Evidence-based pathways to intervention for children with language disorders.

BACKGROUND: Paediatric speech and language therapist (SLT) roles often involve planning individualized intervention for specific children, working collaboratively with families and education staff, providing advice, training and coaching and raising awareness. A tiered approach to service delivery is currently recommended whereby services become increasingly specialized and individualized for children with greater needs. AIMS: To stimulate discussion regarding delivery of SLT services by examining evidence regarding the effectiveness of (1) intervention for children with language disorders at different tiers and (2) SLT roles within these tiers; and to propose an evidence-based model of SLT service delivery and a flowchart to aid clinical decision-making. METHODS & PROCEDURES: Meta-analyses and systematic reviews, together with controlled, peer-reviewed group studies where recent systematic reviews were not available, of interventions for children with language disorders are discussed, alongside the differing roles SLTs play in these interventions. Gaps in the evidence base are highlighted. MAIN CONTRIBUTION: The service-delivery model presented resembles the tiered model commonly used in education services, but divides individualized (Tier 3) services into Tier 3A: indirect intervention delivered by non-SLTs, and Tier 3B: direct intervention by an SLT. We report evidence for intervention effectiveness, which children might best be served by each tier, the role SLTs could take within each tier and the effectiveness of these roles. Regarding universal interventions provided to all children (Tier 1) and those targeted at children with language weaknesses or vulnerabilities (Tier 2), there is growing evidence that approaches led by education services can be effective when staff are highly trained and well supported. There is currently limited evidence regarding additional benefit of SLT-specific roles at Tiers 1 and 2. With regard to individualized intervention (Tier 3), children with complex or pervasive language disorders can progress following direct individualized intervention (Tier 3B), whereas children with milder or less pervasive difficulties can make progress when intervention is managed by an SLT, but delivered indirectly by others (Tier 3A), provided they are well trained and supported, and closely monitored. CONCLUSIONS & IMPLICATIONS: SLTs have a contribution to make at all tiers, but where prioritization for clinical services is a necessity, we need to establish the relative benefits and cost-effectiveness at each tier. Good evidence exists for SLTs delivering direct individualized intervention and we should ensure that this is available to children with pervasive and/or complex language disorders. In cases where service models are being provided which lack evidence, we strongly recommend that SLTs investigate the effectiveness of their approaches.

22q11 deletion syndrome: Parents' and children's experiences of educational and healthcare provision in the United Kingdom.

22q11 deletion syndrome (22q11DS) is a genetic syndrome, prevalence around 1:4000-1:6000 live births, with a complex array of associated features, impacting on healthcare and educational support. This study reports the perceptions of families and individuals with 22q11DS in relation to these needs. Individuals and families of those with 22q11DS were approached though two national charities - the Max Appeal and 22Crew. An initial observational survey design was used to gather views via questions probing access to healthcare and educational experiences. Thirty-four responses were received and the data subjected to descriptive analysis. Over half of the respondents were diagnosed before the age of 1. Ninety-one percent reported ongoing difficulties with learning at school, compounded by school attendance being compromised as a result of medical interventions. Individuals reported engaging heavily with educational support and a high number of health professions (mean 9.5; mode 10). Age of diagnosis of 22q11DS ranged from birth to nine years. Families had ongoing concerns about aspects of education and healthcare services, and lack of knowledge and awareness of the difficulties faced by individuals with 22q11DS was raised. Healthcare and education providers should be aware of the range of services individuals required on a regular basis so as to provide a more holistic approach to care.

Commentary: So was it worth it? A commentary on Fricke et al. and Hagen et al. (2017).

Fricke et al. and Hagen et al. (2017) each report on large-scale pragmatic randomised controlled trials delivered in schools or nurseries, investigating language interventions for vulnerable children and showing moderate positive effect sizes. Such research is part of a recent development of 'what works' research in England, and the number of 'what works' trials continues to increase, largely through funding from the Sutton Trust, who are concerned with disadvantaged children, to the Educational Endowment Foundation (EEF). 'What works' research is not firmly accepted by all educationalists, however, results of trials are now available quickly and presented in a manner intended to be accessible to practitioners. This development may facilitate principled decisions on the adoption of interventions by schools, as trials and their outcomes may be interrogated to support decisions on whether the anticipated impact is worth the cost of implementation.

A qualitative case study in the social capital of co-professional collaborative co-practice for children with speech, language and communication needs.

BACKGROUND: Effective co-practice is essential to deliver services for children with speech, language and communication needs (SLCN). The necessary skills, knowledge and resources are distributed amongst professionals and agencies. Co-practice is complex and a number of barriers, such as 'border disputes' and poor awareness of respective priorities, have been identified. However social-relational aspects of co-practice have not been explored in sufficient depth to make recommendations for improvements in policy and practice. Here we apply social capital theory to data from practitioners: an analytical framework with the potential to move beyond descriptions of socio-cultural phenomena to inform change. AIMS: Co-practice in a local authority site was examined to understand: (1) the range of social capital relations extant in the site's co-practice; (2) how these relations affected the abilities of the network to collaborate; (3) whether previously identified barriers to co-practice remain; (4) the nature of any new complexities that may have emerged; and (5) how inter-professional social capital might be fostered. METHODS & PROCEDURES: A qualitative case study of SLCN provision within one local authority in England and its linked NHS partner was completed through face-to-face semi-structured interviews with professionals working with children with SLCN across the authority. Interviews, exploring barriers and facilitators to interagency working and social capital themes, were transcribed, subjected to thematic analysis using iterative methods and a thematic framework derived. OUTCOMES & RESULTS: We identified a number of characteristics important for the effective development of trust, reciprocity and negotiated co-practice at different levels of social capital networks: macro-service governance and policy; meso-school sites; and micro-intra-practitioner knowledge and skills. Barriers to co-practice differed from those found in earlier studies. Some negative aspects of complexity were evident, but only where networked professionalism and trust was absent between professions. Where practitioners embraced and services and systems enabled more fluid forms of collaboration, then trust and reciprocity developed. CONCLUSIONS & IMPLICATIONS: Highly collaborative forms of co-practice, inherently more complex at the service governance, macro-level, bring benefits. At the meso-level of the school and support team network there was greater capacity to individualize co-practice to the needs of the child. Capacity was increased at the micro-level of knowledge and skills to harness the overall resource distributed amongst members of the inter-professional team. The development of social capital, networks of trust across SLCN support teams, should be a priority at all levels-for practitioners, services, commissioners and schools.

Developing a universal reading comprehension intervention for mainstream primary schools within areas of social deprivation for children with and without language-learning impairment: a feasibility study.

BACKGROUND: Some children in areas of social deprivation in Scotland have lower reading attainment than neighbouring children in less deprived areas, and some of these also have lower spoken language comprehension skills than expected by assessment norms. There is a need to develop effective reading comprehension interventions that fit easily into the school curriculum and can benefit all pupils. A feasibility study of reading comprehension strategies with existing evidence of efficacy was undertaken in three mainstream primary schools within an area of social deprivation in west central Scotland, to decide whether further investigation of this intervention was warranted. AIMS: Aims were to measure comprehension of spoken language and reading via standardised assessments towards the beginning of the school year (T1) in mainstream primary school classrooms within an area of social deprivation; to have teachers introduce previously-validated text comprehension strategies, and to measure change in reading comprehension outcome measures towards the end of the year (T2). METHODS & PROCEDURES: A pre- and post-intervention cohort design was used. Reading comprehension strategies were introduced to staff in participating schools and used throughout the school year as part of on-going reading instruction. Spoken language comprehension was measured by TROG-2 at T1, and reading progress by score changes from T1 to T2 on the WIAT-II(UK) -T reading comprehension scale. OUTCOMES & RESULTS: Forty-seven pupils in five classes in three primary schools took part: 38% had TROG-2 scores below the 10(th) centile. As a group, children made good reading comprehension progress, with a medium effect size of 0.46. Children with TROG-2 scores below the 10(th) centile had lower mean reading scores than others at T1 and T2, although with considerable overlap. However, TROG-2 did not make a unique contribution to reading progress: children below the 10(th) centile made as much progress as other children. The intervention was welcomed by schools, and the measure of reading comprehension proved responsive to change. CONCLUSIONS: The outcomes suggest the reading intervention may be effective for children with and without spoken language comprehension difficulties, and warrants further investigation in larger, controlled, studies.

The linguistically aware teacher and the teacher-aware linguist.

This review evaluates issues of teacher linguistic knowledge relating to their work with children with speech, language and communication difficulties (SLCD). Information is from Ellis and McCartney [(2011a). Applied linguistics and primary school teaching. Cambridge: Cambridge University Press], a state-of-the-art text deriving from a British Association of Applied Linguistics/Cambridge University Press expert seminar series that details: linguistic research underpinning primary school curricula and pedagogy; the form of linguistic knowledge useful for teachers supporting children with SLCD in partnership with speech and language therapists; and how and when teachers acquire and learn to apply such knowledge. Critical analysis of the options presented for teacher learning indicate that policy enjoinders now include linguistic application as an expected part of teachers' professional knowledge, for all children including those with SLCD, but there is a large unmet learning need. It is concluded that there is a role for clinical linguists to disseminate useable knowledge to teachers in an accessible format. Ways of achieving this are considered.

Development of a minimum protocol for assessment in the paediatric voice clinic. Part 1: evaluating vocal function.

The European Laryngological Society (ELS) recommend that functional assessment of voice disorder in adults requires evaluation of a number of different parameters. The current paper presents a discussion of four of the five parameters highlighted in the ELS protocol: perceptual evaluation of voice, videostroboscopic examination, evaluation of aerodynamic performance in voice, and acoustic analysis. Subjective rating of voice in children is explored in a companion paper. These parameters have been extensively evaluated in adults, and a review of the literature pertaining to the paediatric population is presented.

Development of a minimum protocol for assessment in the paediatric voice clinic. Part 2: subjective measurement of symptoms of voice disorder.

The European Laryngological Society (ELS) recommend that functional assessment of voice disorder in adults requires evaluation of a number of different parameters. These include perceptual evaluation of voice, videostroboscopic imaging of vocal fold movement, acoustic analysis of specific voicing aspects, aerodynamic support for voicing, and a subjective rating of voice impact. No specific guidelines are available for children, but a similar range of parameters is needed to guide intervention and measure outcomes. The development of subjective voice measures for adults and their adaptations for the paediatric population are reviewed and compared to the research comparing these to evaluation of vocal function. The need for further refinement of child assessment measures, and a proposal of how these might be developed, is discussed.

Indirect language therapy for children with persistent language impairment in mainstream primary schools: outcomes from a cohort intervention.

BACKGROUND: A manualized language therapy developed via a randomized controlled trial had proved efficacious in the short-term in developing expressive language for mainstream primary school children with persistent language impairment. This therapy had been delivered to a predetermined schedule by speech and language therapists or speech and language therapy assistants to children individually or in groups. However, this model of service delivery is no longer the most common model in UK schools, where indirect consultancy approaches with intervention delivered by school staff are often used. AIMS: A cohort study was undertaken to investigate whether the therapy was equally efficacious when delivered to comparable children by school staff, rather than speech and language therapists or speech and language therapy assistants. METHODS & PROCEDURES: Children in the cohort study were selected using the same criteria as in the randomized controlled trial, and the same manualized therapy was used, but delivered by mainstream school staff using a consultancy model common in the UK. Outcomes were compared with those of randomized controlled trial participants. OUTCOMES & RESULTS: The gains in expressive language measured in the randomized controlled trial were not replicated in the cohort study. Less language-learning activity was recorded than had been planned, and less than was delivered in the randomized controlled trial. Implications for 'consultancy' speech and language therapist service delivery models in mainstream schools are outlined. CONCLUSIONS & IMPLICATIONS: At present, the more efficacious therapy is that delivered by speech and language therapists or speech and language therapy assistants to children individually or in groups. This may be related to more faithful adherence to the interventions schedule, and to a probably greater amount of language-learning activity undertaken. Intervention delivered via school-based 'consultancy' approaches in schools will require to be carefully monitored by schools and SLT services.

Intervention for mixed receptive-expressive language impairment: a review.

Studies indicate that language impairment that cannot be accounted for by factors such as below-average non-verbal ability, hearing impairment, behaviour or emotional problems, or neurological impairments affects some 6% of school-age children. Language impairment with a receptive language component is more resistant to intervention than specific expressive or phonological delays, and carries a greater risk of comorbid behavioural difficulties as well as adverse outcomes for language development and academic progress. This paper considers underlying explanations that may account for receptive-expressive language impairment. It also reviews evidence for the effectiveness of intervention from theory and recent systematic reviews, trials, and speech and language therapy practice.

Direct versus indirect and individual versus group modes of language therapy for children with primary language impairment: principal outcomes from a randomized controlled trial and economic evaluation.

BACKGROUND: Many school-age children with language impairments are enrolled in mainstream schools and receive indirect language therapy, but there have been, to the authors' knowledge, no previous controlled studies comparing the outcomes and costs of direct and indirect intervention delivered by qualified therapists and therapy assistants, and each delivery mode offered to children individually or in groups. AIMS: To investigate the relative effectiveness of indirect and direct intervention therapy modes delivered individually or in groups for children with primary language impairment. METHODS & PROCEDURES: A multi-centre randomized controlled trial investigated 161 children with primary language impairment aged 6-11 years randomized to a usual-therapy control group or to direct individual, indirect individual, direct group or indirect group therapy modes. Intervention was delivered three times a week for 30-40-min sessions in mainstream schools over 15 weeks. Language performance was assessed at baseline, post-therapy and at 12 months. Cost analysis was based on salary and travel costs for intervention modes and usual therapy. OUTCOMES & RESULTS: Compared with controls, children receiving project therapy made short-term improvements in expressive (p = 0.031), but not receptive, language immediately following intervention. Children with specific expressive language delay were more likely to show improvement than those with mixed receptive-expressive difficulties. The four project therapy modes did not differ on primary language outcomes (all p-values>0.392) and there were no further improvements evident at follow-up. Indirect group therapy was the least costly mode, with direct individual therapy the most costly. CONCLUSIONS & IMPLICATIONS: Intervention in this age group can be effective for expressive language and can be delivered equally effectively though speech and language therapy assistants and to children in groups.

Cost analysis of direct versus indirect and individual versus group modes of manual-based speech-and-language therapy for primary school-age children with primary language impairment.

BACKGROUND: The study is the first within trial cost analysis of direct versus indirect and individual versus group modes of speech-and-language therapy for children with primary language impairment. AIMS: To compare the short-run resource consequences of the four interventions alongside the effects achieved measured by standardized scores on a test of expressive and receptive language. METHODS & PROCEDURES: The study design was a cost analysis integrated within a randomized controlled trial using a 2x2 factorial design (direct/indirect versus individual/group therapy) together with a control group that received usual levels of community-based speech-and-language therapy. Research interventions were delivered in school settings in Scotland, UK. Children aged between 6 and 11 years, attending a mainstream school, with standard scores on the Clinical Evaluation of Language Fundamentals (CELF-III(UK)) of less than -1.25 standard deviation (SD) (receptive and/or expressive) and non-verbal IQ on the Wechsler Abbreviated Scale of Intelligence (WASI) above 75, and no reported hearing loss, no moderate/severe articulation/phonology/dysfluency problems or otherwise requiring individual work with a speech-and-language therapist. The intervention involved speech-and-language therapists and speech-and-language therapy assistants working with individual children or small groups of children. A therapy manual was constructed to assist the choice of procedures and activities for intervention. The cost analysis focused on the salary and travel costs associated with each mode of intervention. The cumulative distribution of total costs arising from the time of randomization to post-intervention assessment was estimated. Arithmetic mean costs were compared and reported with their 95% confidence intervals. OUTCOMES & RESULTS: The results of the intention-to-treat analysis revealed that there were no significant post-intervention differences between direct and indirect modes of therapy, or between individual and group modes on any of the primary language outcome measures. The cost analysis identified indirect therapy, particularly indirect group therapy, as the least costly of the intervention modes with direct individual therapy as the most costly option. The programme cost of providing therapy in practice over 30 weeks for children could represent between 30% and 75% of the total gross revenue spend in primary school per pupil, depending on the choice of assistant led group therapy or therapist-led individual therapy. CONCLUSIONS & IMPLICATIONS: This study suggests that speech-and-language therapy assistants can act as effective surrogates for speech-and-language therapists in delivering cost-effective services to children with primary language impairment. The resource gains from adopting a group-based approach may ensure that effective therapy is provided to more children in a more efficient way.

Effects of computer-based intervention through acoustically modified speech (Fast ForWord) in severe mixed receptive-expressive language impairment: outcomes from a randomized controlled trial.

Seventy-seven children between the ages of 6 and 10 years, with severe mixed receptive-expressive specific language impairment (SLI), participated in a randomized controlled trial (RCT) of Fast ForWord (FFW; Scientific Learning Corporation, 1997, 2001). FFW is a computer-based intervention for treating SLI using acoustically enhanced speech stimuli. These stimuli are modified to exaggerate their time and intensity properties as part of an adaptive training process. All children who participated in the RCT maintained their regular speech and language therapy and school regime throughout the trial. Standardized measures of receptive and expressive language were used to assess performance at baseline and to measure outcome from treatment at 9 weeks and 6 months. Children were allocated to 1 of 3 groups. Group A (n = 23) received the FFW intervention as a home-based therapy for 6 weeks. Group B (n = 27) received commercially available computer-based activities designed to promote language as a control for computer games exposure. Group C (n = 27) received no additional study intervention. Each group made significant gains in language scores, but there was no additional effect for either computer intervention. Thus, the findings from this RCT do not support the efficacy of FFW as an intervention for children with severe mixed receptive-expressive SLI.

'Thinking for two': a case study of speech and language therapists working through assistants.

BACKGROUND: Many speech and language therapists (SLTs) in the UK work with speech and language therapy assistants, and the numbers of SLT assistants is expected to grow. There has been very little empirical investigation of how SLTs feel about this situation or the effect on working practices of working indirectly. AIMS: To investigate SLTs' opinions on working with SLT assistants in a small-scale research case study. METHODS AND PROCEDURES: The study design was a case study of five SLTs delivering intervention within a research intervention project. Prepared questionnaire and formal interview techniques were used to elicit opinions on working through assistants, and a content analysis was performed. OUTCOMES AND RESULTS: Although respondents could see value in working through assistants, they stressed the time required to do so and the difficulties of adapting and updating therapy plans when working indirectly. CONCLUSIONS: The study suggests a variety of factors that have to be carefully managed if SLTs are to work competently through assistants.

Becoming a manual occupation? The construction of a therapy manual for use with language impaired children in mainstream primary schools.

BACKGROUND: The construction of therapy protocols for a large-scale randomized controlled trial comparing speech and language therapists and assistants, and group and individual therapy approaches for children aged 6-11 in mainstream schools is outlined. AIMS: The aim was to outline the decision-making processes that led to the construction of the research therapy manual, and to give a preliminary report on compliance with the manual. METHODS & PROCEDURES: A search of the research and professional literature and of published therapy materials was conducted to locate usable examples of effective language therapy for primary school children. Results were collated into a manual of therapy principles and activities to structure research intervention. The use of the manual with children (n=30) receiving individual or group direct therapy from a speech and language therapist in the first phase of intervention was audited. OUTCOMES & RESULTS: Very few high-level research studies were found, but the professional literature gave added information. Therapies for comprehension monitoring, vocabulary development, later grammar and narrative were adapted for the research intervention, and procedures compiled into a manual to guide research speech and language therapists and assistants. The audit of direct therapy suggested that the manual was useable, providing a suitable range of activities and materials for therapy intervention. Its use helped to record the therapy offered to research children, and formed a sound basis for discussion amongst speech and language therapists and between speech and language therapist/assistant pairs. CONCLUSIONS: The construction and use of a therapy manual allowed the provision of replicable therapy within the research project whilst maintaining flexibility.

Cross-sector working: speech and language therapists in education.

Current policies and practices concerning speech and language therapy provision in schools are reviewed and issues which remain to be addressed are considered A general move to cross-sector approaches has resulted in a move to indirect therapy through assistants, and the effectiveness of this requires to be established. Funding streams for therapy differ across the UK, and despite extensive research and policy development remain somewhat unclear and vulnerable. The implications for policies on 'joined up thinking" are considered.