"There is no standard or widely accepted definition of treatment intensity in the communication and language intervention literature.... It is time to begin the creation of a systematic research base examining this critically important dimension of treatment efficacy" (Warren, Fey, Yoder, 2007, p. 71).

This issue of Topics in Language Disorders addresses intervention intensity: How much, how long, how to measure, and how to compare treatments across the many areas of language. It is time for the field of communication disorders to move beyond conventional practice, available resources, and clinical judgment to find answers to these very necessary questions.

Treatment intensity emerged as an issue for me during the course of several publications on what works in treatment and how it can be applied in school settings. Studies such as those of Gillam, (1999), Gillam, Loeb, and Friel-Patti (2001), and Torgesen et al. (2001) could show large and lasting gains from treatment, but it appeared that the change was due not so much to specific curricula as to general quality features of treatment. Eventually, I reduced these ideas to four critical elements of treatment that were present in a variety of successful treatments, including both discrete skill and holistic approaches. I termed these elements RISE: Repeated opportunities, delivered in an Intense schedule, of Systematically support Explicit skill instruction (Ukrainetz, 2006).

In reflecting on how these quality treatment elements could be applied in the schools, it seemed like that one aspect of clinical practice that clearly diverged from research studies was treatment intensity. School clinicians could rarely provide treatment in the intensity delivered in efficacy studies. With two valued colleagues in the schools, Cathy Ross and Heide Harm, we considered ways of increasing intensity within typical school resources. We decided that greater intensity was possible for a short period of time and that such an approach might have positive effects on motivation, attention, and learning continuity in treatment. We decided that a treatment intensity study was needed to test our hypothesis that a short, intense period of treatment would result in as good or better results compared with a long, light schedule of teaching phonemic awareness to kindergartners at risk for academic difficulties. We planned and executed the study in 2006-2007, which appeared in the journal, Language, Speech, and Hearing Services in Schools, as the work of Ukrainetz, Ross, and Harm (2009). The study resulted in valuable findings, and I learned a lot about programming treatment intensity. But the experience also raised many questions for me. During the publication process for that article, I was guided to an exciting article by Warren, Fey, and Yoder (2007). This timely encounter gave form to my burgeoning wonderings about treatment intensity and stimulated the concepts leading to this issue of Topics in Language Disorders on treatment intensity across language areas.

Warren et al. (2007) reported that although research evidence is available for several approaches to language intervention and even some specific intervention techniques, there is an almost complete lack of systematic research on the effects of differential treatment intensity. When treatment research is conducted, often little information is reported on the details of intensity. Methods for operationalizing intensity also differ. Warren et al. reported that intensity estimations have included the quantity of services delivered in a given period of time, the number of hours of intervention over a specific time period, the ratio of adults to children, and the number of specific teaching episodes per unit of time. I have noted that even these are often reported as general figures or ranges and without information on whether the planned intensities actually occurred.

Warren et al. (2007) argued convincingly that this absence of conceptual framework and investigation details seriously limits any conclusions that can be drawn about the efficacy or relative effectiveness of communication treatments. The authors argued further that a more molecular and consistent approach is needed-one that uses a medical dosage framework and starts with specifying the active ingredients of treatment at the level of the teaching episode. Warren et al. explained that a teaching episode "contains one or more interventionist (or confederate) acts hypothesized to lead a child toward a given intervention goal" (p. 71); however, they left the details of the components to vary with the language skill, the treatment approach, and the specific treatment techniques that a clinician employs. Warren et al. then placed teaching episodes into a larger unit termed a dose. A dense presence of teaching episodes within a treatment session constitutes a high-strength dose, whereas few teaching episodes within the same-length session constitute a low-strength dose. Doses must be specified in terms of the method of delivery or dose form (e.g., drill vs. play format), the frequency of delivery, the total intervention duration, and, finally, the cumulative intervention intensity. This distinctly medical terminology feels at odds with naturalistic intervention, and, as Warren et al. recognized, it often does not fit well with behavioral interventions. However, it does provide a necessary beginning point of common terminology and ways of measuring the details of intensity.

Warren et al. (2007) suggested that at least four types of knowledge can be generated using this dosage terminology and framework: (1) optimal intensity for particular approaches or techniques; (2) optimal intensity for particular cognitive and communicative profiles; (3) side effects, negative or positive, that arise with high treatment intensities, and (4) effectiveness of different treatments that are each offered at their particular preferred treatment intensity. The fourth point, involving knowledge of relative effectiveness, is one of great concerns to clients, clinicians, researchers, and other stakeholders. However, it is the one that is difficult to answer at present because researchers have not determined optimal intensities for the treatments in question. Warren et al. gave the example of how discrete trial training methods such as applied behavior analysis have been compared with more naturalistic milieu teaching. The little information offered on intensity in the reports indicates that the treatments have differed on intensity as well as on approach. Merely equating intensities is not a sufficient solution. This is because discrete skill treatments are considered to benefit from a high frequency of practice opportunities whereas naturalistic interventions are considered to benefit from a few highly salient learning opportunities in a meaningful context. Thus comparing treatments does not necessarily mean offering the same intensities; rather, it suggests that the treatments are offered at comparable degrees of optimization. It is not possible to say which is better unless evidence is available regarding how best to deliver each treatment. This requires systematic investigation of different intensity levels for each treatment. Warren et al. concluded their article with three recommendations:

1. Research reports on treatment should contain greater detail on how intensity is defined, executed, and measured.

2. Researchers should investigate the effects of treatment intensity for accepted intervention approaches and techniques in terms of dosages, dose frequency, and cumulative intensity.

3. External funding agencies and foundations should place a high priority on funding research on differential intensity for well-developed behavioral interventions.

This issue of Topics in Language Disorders represents a first step in bringing together the conceptual and empirical evidence for treatment intensity for several areas of communication. I invited each of these authors to consider what is known about instructional intensity in his or her area of expertise. The authors came together initially in a panel presentation at the 2008 ASHA convention (Ukrainetz et al., 2008). Audience interest was clearly strong, with a room full of attentive clinicians and researchers. I warn the reader now, as I did our audience then, we do not have the answers. Each article raises as many questions as it answers. Intensity turns out to be as complicated as it is important.

Proctor-Williams opens the issue with a discussion related to intensity in preschool morphosyntax intervention. This area has enjoyed considerable research attention, including careful consideration of measuring and controlling treatment intensity for particular morphosyntactic structures. As Proctor-Williams states, we do have information on dose form, frequency, and distribution. We lack information, however, on the most effective ways of delivering treatment for specific populations.

Baumann discusses intensity in vocabulary intervention and its effects on reading comprehension. The most puzzling aspect here is determining a teaching episode: presentation of a lexical item (e.g., saying the word extraordinary five times) or time spent in making semantic connections that add depth of understanding (e.g., spending 10 min exploring and mapping extraordinary).

Determining intensity recommendations for narrative intervention proved to be a particularly challenging task. It is addressed by Hoffman, who points out that narrative can be either a vehicle or a target of treatment. Hoffman considers what is being transported or targeted, whether it is 1 skill or 10 skills, and how this affects intensity considerations.

I, this issue editor and author, then address the intensity evidence for phonemic awareness. A large body of research addresses instruction in phonemic awareness, but the need remains to determine both the range of possible teaching episodes with variations, such as choral responses, and using simple skills to scaffold complex skills. In addition, my article addresses how much intensity is needed in treatment in current circumstances in which many general education classroom teachers are explicitly teaching phonemic awareness.

Finally, Breit-Smith, Justice, McGinty, and Kaderavek examine instructional intensity for print referencing. The body of research is small, but treatment dosages are fairly well reported. In their article, Breit-Smith et al. discuss how intensity interacts with individual differences.

My hope is that this issue of Topics in Language Disorders can extend the impact of the earlier article by Warren et al. (2007) to provide impetus and guidance to clinicians and researchers to seriously consider the issue of treatment intensity. How much is enough? There is no single answer that suffices across the many areas of communication, for the many possible individual differences, across intervention approaches and techniques. But this issue should help frame better-defined questions and provide many emergent answers and directions for this important aspect of practice and investigation.

Teresa A. Ukrainetz, PhD

Issue Editor, Professor and Director, Division of Communication Disorders, University of Wyoming, The Laramie

REFERENCES