JCPSLP Vol 17 No 3 2015

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JCPSLP Volume 17, Number 3 2015 141
Compliance fidelity measures include the use of
a treatment manual. The More than Words program
(Sussman et al., 2013) offers a checklist to support
reflection on a core part of the program: home-video
coaching visits. Parent evaluation forms are also part of the
Hanen More than Words program (Sussman et al., 2013)
and feedback on these forms may help with monitoring
compliance fidelity. To deliver Hanen parent programs,
SLPs must be certified by the Hanen centre, and have
a contractual agreement to deliver the programs in the
specified manner and to keep up to date with program
developments by participating in professional learning
activities provided by the centre. However, other types
of compliance measures are lacking in these programs
including the direct observation of practitioners delivering
the programs, self-report surveys of SLPs’ practice, or
checklists to support practice. Although no competency
measures are reported for any of the programs outlined
above, SLPs have extensive training on delivering focused
interventions and so may need less intensive training to
achieve fidelity (Kaderavek & Justice, 2010).
Treatment fidelity in practice
The availability of manualised programs and training should
make it easier for SLPs to deliver treatments with high
fidelity but in reality the situation appears to be more
complex. To illustrate, the results of a survey of SLPs in the
United Kingdom (Roulstone, Wren, Bakopoulou, & Lindsay,
2012) indicated that they routinely used combinations and
adaptations of intervention approaches for children with
speech, language, and communication difficulties. In the
Roulstone et al. study, SLPs reported that fidelity to the
original intervention was difficult in practice and their
predominant procedures for evaluating outcomes were
teacher and parent feedback and data collected for
individual clients. The SLPs indicated minimal reporting of
intervention fidelity or outcomes at an organisational level.
Roulstone et al. highlighted the uncertainties for client
outcomes that are created when treatments are adapted to
fit a particular client need or gap, and the importance of
measuring treatment fidelity. Joffe and Pring (2008) also
found that SLPs frequently combine interventions, in direct
contrast to how they were evaluated.
The limited attention to treatment fidelity measures may
seem surprising given the range of options for monitoring
treatment fidelity and the specific recommendations in
commonly used manualised programs. One explanation
may be that SLPs experience difficulty when there is
divergence among the three components of the evidence-
based model. For example, in situations when SLPs’
professional judgements related to meeting the child and
family preferences might compete with the requirement
to implement programs as prescribed by the developers.
Another key challenge is the applicability of treatment
efficacy studies, which evaluate the causal relationship
between the specific intervention and the clinical outcomes
in tightly controlled settings (Kaderavek & Justice, 2010).
Funded efficacy studies in research settings may involve
delivery of a higher dosage of treatment than is feasible in
community-based organisations (Hoffman et al., 2013). In
contrast, effectiveness research investigates interventions in
real-world settings (Kaderavek & Justice, 2010). Roulstone
(2015) acknowledged the advantages of manualised
interventions, but also identified a need to provide more
specific and consistent descriptions of all SLP interventions
in order to highlight their explicit impact.
procedures, whereas competence measures refer to the
clinician’s level of skill in delivering the intervention to a
client.
Compliance measures recommended for interventions
supporting children’s communication skills include the
use of a treatment manual, specific information regarding
dosage, and checklists to support fidelity to procedures
(Kaderavek & Justice, 2010). Monitoring competence
is more challenging, as it requires an evaluation of the
manner in which a treatment is delivered. Direct fidelity
measures that involve observing a clinician implementing
an intervention, or reviewing video footage of the
implementation at a later date, are considered the “gold
standard”. Indirect fidelity measures such as self-report
checklists, logs, and practitioner surveys may be easier to
implement but may not be as reliable (Kaderavek & Justice,
2010).
Three examples of manualised programs which
are recommended interventions for New Zealand
SLPs supporting children with speech, language, and
communication difficulties (Ministry of Education, 2013)
include information about treatment fidelity procedures.
These are: the Lidcombe Program for Early Stuttering
(Onslow, Packman & Harrison, 2003), the Hanen Parent
Program – More than Words (Sussman, Honeyman, Lowry
& Drake, 2013), and the Picture Exchange Communication
System (PECS; Frost & Bondy, 2002).
The Lidcombe Program (Onslow et al., 2003) is
used to treat stuttering in young children by teaching
parents to use behavioural strategies during interactions
with their children. A study of SLPs implementation of
this program in Australian community clinics indicated
successful outcomes and high levels of treatment fidelity
(O’Brian et al., 2013). These researchers concluded that
this program was at a phase 4 level on Robey’s (2004)
framework for evaluating evidence. The framework ranges
from emerging levels of evidence with phase 1 and 2
interventions indicating potential therapeutic effects, phase
3 demonstrating evidence from clinical trials which have
controlled for internal validity, and phase 4 interventions
have demonstrated effectiveness for specific populations
in “real-world” conditions (Robey, 2004). The Hanen
Parent Program – More than Words (Sussman et al.
2013) supports parents of children with autism spectrum
disorders (ASD) to facilitate communication development
through their everyday parent–child interactions. A
randomised control trial indicated some significant changes
in the way children in the treatment group interacted with
their parents (Carter et al., 2011) which may indicate this
program has a phase 4 level of evidence. The Picture
Exchange Communication System (Frost & Bondy, 2002)
focuses on promoting the initiation of communication using
symbols and pictures. A meta-analysis of PECS highlights
its effectiveness in real-world contexts (Flippin, Reszka &
Watson, 2010) which implies that this may also be a phase
4 intervention.
To ensure context fidelity, these programs require
clinicians to complete 2–3-day training workshops in which
they are provided with information to help them select
appropriate client groups, recommendations for the size of
client groups (Sussman et al., 2013), and recommended
dosage for achieving successful outcomes (Onslow et al.,
2003; Sussman et al., 2013). This information enables
clinicians to match their approaches to client selection and
service provision to those documented in research studies.