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Measurement constitutes a central issue in determining effectiveness of couple and family therapy (CFT). A review of 274 CFT outcome studies published in 25 mental health journals between 1990 and 2005 is presented. Goals of this review were to (1) provide a broad, empirically based overview of CFT outcome research, (2) examine measurement of treatment outcomes, and (3) appraise reporting practices. Findings indicate that a wide range of instruments continue to be used in CFT outcome research, although a foundation for a more integrated and coherent assessment battery has been established. Implications for the field are discussed.

In this article, the authors assist teachers who are working with young students at risk for reading disabilities by helping make sense of the large—but unwieldy—scientific knowledge base. They offer a conceptual framework for thinking about beginning reading instruction and intervention across three dimensions: the content of instruction (what to teach), the delivery of instruction (how to teach), and the timing of instruction (when to teach). The authors discuss each of these dimensions and describe how teachers can use them to help organize and make sense of what we know about beginning reading instruction for students experiencing reading difficulties.

Abstract The purpose of this study was to compare 2 methods for directly teaching word meanings to kindergarten students within storybook read‐alouds that varied in instructional time and depth of instruction along with a control condition that provided students with incidental exposure to target words. Embedded instruction introduces target word meanings during storybook readings in a time‐efficient manner. Extended instruction is more time intensive but provides multiple opportunities to interact with target words outside the context of the story. Participants included 42 kindergarten students who were taught 9 target words, 3 with each method. Target words were counterbalanced in a within‐subjects design. Findings indicated that extended instruction resulted in more full and refined word knowledge, while embedded instruction resulted in partial knowledge of target vocabulary. Implications are discussed in relation to the strengths and limitations of different approaches to direct vocabulary instruction in kindergarten and the trade‐offs between instruction that focuses on teaching for breadth versus depth.

This article examines the role of direct instruction in promoting listening and reading comprehension. Instructional examples from 2 programs of intervention research focused on improving comprehension; the Story Read Aloud Program and the Embedded Story Structure Routine are used to illustrate principles of direct instruction. An analysis of these 2 approaches suggests that direct instruction principles are effective in supporting students with varied achievement levels and that these principles can be used to enhance comprehension among students at very different points in reading development. These evidence-based approaches also illustrate that direct instruction can be designed to support complex learning and the development of higher order cognitive strategies.

Two approaches to systematic word review were integrated into an 18-week program of extended vocabulary instruction with kindergarten students from three high-need urban schools. Words in the embedded and semantically related review conditions received systematic and distributed review. In the embedded review condition, brief word definitions were integrated into the narratives of multiple storybooks. In the semantically related review condition, in-depth word review with explicit emphasis on semantic features and associations was provided during extension activities. Systematic review resulted in an almost twofold increase in target word learning. Embedded review was effective and time efficient, whereas semantically related review was time intensive but resulted in higher levels of word learning. There was a significant gain in Peabody Picture Vocabulary Test—III standard scores following the intervention.

The purpose of this study was to investigate the efficacy of an 18-week program of direct and extended vocabulary instruction with kindergarten students on both proximal measures of target word knowledge and transfer measures of generalized language and literacy. A second purpose was to examine whether treatment effects would be moderated by initial receptive vocabulary knowledge measured at pretest. In a quasi-experimental design, 80 kindergarten students from schools serving large at-risk populations were taught the meanings of 54 vocabulary words within interactive story read alouds over 36 half-hour instructional lessons (2 lessons per week over 18 weeks). An additional 44 students served as a no-treatment control. Findings indicated that students who received vocabulary instruction outperformed controls on a measure of target word knowledge as well as measures of generalized receptive vocabulary and listening comprehension. In addition, initial receptive vocabulary was strongly related to posttest performance on all measures. Implications are discussed in relation to supporting vocabulary development in the early grades within a multitier framework of instruction and intervention.

The purpose of this study was to examine the effectiveness of a vocabulary intervention designed to supplement research–based classroom vocabulary instruction, implemented with students who may be at risk for language and learning difficulties. Participants included 43 kindergarten students who received research–based classroom vocabulary instruction. Students with the 20 lowest scores on the Peabody Picture Vocabulary Test–III administered at pretest received additional small–group supplemental vocabulary intervention. Results of within–subjects comparisons indicated that, overall, at–risk students made greater gains in word knowledge on target words that received the supplemental intervention as compared to words that received only classroom–based instruction. In addition, at–risk students who received the supplemental intervention demonstrated word–learning gains that approached those of their peers who received classroom instruction alone. Implications along with limitations of the current study and directions for future research are discussed.

Purpose A frequent complaint by older adults is difficulty communicating in challenging acoustic environments. The purpose of this work was to review and summarize information about how speech perception in complex listening situations changes across the adult age range. Method This article provides a review of age-related changes in speech understanding in complex listening environments and summarizes results from several studies conducted in our laboratory. Results Both degree of high frequency hearing loss and cognitive test performance limit individuals' ability to understand speech in difficult listening situations as they age. The performance of middle-aged adults is similar to that of younger adults in the presence of noise maskers, but they experience substantially more difficulty when the masker is 1 or 2 competing speech messages. For the most part, middle-aged participants in studies conducted in our laboratory reported as much self-perceived hearing problems as did older adult participants. Conclusions Research supports the multifactorial nature of listening in real-world environments. Current audiologic assessment practices are often insufficient to identify the true speech understanding struggles that individuals experience in these situations. This points to the importance of giving weight to patients' self-reported difficulties. Presentation Video http://cred.pubs.asha.org/article.aspx?articleid=2601619

The purpose of this prospective study was to determine if fiberoptic endoscopic evaluation of swallowing (FEES) maintains high intra- and interrater reliability in detecting pharyngeal dysphagia and aspiration without the addition of FD&C Blue No. 1 to food. Twenty consecutive adults referred for a swallow evaluation participated. Nine subjects received blue-dyed food and 11 subjects received regular nondyed food, i.e., yellow pudding and white skim milk. Four variables were rated: (1) the stage transition characterized by depth of bolus flow to at least the vallecula prior to the pharyngeal swallow; (2) evidence of bolus retention in the vallecula or pyriform sinuses after the pharyngeal swallow; (3) laryngeal penetration defined as material in the laryngeal vestibule but not passing below the level of the true vocal folds either before or after the pharyngeal swallow; and (4) tracheal aspiration defined as material below the level of the true vocal folds either before or after the pharyngeal swallow. Three speech–language pathologists experienced in interpreting FEES results independently and blindly reviewed the digitized videotape three times. Intrarater agreements for the four variables with blue-dyed and non-blue-dyed food trials were 100% and monochrome trials ranged from 95% to 100%. Average kappa values for interrater reliability ranged from moderate to excellent agreement (0.61–1.00) for all viewing conditions. Kappa values for blue-dyed trials versus monochrome trials were 0.83 and for non-blue-dyed trials versus monochrome trials were 0.88, indicative of excellent reliability under both viewing conditions. FEES maintains both high intra- and interrater reliability in detecting the critical features of pharyngeal dysphagia and aspiration using either blue-dyed or non-blue-dyed foods. The endoscopist, therefore, can be assured of reliable FEES results using regular, non-dyed food trials.

In the acute-care setting patients with altered mental status as a result of such diverse etiologies as stroke, traumatic brain injury, degenerative neurologic impairments, dementia, or alcohol/drug abuse are routinely referred for dysphagia testing. A protocol for dysphagia testing was developed that began with verbal stimuli to determine patient orientation status and ability to follow single-step verbal commands. Although unknown, it would be beneficial to ascertain if this information on mental status was predictive of aspiration risk. The purpose of this investigation was to determine if there was a difference in odds for aspiration based upon correctly answering specific orientation questions, i.e., 1. What is your name? 2. Where are you right now? and 3. What year is it?, and following specific single-step verbal commands, i.e., 1. Open your mouth. 2. Stick out your tongue. and 3. Smile. In a consecutive retrospective manner data from 4070 referred patients accrued between 1 December 1999 and 1 January 2007 were analyzed. The odds of liquid aspiration were 31% greater for patients not oriented to person, place, and time (odds ratio [OR] = 1.305, 95% CI = 1.134–1.501). The odds of liquid aspiration (OR = 1.566, 95% CI = 1.307–1.876), puree aspiration (OR = 1.484, 95% CI = 1.202–1.831), and being deemed unsafe for any oral intake (OR = 1.688, 95% CI = 1.387–2.054) were, respectively, 57, 48, and 69% greater for patients unable to follow single-step verbal commands. Being able to answer orientation questions and follow single-step verbal commands provides information on odds of aspiration for liquid and puree food consistencies as well as overall eating status prior todysphagia testing. Knowledge of potential increased odds of aspiration allows for individualization of dysphagia testing thereby optimizing swallowing success.

Background: Safe and timely oral alimentation is crucial for optimum patient care.Objective: To determine the short-term success of recommending specific oral diets, including drinking thin liquids, to acute care hospitalized patients at risk for dysphagia based on passing a 3-ounce water swallow challenge protocol.Design: Prospective single group consecutively referred case series.Setting: Large, urban, tertiary care, teaching hospital.Participants: 1000 hospitalized patients.Intervention: 3-ounce (90 cc) water swallow challenge protocol.Measurements: Specific diet recommendations and volume (in cc) of liquid ingested at the next day's meal 12–24 h after passing a 3-ounce challenge protocol were accessed electronically from oral intake information entered on each participant's daily care logs. Eating and drinking success, clinically evident aspiration events and compliance with ordering the recommended diet were recorded. Care providers were blinded to the study's purpose.Results: Of 1000 patients, 907 met the inclusion criteria of stable medical, surgical or neurological conditions 12–24 h after passing a 3-ounce water swallow challenge protocol. All 907 were both eating and drinking thin liquids successfully and without overt signs of dysphagia. Median volume of liquid ingested was 340 cc [interquartile range (IQR), 240–460]. Specific diet recommendations were followed with 100% accuracy.Conclusions: A 3-ounce water swallow challenge protocol successfully identified patients who can be safely advanced to an oral diet without subsequent identification of overt signs of aspiration within 12–24 h of testing. Importantly, when a clinical 3-ounce challenge protocol administered by a trained provider is passed, specific diet recommendations, including drinking thin liquids, can be made safely and without the need for additional instrumental dysphagia testing.

Background:  Pulmonary aspiration is a leading cause of nosocomial infection in the intensive care unit (ICU) and step-down unit (SDU). A key goal is to identify patients who exhibit increased aspiration risk before beginning oral alimentation. This study investigated the success of recommending specific oral diets to ICU and SDU patients based on passing a 3-oz water swallow challenge. Methods:  A referral-based sample of 401 ICU and 92 SDU patients were prospectively analyzed. Amount of liquid and food ingested at the next day's meal 12 hours to 24 hours after passing a 3-oz challenge and specific diet recommendations were accessed electronically from oral intake information entered on each participant's daily care sheets. Drinking and eating success, clinically evident aspiration events, and accuracy of diet order recommendations were recorded. Care providers were blinded to the purpose of the study. Results:  All 401 ICU and 92 SDU patients were successfully drinking thin liquids and eating 12 hours to 24 hours after passing a 3-oz challenge. Mean volume of liquid ingested at the next day's meal was 360 mL ± 181.2 mL for ICU and 356.4 mL ± 173.5 mL for SDU patients. Percent of meal eaten ranged from 10% to 100%. Patient care sheets indicated specific diet recommendations were followed with 100% accuracy. Conclusions:  Successfully recommending specific oral diets for ICU and SDU patients based on passing a 3-oz water swallow challenge was supported. Importantly, when a simple bedside 3-oz challenge administered by a trained provider is passed, specific diet recommendations can be made safely and confidently without the need for further objective dysphagia testing.

Objective. To determine what effect, if any, the presence or absence of a nasogastric (NG) tube in the same person had on the incidence of anterograde aspiration. Design. Case series with planned data collection. Setting. Large, urban, tertiary care teaching hospital. Subjects and Methods. Referred sample of 62 consecutively enrolled adult inpatients for fiber-optic endoscopic evaluation of swallowing (FEES). Group 1 (n = 21) had either small-bore (n = 13) or large-bore (n = 8) NG tubes already in place and had a FEES first with the NG tube in place and a second FEES after NG tube removal. Group 2 (n = 41) did not have an NG tube and had a FEES first without an NG tube and a second FEES after placement of a small-bore NG tube. Time between FEES was approximately 5 minutes. Patients were tested with thin liquid and puree food consistencies. Occurrence of aspiration for each consistency dependent on the presence or absence of an NG tube was recorded. Results. There were no significant differences (P > .05) in aspiration status for both liquid and puree consistencies in the same person dependent on presence or absence of either a small-bore or large-bore NG tube. Conclusions. Since objective swallowing evaluation (eg, FEES) can be performed with an NG tube in place, it is not necessary to remove an NG tube to evaluate for aspiration. Similarly, there is no contraindication to leaving an NG tube in place to supplement oral alimentation until nutritional requirements are achieved.

Purpose: This qualitative study explored the practices of hospital-based speech-language pathologists (SLPs) conducting modified barium swallow studies (MBS) for infants at risk for dysphagia. Specifically, this research aimed to determine whether or not SLPs use side-lying position during MBS, to examine possible differences in the use of positioning, and to better understand SLPs' perceptions and experiences in this practice. Using a constructivist view, research questions guiding this inquiry were as follows: What is the current practice of hospital-based pediatric SLPs in regard to the use of side-lying position during infant MBS? What is the experience of the hospital-based SLP in their use of side-lying position during MBS? How do SLPs report perceived barriers or benefits to using side-lying position during MBS? Method: Employing a purposive-convenience sampling technique, data were collected using semistructured interviews of SLPs serving at-risk infants with dysphagia. All participants were practicing in Level-III or -IV neonatal intensive care units. Interviews were recorded, transcribed, loaded into NVivo, and coded using initial and consensus coding. Themes achieved saturation following six interviews. Results: Three themes emerged from the analysis: (a) variations in practice patterns, (b) factors influencing clinical practice, and (c) items that SLPs identified as needs to facilitate change in their clinical practice. Conclusions: Although SLPs acknowledged the importance of MBS replicating an infant's typical feeding, some SLPs who consistently use side-lying position during feeding do not assess feeding in side-lying position during MBS. This inconsistency in practice results from SLPs' perceived barriers, including lack of experience, concern over interdisciplinary conflict, need for MBS protocols, and lack of research on the potential impacts of side-lying positioning on swallowing. Participants reported the need for research to determine whether side-lying position alters, possibly improves, swallow functions and safety (e.g., airway protection) for at-risk infants.