) reported tive-linguistic abilities or an increased or decreased
that “the number of patients reaching a significant occurrence of a particular behaviour? Could such
improvement in all language modalities was greater goals be subject to similar conditions of practice-
in the intensive therapy group”. In a study compar- dependent and practice-independent learning? Inter-
ing the relative benefit of two different session fre- vention research targeting phonologically-based
quencies, but identical session numbers (specifically, speech sound disorders in children would seem to
24 sessions), Barratt, Littlejohns, and Thompson suggest so. For instance, phonological learning typi-
(1992, p. 106) reported that “40 minute sessions cally occurs in response to repeated space interven-
4 days per week for 3 weeks, in each 3 months of a tion sessions over time (e.g., Bowen & Cupples,
6 month period” was associated with significantly 1999; Jarvis, 1989). Phonological learning also
better expressive language performance relative to occurs when a child exhibits system-wide general-
40-minute sessions conducted once weekly for ized change in response to intervention on a strategi-
6 months. cally selected complex intervention target (Gierut,
While studies examining the duration, frequency, 2007; Topbas¸ & Ünal, 2010). For example, child 6
and/or amount of intervention are informative, they (3;8) detailed in Gierut (2007), produced no clusters
provide little insight into the intensity of intervention prior to intervention that targeted the initial conso-
within a session (Brandel & Loeb, 2011). If we are nant cluster /bl/. Following intervention the child
to fully establish the optimal intervention intensity acquired 10 different consonant clusters /tw, kw, pl,
of speech-language pathology interventions (i.e., bl, sw, fl, sm, sn, sp, st/ in addition to varying but
know exactly what and how much is needed, in what improved production on a range of singleton conso-
form, how often, and for how long), we need to look nants /f, v, θ, ð, s, z, tò, h, l, ɹ/. In this case, the acqui-
inside interventions to identify the active ingredients sition of the untreated consonant clusters and
in order to determine dose. This is clearly a more singletons was not exclusively dependent on prac-
challenging task and requires consideration of two tice, but the type of intervention target prioritized
404 E. Baker

for intervention. A similar phenomenon has been translated, into the quasi-univariate equation of a
demonstrated in other areas of speech-language dosage formula that is predicated on the frequency
pathology whereby training of a more complex lin- of discrete teaching episodes, similar to the delivery
guistic target has promoted generalized acquisition of a pill” (Hoffman, 2009, p. 339).
or learning of simpler linguistically related targets Whether or not it is better, important, or indeed
(Thompson & Shapiro, 2007). These findings possible to isolate and carefully measure the impact
suggest that, while learning can be dependent on of the distinct evidence-based kernels that comprise
practice, not all learning is the result of practice. speech-language pathology interventions remains to
The identification of optimal intervention intensity be determined. Some intervention approaches may
requires careful consideration of what is to be tar- be simple, comprising one evidence-based kernel
geted in intervention, because the target itself could that can be isolated, studied, and prescribed in a
influence just how many sessions are required, and, dose. Some evidence-based kernels may work better
ultimately, the total intervention duration. as a collective, because the integration of a group of
kernels is thought to be better than the sum of the
parts (Proctor-Williams, 2009; Williams, 2005).
Some evidence-based kernels may also have interac-
How are intervention goals addressed?
tive and additive effects when used in sequence or
Having established the importance of the goal of combination with other kernels (Baumann, 2009;
intervention, it is equally important to consider how Hoffman, 2009; Proctor-Williams, 2009). Research-
goals are addressed. To do this, we need to look ers need to consider how or indeed whether inter-
inside intervention programs to identify the active ventions in their field of expertise could be examined
ingredients that make up teaching episodes. This is in such a way as to identify the active ingredient or
easier said than done. package of ingredients in order to study and recom-
The identification and study of the active ingredi- mend a prescribed dose of intervention.
ents of intervention is a complex and challenging This challenge aside, exclusive consideration of
undertaking. This is because an intervention is not what a clinician does fails to account for the contri-
as simple as a topical ointment or swallowing a butions of a client towards an intervention outcome.
pill. Rather, effective behavioural interventions are Much of what we ask, teach, or expect of our clients
thought to comprise one or more active ingredients. facilitates learning. Learning is an amazingly com-
Embry and Biglan (2008) refer to these active ingre- plex neural phenomenon. It occurs when the neural
dients as evidence-based kernels. They define an circuitry of the brain changes and adapts in response
evidence-based kernel as “a behavior-influence pro- to behavioural, sensory, and cognitive experiences
cedure shown through experimental analysis to affect (Kleim & Jones, 2008). These changes are not instan-
a specific behavior and that is indivisible in the sense taneous. Rather, learning occurs when conditions
that removing any of its components would render known to facilitate experience-dependent plasticity
it inert” (Embry & Biglan, 2008, p. 1573). The use exist, such as repeated practice and intense practice
of time delay, models, recasts, expansions, imita- (Kleim & Jones, 2008). Lee Silverman Voice Treat-
tions, questions, and direct instructions are examples ment® (LSVT) is a prime example of an intervention
of different types of evidence-based kernels in mor- approach in which repeated and intense practice by
phosyntax intervention (Proctor-Williams, 2009). a client is considered integral to the success of the
They reflect what a clinician does to cause an approach (Ramig & Fox, 2006). If we are to establish
improvement in a client’s targeted skill or behaviour, the optimal intensity of speech-language pathology
with the measurement of dose constituting the num- interventions, we need to capture and quantify all
ber of times an evidence-based kernel is delivered. types of active ingredients that contribute towards a
While the idea of intervention approaches being goal. As depicted in Figure 2, we need to look inside
reduced to evidence-based kernels is simple and the teaching episodes that occur in sessions to isolate
appealing, many speech-language pathology inter- and evaluate the quality and quantity of what a client
vention approaches do not comprise a distinct ker- does (i.e., client acts) in addition to the quality and
nel, but multiple kernels delivered in a unique quantity of what a clinician does (i.e., therapeutic
combination and/or sequence that overlap and inter- inputs).
mix (Proctor-Williams, 2009; Warren et al., 2007).
For example, enhanced milieu teaching with phono-
logical emphasis is “grounded in behavioural prin-
Measuring optimal intervention intensity
ciples for prompting, reinforcing, modelling, and
shaping new language”, and includes embedded How might researchers best account for the contribu-
milieu prompting procedures such as mand-model tions from clinicians and clients when establishing
and time delay, in addition to other teaching proce- the optimal intensity of an intervention? The frame-
dures (Scherer & Kaiser, 2010, p. 429). Narrative work offered by Warren et al. (2007) focused on
language intervention is another complicated exam- therapeutic inputs, such as conversational recast.
ple because it typically contains “complex multi- Admittedly, they were interested in the benefits of
variate processes that are not readily reduced, or intervention designed to enhance the communication
 Optimal intervention intensity 405

Figure 2. Relationship between dose form, teaching episodes, and the active ingredients (therapeutic inputs and client acts) that comprise
speech-language pathology interventions.

and language development of young children with towards an intervention outcome, SLP and non-SLP
developmental delays. Across other areas of speech- administrations of active ingredients are counted
language pathology practice, intensity research has separately. Each ingredient could be further catego-
focused primarily on client acts such as auditory rized as either a therapeutic input or client act. Each
comprehension, repetition naming, a conversation ingredient would be administered according to a
skill, or speech production practice (e.g., Cherney, prescribed dose or number of inputs and/or acts, in
Patterson, Raymer, Frymark, & Schooling, 2008; keeping with a particular session frequency per unit
Pulvermuller, Neininger, Elbert, Mohr, Rockstroh, of time (e.g., day, week, fortnight, month, or school
Koebbel, et al., 2001; Spielman et al., 2007). Given term), for a total period of time. The cumulative
that intervention approaches comprise one or both intervention intensity would comprise the total from
types of contributions it would seem that an interven- each ingredient provided using SLP time, and the
tion intensity framework should also account for total from each ingredient involving non-SLP time.
both. The option for SLP and non-SLP contributions of
Additionally, it would be important that contribu- one or more different ingredients exemplifies the
tions beyond intervention sessions be considered. flexibility of the framework. Flexibility is important,
For example, in an evaluation of an extended ver- to allow for study of the benefits of different permu-
sion of the Lee Silverman Voice Treatment® tations and combinations of an efficient and effective
(LSVT-X), participants engaged in repeated prac- intervention service, in the interests of establishing
tice of hierarchically arranged speech and voice- an optimal intervention intensity.
related tasks, during 1-hour sessions twice weekly In an effort to illustrate how the measurement of
for 8 weeks (Spielman et al., 2007). Participants also intervention intensity might be used, I have applied
completed 96 homework assignments over the same the principles of Figure 3 to Hodson’s (2007) cycles
8-week period. Given that contributions beyond phonological remediation approach, an intervention
clinic sessions have been shown to influence inter- for targeting speech sound disorders in children. As
vention outcomes (e.g., Gunther & Hautvast, 2010; part of Hodson’s (2007) cycles approach, a clinician
Spielman et al., 2007), it would be important that provides 30 seconds of amplified auditory stimula-
they be factored into any measure of intervention tion of a child’s targeted pattern at the beginning and
intensity. This would include tasks conducted inde- end of a 60-minute session, per cycle, for the total
pendently by the client, with or without input from duration of intervention (i.e., therapeutic input),
non-SLP personnel and computer technologies while the child produces a targeted speech skill dur-
(e.g., Halpern, Matos, Ramig, Petska, Spielman, & ing 50 minutes of production-practice activities, per
Will, 2005; Laganaro, Di Pietro, & Schnider, 2003; session per cycle for the total duration of the inter-
Ramsberger & Marie, 2007). vention (i.e., client act). Phonological awareness
Figure 3 illustrates how all contributions (thera- activities may also be included for an additional few
peutic inputs and client acts) delivered within and/ minutes, depending on a child’s age and stage of
or beyond regular clinic sessions might be accounted intervention. Assuming that lists of words for audi-
for when measuring intervention intensity. In the tory stimulation comprised 20 words, and that the
interests of quantifying direct SLP contributions number of production practice trials per session was
406 E. Baker

Combined total SLP and non-SLP cumulative intervention intensity

Total non-SLP cumulative intervention intensity Total SLP cumulative intervention intensity

Cumulative intervention intensity Cumulative intervention intensity

i.e., dose x dose frequency x duration i.e., dose x dose frequency x duration
durations provided by non-SLP to be added as necessary
Additional active ingredients, doses, frequency and

durations provided by SLP to be added as necessary

Additional active ingredients, doses, frequency and
Total intervention duration
Total intervention duration
i.e., total period of intervention in
i.e., total period of intervention in time
time

Dose frequency Dose frequency

i.e., session frequency per unit of i.e., session frequency per unit of time
time (e.g., day, week, fortnight or (e.g., day, week, fortnight or month,
month, term) term)

Session duration and dose Session duration and dose

i.e., number of therapeutic inputs, or, i.e., number of therapeutic inputs, or,
client acts in a session of a particular client acts in a session of a particular
duration duration

Active ingredient not requiring SLP

Active ingredient requiring SLP
time (e.g., teaching assistant, parent,
time i.e., therapeutic input or client
computer) i.e., therapeutic inputor
act within clinic session
client act within non-clinic session

Figure 3. Framework for guiding the measurement of all client acts and/or therapeutic inputs within and beyond sessions, to determine
the optimal intervention intensity of speech-language pathology interventions.

100, and that the number of sessions required to tion approach for the same session duration and
help a child progress from unintelligible to intelli- frequency from the same therapist. In a retrospec-
gible speech was 30 (Hodson, 2007), a cumulative tive evaluation of these cases, Baker and Bernhardt
intervention intensity would constitute a therapeutic (2004) speculated that a number of client-related
input of 30 minutes of amplified auditory stimulation variables may have contributed to the latter child’s
(comprising 60 repetitions of the 20-item word list, slower progress (e.g., language and oral-motor
equivalent to 1200 productions spoken by the clini- abilities, lack of insight about his communication
cian), and client acts of production practice equiva- and speech difficulties). Such variables of course
lent to 25 hours (comprising 3000 productions of are within the client. What about variables relevant
target words by the client). The cumulative intensity to a client’s life situation or circumstance? For
of the phonological awareness activities, and any some clients it may be that they are unable to
homework practice would of course need to be adhere to a high dose, high session frequency or
added. extended duration of intervention due to limited
financial resources, distance from SLP services,
lack of support from family, friends, or local com-
munity group, reduced motivation, or misguided
Factors influencing the investigation and
knowledge about their condition or the intensity
application of intervention intensity
required to treat the condition. In contrast, it may
While it may be possible to measure the intensity be that a client who is highly motivated, financially
of an intervention, a variety of client-, condition-, well equipped, and knowledgeable about his or her
clinician-, and service-related variables could pos- condition is well supported to adhere to an opti-
itively or negatively influence the investigation of mal intervention intensity. Early intensive behav-
what is possible, and the practical application of ioural intervention (EIBI) for children with autism
what is best. With regards to client variables, mul- is one such example where success could be pred-
tiple issues unique from one individual to the next icated on parents being financially able and moti-
may influence the application and/or outcome of vated to provide “one-to-one intervention for a
a particular intervention intensity (Lee, Kaye, & significant time period each week, often for several
Cherney, 2009). For example, in an intervention years” (Symes, Remington, Brown, & Hastings,
study about two children who had a phonological 2006, p. 31).
impairment, Baker and McLeod (2004) reported With regards to condition-related variables, the
that what took one child 7 weeks to achieve took nature of a communication or swallowing problem
another child 5 months—this was despite the chil- may influence the extent to which an optimal
dren receiving the same dose of the same interven- intervention intensity could be determined and
 Optimal intervention intensity 407

practically applied. For example, the time required perhaps best illustrated by a randomized controlled
to treat a particular condition may allow or inhibit trial in which the impact of routine community-
study of the optimal total intervention duration. based speech and language services for children
For instance, relative to a complex and persisting with delayed speech and language was examined
condition such as Childhood Apraxia of Speech (Glogowska et al., 2000). In this study 159 children
(CAS) where the mean number of sessions required were randomly allocated to either a treatment
to treat the disorder is unknown (Morgan & Vogel, group (n ⫽ 71) or watchful waiting group (n ⫽ 88).
2008), a known median of 11 sessions required to Glogowska et al. (2000) reported that an average
treat preschool-age stuttering using the Lidcombe 6.2 hours of therapy over a 12-month period
Program (Koushik, Hewat, Shenker, Jones, & resulted in outcomes equivalent to the watchful
Onslow, 2011) may mean that research examining waiting group. This was noted to not be enough to
different aspects of intervention intensity is achiev- facilitate an improvement in the children’s speech
able (e.g., Lewis, Packman, Onslow, Simpson, & and language abilities (Law & Conti-Ramsden,
Jones, 2008). 2000). Findings by Jacoby et al. (2002) support
The presence or absence of concomitant condi- this suggestion. In their study they examined the
tions may also influence the extent to which an number of individual treatment units (equivalent
optimal intervention intensity could be established to 15 minutes periods) needed to facilitate func-
or applied. For example, children who have autism tional communication improvements in children’s
in addition to severe developmental delay “have speech and language abilities. Jacoby et al. reported
been explicitly excluded from most investigations that the majority of participants improved by at
of intensive behavioural intervention” (Graff, least one or more functional communication mea-
Green, & Libby, 1998, p. 22) because their prog- sure (FCM) level, following 20 or more hours of
nosis has been considered poor. In such cases, therapy. Clearly, solutions to service-related barri-
where concomitant diagnoses exist, it may be that ers need to be identified if evidence-based recom-
the optimal intervention intensity needs to be mendations regarding intervention intensity are at
inferred from evidence associated with isolated odds with what is possible or practical.
conditions.
What about clinician-related variables? While it is
possible that a clinician’s expertise influences the Conclusion: The challenges ahead
success with which an intervention intensity is
applied, little is known about the impact of SLPs’ Establishment of the optimal intensity of speech-
expertise on intervention outcomes (Justice, 2010). language pathology interventions is an ambitious
Conceivably, a range of clinician-related variables goal. It is, however, fundamental to the delivery of
could influence one’s ability to faithfully administer effective services, because clinicians need to know
an ideal dose, dose frequency, session duration, or how to faithfully deliver the active ingredients that
total intervention duration. Drawing on Kamhi’s comprise interventions in the best form possible, as
(1995) model of clinical expertise, these variables often as required for as long as necessary. To move
could include (1) knowledge about a condition and forward in the accomplishment of this goal a number
evidence-based interventions for that condition, of tasks need to be done. The active ingredients and
(2) procedural and problem-solving skills about how best forms in which to deliver those ingredients need
to elicit and provide high dose of an intervention for to be identified. Experimental manipulation and
a particular condition, and (3) interpersonal skills measurement of the effect of the different aspects of
and attitudes to foster client motivation to adhere to intensity is needed, particularly total intervention
an optimal intervention intensity including practise duration (Baker, 2010; Baker & McLeod, 2011).
beyond clinic sessions. The identification and resolution of divides between
Finally, service-related variables could influence what is optimal and what is practical is also war-
the practical application of an optimal intervention ranted. This is a particularly important issue to con-
intensity. Service-related variables could include sider, not only because fidelity is assumed to
the number of clients on SLPs’ caseloads, the num- attenuate when the gold-standard prototype of an
ber of clients on waiting lists needing services, the established intervention approach is applied to
number of SLPs available to provide a service, gov- everyday clinical practice (Kaderavek & Justice,
ernment policies regarding access and provision of 2010), but because intervention intensities used in
speech-language pathology services, and the limit research settings cannot always be applied directly
that insurance companies place on the provision of to clinical practice. Clearly, some areas of speech-
speech-language pathology services (e.g., Jacoby, language pathology are further along than others in
Lee, Kummer, Levin, & Creaghead; 2002; Katz, establishing the optimal intensity of interventions.
Maag, Fallon, Blenkarn, & Smith, 2010; McAllis- Some areas also face unique challenges. The expert
ter, McCormack, McLeod, & Harrison, 2011; commentaries in this issue offer valuable insights
McLeod, Press, & Phelan, 2010). The challenge into what is already known and what remains to be
of providing an optimal intervention intensity is discovered.
408 E. Baker

Declaration of interest: The author reports no Gunther, T., & Hautvast, S. (2010). Addition of contingency man-
conflict of interest. The author alone is responsible agement to increase home practice in young children with a
speech sound disorder. International Journal of Language and
for the content and writing of the paper. Communication Disorders, 45, 345–353.
Halpern, A., Matos, C., Ramig, L., Petska, J., Spielman, J., & Will,
L. (2005). Technology supported speech treatment for Parkin-
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