Association of proximal elements of social disadvantage with children's language development at 2 years: an analysis of data from the Children in Focus (CiF) sample from the ALSPAC birth cohort.

BACKGROUND: An association between social disadvantage and early language development is commonly reported in the literature, but less attention has been paid to the way that different aspects of social disadvantage affect both expressive and receptive language in the first 2 years of life. AIMS: To examine the contributions of gender, parental report of early language skills and proximal social variables (the amount of stimulation in the home, the resources available to the child and the attitudes/emotional status of the primary carer and the support available to him/her) controlling for distal social variables (family income and maternal education) to children's expressive and receptive language development at 2 years in a community ascertained population cohort. METHODS & PROCEDURES: Data from 1314 children in the Children in Focus (CiF) sample from the Avon Longitudinal Study of Parents and Children (ALSPAC) were analyzed. Multivariable regression models identified the contribution of proximal (what parents do with their children) measures of social disadvantage adjusting for more distal (e.g., family income and material wealth) measures as well as early language development at 15 months to the development of verbal comprehension, expressive vocabulary and expressive grammar (word combinations) at 2 years of age. OUTCOME & RESULTS: In the final multivariable models gender, earlier language and proximal social factors, co-varying for distal factors predicted 36% of the variance for expressive vocabulary, 22% for receptive language and 27% for word combinations at 2 years. Language development at 15 months remained a significant predictor of outcomes at 24 months. Environmental factors were associated with both expressive scales but the picture was rather more mixed for receptive language suggesting that there may be different mechanisms underlying the different processes. CONCLUSIONS & IMPLICATIONS: This study supports the argument that social advantage makes a strong contribution to children's language development in the early years. The results suggest that what parents/carers do with their children is critical even when structural aspects of social disadvantage such as family income and housing have been taken into consideration although this relationship varies for different aspects of language. This has the potential to inform the targeting of public health interventions focusing on early language and pre-literacy skills on the one hand and home learning environments on the other and, potentially, the two in combination.

Two-Year Outcomes of a Population-Based Intervention for Preschool Language Delay: An RCT.

OBJECTIVE: We have previously shown short-term benefits to phonology, letter knowledge, and possibly expressive language from systematically ascertaining language delay at age 4 years followed by the Language for Learning intervention. Here, we report the trial's definitive 6-year outcomes. METHODS: Randomized trial nested in a population-based ascertainment. Children with language scores >1.25 SD below the mean at age 4 were randomized, with intervention children receiving 18 1-hour home-based therapy sessions. Primary outcome was receptive/expressive language. Secondary outcomes were phonological, receptive vocabulary, literacy, and narrative skills; parent-reported pragmatic language, behavior, and health-related quality of life; costs of intervention; and health service use. For intention-to-treat analyses, trial arms were compared using linear regression models. RESULTS: Of 1464 children assessed at age 4, 266 were eligible and 200 randomized; 90% and 82% of intervention and control children were retained respectively. By age 6, mean language scores had normalized, but there was little evidence of a treatment effect for receptive (adjusted mean difference 2.3; 95% confidence interval [CI] -1.2 to 5.7; P = .20) or expressive (0.8; 95% CI -1.6 to 3.2; P = .49) language. Of the secondary outcomes, only phonological awareness skills (effect size 0.36; 95% CI 0.08-0.65; P = .01) showed benefit. Costs were higher for intervention families (mean difference AU$4276; 95% CI: $3424 to $5128). CONCLUSIONS: Population-based intervention targeting 4-year-old language delay was feasible but did not have lasting impacts on language, possibly reflecting resolution in both groups. Long-term literacy benefits remain possible but must be weighed against its cost.

Systematic review of tools to measure outcomes for young children with autism spectrum disorder.

BACKGROUND: The needs of children with autism spectrum disorder (ASD) are complex and this is reflected in the number and diversity of outcomes assessed and measurement tools used to collect evidence about children's progress. Relevant outcomes include improvement in core ASD impairments, such as communication, social awareness, sensory sensitivities and repetitiveness; skills such as social functioning and play; participation outcomes such as social inclusion; and parent and family impact. OBJECTIVES: To examine the measurement properties of tools used to measure progress and outcomes in children with ASD up to the age of 6 years. To identify outcome areas regarded as important by people with ASD and parents. METHODS: The MeASURe (Measurement in Autism Spectrum disorder Under Review) research collaboration included ASD experts and review methodologists. We undertook systematic review of tools used in ASD early intervention and observational studies from 1992 to 2013; systematic review, using the COSMIN checklist (Consensus-based Standards for the selection of health Measurement Instruments) of papers addressing the measurement properties of identified tools in children with ASD; and synthesis of evidence and gaps. The review design and process was informed throughout by consultation with stakeholders including parents, young people with ASD, clinicians and researchers. RESULTS: The conceptual framework developed for the review was drawn from the International Classification of Functioning, Disability and Health, including the domains 'Impairments', 'Activity Level Indicators', 'Participation', and 'Family Measures'. In review 1, 10,154 papers were sifted - 3091 by full text - and data extracted from 184; in total, 131 tools were identified, excluding observational coding, study-specific measures and those not in English. In review 2, 2665 papers were sifted and data concerning measurement properties of 57 (43%) tools were extracted from 128 papers. Evidence for the measurement properties of the reviewed tools was combined with information about their accessibility and presentation. Twelve tools were identified as having the strongest supporting evidence, the majority measuring autism characteristics and problem behaviour. The patchy evidence and limited scope of outcomes measured mean these tools do not constitute a 'recommended battery' for use. In particular, there is little evidence that the identified tools would be good at detecting change in intervention studies. The obvious gaps in available outcome measurement include well-being and participation outcomes for children, and family quality-of-life outcomes, domains particularly valued by our informants (young people with ASD and parents). CONCLUSIONS: This is the first systematic review of the quality and appropriateness of tools designed to monitor progress and outcomes of young children with ASD. Although it was not possible to recommend fully robust tools at this stage, the review consolidates what is known about the field and will act as a benchmark for future developments. With input from parents and other stakeholders, recommendations are made about priority targets for research. FUTURE WORK: Priorities include development of a tool to measure child quality of life in ASD, and validation of a potential primary outcome tool for trials of early social communication intervention. STUDY REGISTRATION: This study is registered as PROSPERO CRD42012002223. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Dynamic assessment of word learning skills of pre-school children with primary language impairment.

Dynamic assessment has been shown to have considerable theoretical and clinical significance in the assessment of socially disadvantaged and culturally and linguistically diverse children. In this study it is used to enhance assessment of pre-school children with primary language impairment. The purpose of the study was to determine whether a dynamic assessment (DA) has the potential to enhance the predictive capacity of a static measure of receptive vocabulary in pre-school children. Forty pre-school children were assessed using the static British Picture Vocabulary Scale (BPVS), a DA of word learning potential and an assessment of non-verbal cognitive ability. Thirty-seven children were followed up 6 months later and re-assessed using the BPVS. Although the predictive capacity of the static measure was found to be substantial, the DA increased this significantly especially for children with static scores below the 25th centile. The DA of children's word learning has the potential to add value to the static assessment of the child with low language skills, to predict subsequent receptive vocabulary skills and to increase the chance of correctly identifying children in need of ongoing support.

Language and social/emotional problems identified at a universal developmental assessment at 30 months.

BACKGROUND: Preschool language and neurodevelopmental problems often persist and impede learning. The aims of the current study are to assess the uptake of a new universal 30 month health visitor contact and to quantify the prevalence of language delay and social/emotional difficulties. METHODS: All families of 30 month old children in four Glasgow localities were offered a visit from their health visitor. Structured data were collected relating to language, social and emotional development using three instruments; The Strengths and Difficulties Questionnaire (SDQ), the abbreviated Sure Start Language Measure and a two-item language screen. RESULTS: From an eligible population of 543 children, there was a 90% return rate of contact forms from the health visitors, and assessments were completed on 78% of eligible children. Visit completion rates did not differ significantly by socio-economic status. 3-8% of children were reported to have language delay depending on the method of assessment. 8.8% of children scored in the "abnormal" range of SDQ total difficulties scores and 31.1% had an abnormality in at least one subscale. There was substantial overlap between language delay and abnormal scores on the SDQ. CONCLUSIONS: Universal assessment of neurodevelopmental function at 30 months identified a significant proportion of children, including those previously considered at low risk, with both language and social/emotional difficulties. Further work is required to assess the precise nature of these difficulties and to assess the potential impact on services.

The relationship between gender, receptive vocabulary, and literacy from school entry through to adulthood.

It is commonly assumed that boys have poorer language skills than girls, but this assumption is largely based on studies with small, clinical samples or focusing on expressive language skills. This study examines the relationship between gender and receptive vocabulary, literacy, and non-verbal performance at 5 years through to adulthood. The participants were a UK birth cohort of 11,349 children born in one week in March 1970. Logistic regression models were employed to examine the association of gender with language and literacy at 5 and 34 years. Non-verbal abilities were comparable at 5 years, but there were significant differences for both receptive vocabulary and reading, favouring the boys and the girls, respectively. Boys but not girls who had parents who were poor readers were more likely to be not reading at 5 years. Gender was not associated with adulthood literacy. Boys may have a slight advantage over girls in terms of their receptive vocabulary, raising questions about the skills tested and the characteristics of clinical populations. The findings are discussed in terms of the nature of the way that children are assessed and the assumptions underpinning clinical practice.

Costing children's speech, language and communication interventions.

BACKGROUND: There are few economic evaluations of speech and language interventions. Such work requires underpinning by an accurate estimate of the costs of the intervention. This study seeks to address some of the complexities of this task by applying existing approaches of cost estimation to interventions described in published effectiveness studies. AIMS: The study has two aims: to identify a method of estimating unit costs based on the principle of long-run marginal opportunity costs; and to illustrate the challenges in estimating unit costs for speech and language interventions. METHOD & PROCEDURES: Descriptions of interventions were extracted from eight papers and combined with information on the unit cost of speech and language therapists to identify information requirements for a full-cost estimation of an intervention. OUTCOMES & RESULTS: Four challenges were found relating to the level of detail about the therapists, the participants, the scope of activities and parents. Different assumptions made about any of these elements will have a marked effect on the cost of the intervention. CONCLUSIONS & IMPLICATIONS: Nationally applicable unit cost data for speech and language therapists can be used as a reference point, but sufficient descriptive data about delivery and receipt of the intervention are key to accuracy.

Improving outcomes of preschool language delay in the community: protocol for the Language for Learning randomised controlled trial.

BACKGROUND: Early language delay is a high-prevalence condition of concern to parents and professionals. It may result in lifelong deficits not only in language function, but also in social, emotional/behavioural, academic and economic well-being. Such delays can lead to considerable costs to the individual, the family and to society more widely. The Language for Learning trial tests a population-based intervention in 4 year olds with measured language delay, to determine (1) if it improves language and associated outcomes at ages 5 and 6 years and (2) its cost-effectiveness for families and the health care system. METHODS/DESIGN: A large-scale randomised trial of a year-long intervention targeting preschoolers with language delay, nested within a well-documented, prospective, population-based cohort of 1464 children in Melbourne, Australia. All children received a 1.25-1.5 hour formal language assessment at their 4th birthday. The 200 children with expressive and/or receptive language scores more than 1.25 standard deviations below the mean were randomised into intervention or 'usual care' control arms. The 20-session intervention program comprises 18 one-hour home-based therapeutic sessions in three 6-week blocks, an outcome assessment, and a final feed-back/forward planning session. The therapy utilises a 'step up-step down' therapeutic approach depending on the child's language profile, severity and progress, with standardised, manualised activities covering the four language development domains of: vocabulary and grammar; narrative skills; comprehension monitoring; and phonological awareness/pre-literacy skills. Blinded follow-up assessments at ages 5 and 6 years measure the primary outcome of receptive and expressive language, and secondary outcomes of vocabulary, narrative, and phonological skills. DISCUSSION: A key strength of this robust study is the implementation of a therapeutic framework that provides a standardised yet tailored approach for each child, with a focus on specific language domains known to be associated with later language and literacy. The trial responds to identified evidence gaps, has outcomes of direct relevance to families and the community, includes a well-developed economic analysis, and has the potential to improve long-term consequences of early language delay within a public health framework. TRIAL REGISTRATION: Current Controlled Trials ISRCTN03981121.

Cost-effectiveness of interventions for children with speech, language and communication needs (SLCN): a review using the Drummond and Jefferson (1996) 'Referee's Checklist'.

BACKGROUND: Although economic evaluation has been widely recognized as a key feature of both health services and educational research, for many years there has been a paucity of such studies relevant to services for children with speech, language and communication needs (SLCN), making the application of economic arguments to the development of services difficult. AIMS: The study has two aims, namely to review systematically the cost-effectiveness literature related to services for children with SLCN and to highlight key issues that need to be included in future economic effectiveness studies. METHODS & PROCEDURES: A comprehensive search of the international literature for the last 30 years was completed and the studies were evaluated against the 'gold standard' criteria developed by Drummond and colleagues in 1996 and 2005. OUTCOMES & RESULTS: Five studies met the review inclusion criteria. All focused on young (2-11 years) children with SLCN and most compared clinic-based and parent-administered interventions. The studies provide variable levels of detail on the key elements needed, but few provided sufficient details of costs to draw comparisons across studies. Only two studies attempted to bring together costs and effectiveness data. CONCLUSIONS & IMPLICATIONS: The studies point to the importance of home-based and indirect intervention and, in many cases, emphasize the parental perspective. There is a need for intervention studies to include a cost dimension based on readily comparable methods of establishing unit costs and for greater use to be made of cost-effectiveness analysis more generally.

Managing change in the care of children with complex needs: healthcare providers' perspectives.

AIM: This paper is a report of a descriptive qualitative study of the role and activities of nursing and allied health professionals caring for children with complex needs in a community setting. BACKGROUND: Health care is changing in terms of service provision and delivery, with an increased focus on person-centred care, prevention and community-based services. The role of nursing and allied health professionals is central to these changes but is not well described in terms of capacity, or the knowledge and skills required to meet increasing demand. METHOD: Within four Health Boards, semi-structured telephone interviews were conducted in 2007 with three nursing and four allied health managers, followed by four focus groups with 15 nursing and 11 allied health practitioners; in addition, three nurses and one speech therapist were interviewed by telephone. RESULTS: Respondents identified challenges related to communication and information systems, equity of service provision, family-centred care and partnership working. Generic and specialized knowledge and skills are needed, although providing the right skills in the right place can often prove problematic with potential implications for service provision. CONCLUSION: Findings support the adoption of integrated partnership working, going beyond the identification of key professionals, to developing a set of criteria against which future service provision could be judged. Research priorities were identified; comparative evaluation of services, better understanding of the transition process and a clearer sense of the individual's response to the increasing customization of services.