Evidence-based pathways to intervention for children with language disorders

Core outcomes for speech-language services in Ontario schools: a group concept mapping study and guiding framework

BACKGROUND

Establishing the most important outcomes for school-based speech-language therapy is essential to guide future research and program evaluation for these services. Many health disciplines have developed core outcomes sets (COS) for this purpose. A COS encompasses the most important outcomes for particular health services as identified by appropriate interested parties. These interested parties usually represent health care providers and those with the health condition. In this paper, we report the development of a guiding framework for a COS for speech-language therapy services in schools in a Canadian context.

METHODS

Using a group concept mapping method, we identified the outcomes for inclusion in the COS guiding framework through the elicited opinions of key interested parties: speech-language therapists, teachers, and family members of children with speech, language, and communication needs. We extracted 103 statements (potential outcomes) from a previous data set of interview transcripts. We then asked participants to sort the statements into conceptually similar groups, which were aggregated and transformed into a cluster map using multidimensional scaling followed by hierarchical cluster analysis. Participants also rated each statement on 5-point scales for importance and feasibility. We calculated mean ratings for individual statements and for all statements in a cluster, for all participants and for participant groups separately.

RESULTS

We identified seven core outcomes for school-based speech-language services in Ontario, Canada. These included: classroom-based services, a holistic approach, support for teachers, care coordination, accessible services, family supports, and student success. All outcomes were rated highly for importance. Feasibility ratings were consistently below importance ratings. All participant groups concurred that a holistic approach was the most important outcome and accessible services was the least feasible outcome to achieve.

CONCLUSIONS

The seven outcomes identified in this study are recommended to guide the development of a full COS to direct future research and program evaluation for school-based speech-language services. These outcomes have not been widely included in previous research and should be incorporated into future research alongside specific intervention outcomes. Data for some outcomes may be available from non-traditional sources such as administrative data sets. Consequently, their use for program evaluations should be accompanied by appropriate institutional support to allow speech-language therapists to make meaningful use of appropriate outcomes data.

Parent implementation of a treatment for late talkers based on cross-situational statistical learning principles: Treatment fidelity and acceptability

PURPOSE

Early intervention based on principles of cross-situational statistical learning (CSSL) for late-talking children has shown promise. This study explored whether parents could be trained to deliver this intervention protocol with fidelity and if they found the intervention to be acceptable.

METHOD

Mothers of four English-speaking children aged 18-30 months who scored <10th centile for expressive vocabulary were recruited to an 8-week group training program. Parents were taught principles of CSSL and asked to perform 16 home treatment sessions (30 minutes each) in total, providing auditory bombardment of target words in full sentences at high dose number and syntactic variability, using a range of physical exemplars. Home diaries and two videotaped sessions measured treatment fidelity. Pre- and post-treatment questionnaires measured acceptability.

RESULT

One parent discontinued the study after the second group training session. Three parents completed 15/16 group training sessions and reported completing 87% of home sessions. Two parents demonstrated implementing the intervention as per the target dose number by the first fidelity session (Weeks 2/3), and the third parent was very close to meeting target dose number by the second fidelity session (Weeks 7/8).

CONCLUSION

Parents can be trained to deliver an intervention based on cross-situational statistical learning principles.

Naturalistic Developmental Behavioral Interventions for Developmental Language Disorder

PURPOSE

Naturalistic-developmental-behavioral interventions (NDBIs) are a widely accepted and validated approach for treating language-related symptoms in autism spectrum disorder, including deficits in vocabulary, social skills, and grammar. The purpose of this article is to define the elements naturalistic, developmental, and behavioral as applied to children with developmental language disorder (DLD) and to provide an example of how this type of intervention can be implemented to teach vocabulary and test cross-modal generalization between expressive and receptive modalities.

METHOD

A vocabulary intervention using hybrid NDBI methods (storybook reading and conversational recast interaction) was provided to three participants with DLD using a single-case design.

RESULTS

The results indicated that all participants successfully learned receptive and expressive vocabulary targets with extensive cross-modal generalization. However, generalization was limited in some of the participants.

CONCLUSIONS

This article provided definitions of key elements of NDBI (naturalistic, developmental, and behavioral) including a rationale for extending NDBI procedures to language intervention for children with DLD. In addition, a single-case design demonstrated that NDBI can be implemented in DLD and that broadly defined naturalistic-developmental applied behavior analysis techniques are applicable to language interventions for children with language disorders. Moreover, diverse naturalistic and developmental procedures meet the highest standards for evidence-based practice to treat DLD.

"Aha, so that's how it's done!" - parents' voices on an early language and literacy intervention

The early intervention Språkstart Halland targets children aged 0-3 years. During home visits at 6 and 11 months, library staff deliver gift-packs containing books, toys, songs, and rhymes to promote early language stimulation. Parents are encouraged to engage in 'talk, play, sing, read' activities to support language development. The aim of the present study was to examine parents' experiences of the 6- and 11-month visits and develop an understanding of their general impressions and thoughts regarding the perceived impact of the visits. Parents (n = 15) were interviewed in four focus groups and two one-on-one interviews. Data was analysed using qualitative content analysis. The findings show that the intervention changed the parents' mindset and increased their knowledge regarding early language stimulation. Tools and strategies benefitting the parent-child interaction were gained. A positive experience and personal guidance created motivation for the parents to carry out the language stimulating activities after the visit. Social gains were described. The findings imply usefulness of the intervention in supporting children's language and literacy development.

Challenges and opportunities of tele-speech therapy: Before and during the COVID-19 pandemic

In 2020, with the onset of the COVID-19 pandemic, the treatment and rehabilitation process faced problems and challenges. One of the most efficient therapy approaches in this period was telerehabilitation. Telepractice in speech therapy presents many challenges and opportunities. In this article, we review published articles up to June 2023 and summarize the challenges and opportunities of the COVID-19 pandemic for speech therapy. Researchers and clinicians have found that tele-speech therapy is an effective tool for improving access to high-quality services and a viable mechanism for delivering speech and language interventions. The results of teletherapy or telepractice during the COVID-19 pandemic were divided into opportunities and challenges. Speech therapy has moved toward telerehabilitation to improve treatment competence during the pandemic. Finally, teletherapy methods were more suitable for speech and language pathology.

Behavioral Interventions for Autism Spectrum Disorder: A Brief Review and Guidelines With a Specific Focus on Applied Behavior Analysis

We conducted a comprehensive review of behavioral and educational interventions for individuals with autism spectrum disorder (ASD). The most prominent type of intervention, Comprehensive Early Intervention, often referred to as Early Intensive Behavioral Intervention (EIBI), has been found to be particularly effective in improving intelligence and adaptive behaviors. The naturalistic developmental behavioral intervention, designed to enhance social and communication abilities, showed effectiveness in improving language, cognitive function, and social initiation. However, more studies are needed to examine its effectiveness. Intensive individualized intervention, which provides a tailored intervention for a specific target behavior, was effective in improving social skills and communication, as well as reducing sleep, eating, and toileting problems. Cognitive behavioral therapy (CBT) is the most effective method for dealing with emotional difficulties, but it has not been widely used because of the shortage of trained experts. Parent-mediated intervention (PMI) involves parents acquiring knowledge and specific skills to improve their child's functioning or reduce challenging behaviors. Speech and language therapy, sensory integration, Treatment and Education of Autistic and related Communications Handicapped Children, developmental approaches, and social stories are frequently used interventions. However, evidence of their effectiveness has yet to be well established. Based on these findings, intervention recommendations for autism include EIBI, Early Start Denver Model, intensive individualized intervention, CBT, and PMI. The choice of intervention should be tailored to the individual's needs and delivered by qualified professionals with expertise in the specific intervention.

The complexities of diagnosis: New Zealand parents' knowledge, perceptions, and experiences of identification of their children's language and literacy difficulties

PURPOSE

This study reported the experiences of New Zealand caregivers of children with language and literacy difficulties in having their child's needs identified.

METHOD

The participants were 14 mothers of children with idiopathic language and literacy difficulties, recruited through social media language and literacy difficulties support groups. Two mothers identified as Māori and 12 New Zealand European. Data were collected through semi-structured interviews. A phenomenological approach using reflexive thematic analysis was used.

RESULT

These mothers had learned about language, literacy, and the education system to advocate for their child and perceived a lack of knowledge on the part of schools. Nearly all had sought a diagnosis, with understanding and access to support reported as positive consequences and stigma as a negative. Some preferred labels emphasising difference rather than disorder, consistent with traditional Māori and neurodiversity views. The mothers described their experience as a fight, due to their concerns being ignored, the need to pay for private diagnostic assessments and difficulty accessing services. They appreciated assessors who gave useful, comprehensible information and supported school liaison.

CONCLUSION

These mothers wanted improved teacher training and publicly funded diagnostic assessment services to improve access to best practice language and literacy instruction for their children.

Evidence-based practice and clinical practice in child language: an online survey with Brazilian speech-language pathologists

PURPOSE

To characterize the knowledge, skills, opinions, and main barriers perceived by speech-language pathologists, in child language in Brazil, regarding evidence-based practice (EBP).

METHODS

The study was conducted between August 2021 and July 2022 using an online questionnaire. In addition to sociodemographic and field data, 22 items related to EBP were considered and subdivided into "knowledge", "skills", "opinion" and "barriers". Each item had five response options (strongly disagree, disagree, not decided, agree, strongly agree). A total of 122 speech-language pathologists who work with child language answered the questionnaire. Their responses were described by the percentage of frequency distribution. The time since graduation and the level of proficiency in English were considered to compare the distribution pattern of the answers.

RESULTS

Although most speech-language pathologists report having learned the basics of EBP in their academic training, there are weaknesses in their knowledge and lack of mastery of search strategies and critical evaluation of scientific articles. Although most agree that EBP's use is necessary for speech-language practice and consider the need to increase the use of scientific evidence in their daily practice, the lack of articles, difficulties related to the practical application of scientific results and lack of collective support among colleagues are identified as barriers.

CONCLUSION

This study alerts the academic community to the urgency of considering EBP in the context of Brazilian Speech-Language Pathology.

Implementation Science in School-Based, Universal-Level Intervention Research: A Scoping Review

PURPOSE

The aim of this study was to map the use of implementation science frameworks, models, and theories in intervention research targeting learning needs in the classroom.

METHOD

A scoping review was conducted. Electronic database and manual searches were conducted. Two reviewers independently completed screening, data extraction, and quality appraisal. Qualitative content analysis was undertaken using Nilsen's taxonomy and the domains of the Consolidated Framework for Implementation Research (CFIR). The data were further analyzed using the CFIR valence and strength rating scales.

RESULTS

Included papers (n = 22) used a diverse sample of implementation science frameworks and models. Most studies used determinant frameworks to guide data collection and analysis. Few studies used implementation science theory. Most studies were mixed methods (n = 11), published since 2019 (n = 20), and conducted in North America (n = 15). Over half of the interventions targeted social, emotional, and mental health (n = 13). A complex interplay of inner setting factors was identified as having a strong influence on implementation. Teachers' knowledge and beliefs, adaptability, and complexity of interventions were also identified as important considerations when conducting research in this context.

CONCLUSIONS

Early engagement with stakeholders in education is recommended when designing universal level speech, language, and communication interventions for use in the ordinary classroom. Adaptive, hybrid designs that test both implementation strategies and effectiveness of interventions may be warranted given the influence of inner setting factors on implementation outcomes.

An evaluation of a prescribed joint book reading intervention for preschool children with speech, language and communication needs

Purpose: The aims of the present study were twofold: first, to investigate reading and screen time habits in a large clinical sample of caregivers of children with speech, language and communication needs (SLCN) before and after an 8 week intervention focussed on daily joint book reading and, second, to capture the caregivers' experiences of the activity.Method: Preschool aged children with SLCN and their caregivers were consecutively recruited during their first visit to the department of Speech and Language Pathology, Gävle County Hospital, Sweden. They participated in a survey-based interview before and after receiving an intervention with recommendations of at least 10 minutes of daily book reading with an interactional focus, as an add-on to ordinary speech-language pathology services. The results were analysed using descriptive statistics of the answers to the questions in the interview, as well as a thematic analysis of free-text comments.Result: The 135 families who participated in the pre-intervention interview survey reported variable reading frequency and screen time. The post-intervention interview survey was completed by 107 families. The results demonstrated significant increases in reading frequency and reading time, and a significant decrease in screen time per day. Caregivers also reported positive experiences of the daily interactive book reading.Conclusion: The results of this study demonstrate that a speech-language pathologist-(SLP) managed, caregiver-led book reading intervention is feasible and might have a positive impact on reading, other factors related to reading, and screen time in families of children with SLCN.

Psychosocial interventions for autistic children and adolescents delivered by non-specialists in low- and middle-income countries: a scoping review

Background

Most autistic individuals reside in low- and middle-income countries (LMIC) and have limited access to medical providers and specialists. Support for delivery of psychosocial interventions by non-specialists is growing to address this mental health care gap. This scoping review involved a systematic analysis of studies of non-specialist delivered psychosocial interventions for children and adolescents diagnosed with autism and living in low- and middle-income countries.

Methods

The primary objective of this review was to identify psychosocial interventions for autistic children and adolescents in LMIC delivered by non-specialists (parent, teacher, peer, community, multi-level) and to summarize resulting effects on targeted outcomes. The search strategy was completed in four databases with predetermined inclusion and exclusion criteria. The systematic search generated 3,601 articles. A total of 18 studies met inclusion/exclusion criteria. Data extraction was completed, and results summarized by; (1) participant sample; (2) intervention procedures; (3) implementation by non-specialists; (4) effect on evaluated outcomes; and (5) assessment of risk of bias. Studies examined a range of child and adolescent outcomes including assessment of communication skills, social skills, motor skills, functional and adaptive behaviors, emotional regulation, attention and engagement, sensory challenges, depression, anxiety, and quality of life. Several studies also evaluated intervention effects on family relationships, parent/caregiver stress and parent/caregiver mental health.

Results

Collectively, the 18 studies included a total of 952 ASC participants ranging in age from 2 to 16 years. Of the included studies, 8 studies were parent/caregiver-mediated, 1 study was peer-mediated, 2 studies were teacher-mediated, and 7 studies included multi-level non-specialist mediated components. Effects on evaluated outcomes are reported.

Conclusion

Non-specialist delivered interventions for autistic children and adolescents are effective for an array of outcomes and are particularly well suited for low- and middle-income countries. Implications for future research are discussed.

Feasibility and Effectiveness of Speech Intervention Implemented with a Virtual Reality System in Children with Developmental Language Disorders: A Pilot Randomized Control Trial

Language disorders are characterized by impairments in verbal expression/understanding, including difficulties with one or more language components. The Virtual Reality Rehabilitation System (VRRS) is a bioelectromedical device equipped with exercise sections aimed at improving cognitive and language deficits. It also increases patient motivation and engagement. The aim of our study was to test the feasibility and efficacy of VRRS intervention to improve speech therapy treatment for children with speech disorders. Thirty-two patients were enrolled in this study and randomly assigned to the experimental (EG) or control group (CG). The CG underwent conventional speech therapy, while EG underwent VRRS-implemented speech therapy. Both groups were evaluated before (T0) and after (T1) the intervention using the Language Assessment Test. The results showed improvements in both groups. However, the EG group showed greater improvement in various areas, including comprehension of total words, repetition, naming of body parts, naming of everyday objects, total naming, morphosyntactic accuracy, sentence construction, average length of utterance, and spontaneous word production. This study demonstrated that VRRS can be a valuable tool for implementing effective speech rehabilitation. Further studies are needed, as the use of VRRS is still in its early stages, requiring larger samples sizes and long-term follow-up.

Evaluating the dose-response relationship of the number of sessions of "It Takes Two to Talk®" in young children with language delay

PURPOSE

To evaluate the dose-response relationship between the number of It Takes Two to Talk® (ITTT) sessions attended and the language outcomes of young children with language delay and their parent's responsivity in a multicultural clinical population.

METHOD

A clinical caseload of 273 early language delayed children (mean age 29.2 months, SD 7.8) and their families participated in parent group workshops and individual coaching sessions of the parent responsivity program ITTT. The children's vocabulary and early syntax, collected using the MacArthur-Bates Communicative Development Inventories and mean length of the three longest utterances respectively, were collated from pre- and post-intervention from pre-existing clinical data. Parental responsivity was evaluated utilising the Parent-Child Interaction checklist at three time points. Multilevel regression was used to determine the relationship between the number of sessions attended and outcomes, while accounting for covariates such as age and language spoken.

RESULT

ITTT dosage did not predict child language outcomes. Rather, vocabulary and early syntax outcomes were predicted by age, pre-scores and parent responsivity at the beginning of treatment. A higher dosage of ITTT did however positively predict parent responsivity, as did speaking only English at home. Socioeconomic status, gender and presence of receptive language difficulties did not contribute significantly to either child or parent outcomes.

CONCLUSION

A lower dosage of the intervention may be considered for parents and children with fewer known risk factors without significant implications.

Exploring the acceptability, feasibility, and appropriateness of a communication-friendly classroom tool for use in Irish schools: A qualitative inquiry

BACKGROUND

Ten percent of the school-aged population have speech, language, and communication needs (SLCN) that impact access to the curriculum. Successful implementation of classroom-based SLCN interventions can reduce barriers to learning, thereby improving educational outcomes for this vulnerable population. The challenges of implementing innovations in educational settings are well-documented, yet limited studies have addressed such considerations when developing, and piloting universal level SLCN interventions for use in Irish schools.

METHODS

A qualitative exploratory study was undertaken to establish the acceptability, feasibility, and appropriateness of a universal level SLCN intervention. An advisory panel of teachers (n = 8) and children with SLCN (n = 2) were engaged as co-researchers in the study. The Communication Supporting Classrooms Observation Tool, developed as part of the Better Communication Project in the UK, was trialled across a diverse sample of school settings (n = 5). Semi-structured interviews were conducted with school practitioners and school leaders, and a deductive content analysis was undertaken using the domains of the Consolidation Framework for Implementation Research.

DISCUSSION

The observation tool was viewed as acceptable with suggested additions. Integrating use of the tool within existing data-informed, school self-evaluation processes aimed at supporting school improvement was noted as a potential means of supporting implementation. A knowledge gap in relation to school-based models of support for SLCN was identified which may negatively impact implementation. An implementation strategy targeting coherence, cognitive engagement and contextual integration is indicated if the tool is to be normalised into routine practice in Irish classrooms. Implementation needs appeared to vary at the school level.

CONCLUSIONS

The importance of early-stage exploration to guide implementation planning with regards to developing and testing universal level interventions for SLCN in schools is highlighted. Engaging an advisory panel provides important insights to guide implementation decisions. Findings suggest an adaptive design is required when planning implementation studies targeting classroom setting.

School-based allied health interventions for children and young people affected by neurodisability: a systematic evidence map

PURPOSE

To systematically map available evidence for school-based interventions led by allied health (i.e., occupational therapy, physiotherapy, and/or speech and language therapy).

MATERIALS AND METHODS

We searched for studies in pre-school, primary, secondary, or post-secondary settings, published 2004-2020. We coded study, population, and intervention characteristics. Outcomes were coded inductively, categorised, and linked to the International Classification of Functioning, Disability, and Health.

RESULTS

We included 337 studies (33 countries) in an interactive evidence map. Participants were mainly pre-school and primary-aged, including individuals with neurodisability and whole-school populations. Interventions targeted wide-ranging outcomes, including educational participation (e.g., writing, reading) and characteristics of school environments (e.g., educators' knowledge and skills, peer support). Universal, targeted, and intensive interventions were reported in 21.7%, 38.9%, and 60.2% of studies, respectively. Teachers and teaching assistants delivered interventions in 45.4% and 22.6% of studies, respectively. 43.9% of studies conducted early feasibility testing/piloting and 54.9% had ≤30 participants. Sixty-two randomised controlled trials focused on intervention evaluation or implementation.

CONCLUSIONS

In the United Kingdom, future research should take forward school-based allied health interventions that relate directly to agreed research priorities. Internationally, future priorities include implementation of tiered (universal, targeted, intensive) intervention models and appropriate preparation and deployment of the education workforce. IMPLICATIONS FOR REHABILITATIONAllied health professionals (occupational therapists, physiotherapists, and speech and language therapists) work in schools supporting children and young people affected by neurodisability but the content, impact, and cost-effectiveness of their interventions are not well-understood.We systematically mapped the available evidence and identified that allied health school-based interventions target highly diverse health-related outcomes and wider determinants of children and young people's health, including educational participation (e.g., literacy) and characteristics of the school environment (e.g., educators' knowledge and skills).Our interactive evidence map can be used to help stakeholders prioritise the interventions most in need of further evaluation and implementation research, including tiered models of universal, targeted, and intensive allied health support.Teachers and teaching assistants play a central role in delivering allied health interventions in schools - appropriate preparation and deployment of the education workforce should therefore be a specific priority for future international allied health research.

Evidence for Implementing Tiered Approaches in School-Based Occupational Therapy in Elementary Schools: A Scoping Review

IMPORTANCE

Internationally, it is suggested that school-based occupational therapy (SBOT) has an important role in supporting inclusion in educational settings. In SBOT, multitiered service delivery models are identified as a way forward to maximize school inclusion. Therefore, identifying evidence for the implementation of tiered interventions in SBOT is vital.

OBJECTIVE

To identify and map evidence in the occupational therapy literature relating to SBOT interventions delivered in elementary schools for all children, for those at risk, and for those with identified diagnoses.

DATA SOURCES

Peer-reviewed literature published in 14 occupational therapy journals between 1990 and 2020, indexed in the EBSCOhost database.

STUDY SELECTION AND DATA COLLECTION

Included studies were those within the scope of SBOT that reported on school occupations and focused on elementary school-age children (excluding kindergarteners or preschoolers).

FINDINGS

Forty studies met the criteria. Individual-tier intervention studies (n = 22) primarily reported direct interventions with children at risk or with identified diagnoses (Tier 2 or Tier 3), focusing mostly on remedial approaches. None adopted a whole-school approach. Despite handwriting and self-regulation being dominant areas of concern, these studies were not explicitly related to inclusion outcomes. Evidence for implementing multitiered models primarily used indirect, collaborative consultation, embedded in the school context (n = 18). These studies identified positive school staff and child outcomes when collaboration was timely, consistent, and authentic.

CONCLUSIONS AND RELEVANCE

More rigorous individual-tier intervention studies are required to inform the design and implementation of multitiered interventions in SBOT and to support participation and inclusion in schools. What This Article Adds: This scoping review provides evidence to support occupational therapists' professional reasoning in developing evidence-based, contextual, educationally relevant multitiered models of intervention in SBOT.

Reading Strategies for Children with Developmental Language Disorder

Developmental language disorder (DLD) is considered a neurodevelopmental disorder that compromises language comprehension and/or expression and constitutes a risk factor for learning to read. The aim of the present study was to analyse the reading strategies used by students with DLD to read sentences. There is evidence in the literature that, when linguistic resources are insufficient, the keyword strategy (identifying some of the words in the sentence with their own semantic content, with barely no processing of the function words) is used to read sentences. A total of 31 primary and secondary school students diagnosed with DLD were evaluated using the PEALE battery. The results reveal that students with DLD present heterogeneous profiles that are below the established reading level for their age. In addition, children with DLD and better reading skills use the keyword strategy to read sentences. In conclusion, clinical and educational implications for reading intervention in individuals with DLD are discussed.

Teaching foreign language grammar to primary-school children with developmental language disorder: A classroom-based intervention study

INTRODUCTION

Children with developmental language disorder (DLD) start learning foreign languages, usually English as a foreign language (EFL), at an increasingly young age. However, current scholarship lacks crucial insights into how children with DLD respond to language learning in classroom settings and how they can be supported in doing so. The purpose of this early efficacy study is to determine whether a business-as-usual curriculum or a new teaching method tailored to the specific needs of pupils with DLD results in (greater) progress in the foreign language (English) and in the school language (Dutch).

METHOD

The participants were 75 pupils with DLD in the last three years of primary school, learning EFL in special education in the Netherlands. The intervention group (n=41) received 12 lessons following the CodeTaal approach, including metalinguistic instruction of grammar rules, explicit cross-linguistic contrasts and multimodal interaction with the material. The control group (n=34) received their regular English lessons. The study used a pre- to post-test design and compared the performance of the two groups on a Grammaticality Judgment Task (GJT) in English and a narrative task in both English and Dutch.

RESULTS

Only the intervention group significantly improved in their ability to identify ungrammaticalities in English and generalised the learnt rules to new sentences. Although the performance on the GJT predicted accuracy of English narratives, neither group showed a significant decrease of error rates in English. In contrast, the accuracy of Dutch narratives showed improvement, but only in the intervention group. However, the effects were small and there was significant variability in responsiveness to the intervention.

CONCLUSION

We conclude that pupils with DLD are able to make progress in foreign language learning in a classroom setting if provided with adequate support.

Responding to Autism in Low and Middle Income Countries (LMIC): What to Do and What Not to Do

Autism is a spectrum disorder that occurs globally with increasing numbers of children and adults being identified with this condition. Although rates are higher in more affluent nations, the bulk of people with autism reside in Low and Middle Income Countries (LMICs). However, most do not have access to timely and appropriate support. The types of services delivered in high income countries are often ill-suited to the needs and resources of LMICs. Rather alternative forms of provision need to be devised. In common with other public health initiatives, these should be family-focused and community based, with suitably qualified and experienced leaders who in turn train and supervise a cadre of knowledgeable support workers drawn from local communities and cultures. As well as providing personalized, home-based guidance to people with autism and to their primary carers, regular group-based advocacy and training activities are undertaken in partnership with available mainstream services such as schools and social services. The principles and operations of these new forms of services are described in this paper albeit with an acknowledgment of their limitations. In recent decades, the cost-effectiveness of these approaches have been demonstrated with other chronic illnesses and disabling conditions in LMICs but their extension to autism has barely begun. More affluent countries are being forced to adopt similar strategies in response to the increased numbers of people identified with autism. A transformation in research strategies is essential to building better international support for persons with autism.

Luck, our journey, doing the best we could: The experiences of speech-language pathologists, parents, and teachers in service delivery for school-aged children

Purpose: Speech-language pathology intervention is effective in supporting the needs of school-aged children with speech and language difficulties, particularly when implemented collaboratively among speech-language pathologists (SLPs), parents, and teachers. However, such intervention is not always accessible, affordable, or timely. The present study explored the experiences of SLPs, parents, and teachers with regard to service delivery for school-aged children as recorded in submissions to the Senate Inquiry into speech-language pathology services in Australia almost 10 years ago and related those experiences to current service provision.Method: In 2013, the Australian Government Senate formed a committee for inquiry and report into the prevalence of speech, language, and communication disorders and speech-language pathology services in Australia. The current study used a phenomenological approach to analyse submissions from SLPs (n = 9), parents (n = 8), and teachers (n = 3) of primary school-aged children who had submitted their experiences of speech-language pathology intervention.Result: Themes that emerged from the submissions showed that participants' experiences of service delivery were associated with "luck", "our journey", and "doing the best we could". Participants described their experiences as "luck" when they were able to access services that they knew others could not; they described their experiences as a "journey" when they reflected on the process of seeking, accessing, and obtaining services which was often quite circuitous; and they described their experience as "doing the best we could" when they persisted in seeking or providing services, despite frustration in not fulfilling their perceived duty of care.Conclusion: The experiences of SLPs, parents and teachers highlight the importance of listening to the stories of these groups to understand the strengths and challenges of service delivery for school-aged children and the need for timely, targeted, and evidence-based care. The experiences of service delivery described by participants in the Senate Inquiry are still common today and thus the need to address the issues they raised remains.

Screening for Language Difficulties in Disadvantaged Populations on Entry to Early Years Education: Challenges and Opportunities

Children aged 3-4 years (n = 876) were recruited from deprived areas in England, and a significant minority of the sample were second language learners. Oral language ability was assessed using child administered standardized measures, and parents reported on children's language. We adapted the Language Use Inventory [LUI; (1)] to capture carer's reports of the children's structural language in the language of instruction and their home language (where appropriate). The final measure included six subscales from the original: use of simple words, requests for help, gaining attention, talking about activities/actions, interactions with others, and building sentences. Children's language abilities and non-verbal abilities were below norms on all standardized tests administered except non-word repetition. Factor analysis indicated that all the six scales of the adapted parent completed measure loaded on one language factor. The revised total scale score correlated significantly (p < 0.0005) with child assessed language measures, specifically expressive vocabulary and grammar. Different patterns across gender, language status and parental education were examined. Sensitivity and specificity of the scale to identify children with the greatest delays were evaluated. These preliminary data indicated that parent-reported information on children's language skills at 3 years of age has the potential to provide a reliable indicator to inform pedagogy and practice at the start of nursery school. Study limitations are examined and avenues for future development explored.

Reflective practice across speech and language therapy and education: a protocol for an integrative review

Effective co-practice is considered a linchpin of inclusive education. Speech and language therapists (SLT), in collaboration with teachers, are amongst the professionals who have a role in ensuring inclusion for students. The challenges of collaboration are well documented, with communication considered a potential antidote. Proposals for how collaborative communication can take place often align with models of reflection. Uncertainty around a shared language for reflection within and across the professions of teaching and SLT may pose a barrier to it occurring. Reflection has long been documented as a strategy used by effective clinicians to improve practice. Hence, teachers and SLTs reflecting together could be considered 'a port of entry' for effective collaborative practice. This study aims to synthesise literature and knowledge on the phenomenon of reflective practice across the professions to facilitate collaboration for inclusive education. The method of qualitative evidence synthesis will be an integrative review. A systematic search will be conducted to extract empirical studies, reviews and theoretical papers on the topic of reflection across both professions.  An adapted version of the PRISMA reporting guidelines will be used in the development, design and reporting of this review. Four databases will be searched: CINAHL, SCOPUS, Education Source and ERIC. A web-based search will also be conducted to retrieve relevant policy documents. Included literature will be appraised using the M-MAT and an adapted checklist from the Joanna Briggs Institute. Deductive content analysis will endeavour to determine if a shared language exists about reflection, across the professions of teaching and speech and language therapy. Establishing a shared language represents a first step towards the development of a framework for collaborative reflection between teachers and SLTs. This is turn serves to inform future research, policy and practice regarding how speech and language therapist can work collaboratively with teachers in schools.

Development and norming of the Hungarian CDI-III: A screening tool for language delay

BACKGROUND

Difficulties in language development are related to social and emotional problems, lower academic outcomes, and lower quality of life from childhood to adolescence. These grave consequences might be significantly reduced by timely identification and professional support. The introduction of systematic screening for language delay (LD) in 3-year-old children in Hungary was based on the recent adaptation of the MacArthur-Bates CDI-III (HCDI-III).

AIMS

To explore the relevant psychometric properties of the HCDI-III; to identify factors characteristic of the families and children influencing language development at the age group under investigation; and to evaluate the adequacy of the tool for the purpose of screening LD in kindergarten at the age of 3 years.

METHODS & PROCEDURES

The norming study of the HCDI-III was conducted in a collaborative research project with the Metropolitan Pedagogical Services in Budapest. HCDI-III parent report forms along with a demographic survey form were distributed to parents of all Hungarian-speaking children between the ages of 2;0 and 4;2 without special education needs. The normative sample comprised data from 1424 children aged 2;0-4;2 with 51.1% boys and 48.9% girls. The data set contained information including language skills, basic demographics, birth conditions, health issues and socio-economic status (SES).

OUTCOMES & RESULTS

In the HCDI-III form, six outcome variables were created to cover the domains of expressive vocabulary, morphosyntax and language use. Statistical analyses revealed appropriate psychometric properties of five outcome variables that showed a normal distribution and were strongly correlated to age. Outcomes of girls were slightly (but significantly) higher on scales corresponding to vocabulary, syntax, language use and productivity. Most variables were highly correlated with one another even with age partialled out. Multiple regression analyses revealed significant effect of age, gender and parental education on all main outcome variables. Neither one of the other eight predictors, including familial and birth-related factors, affected linguistic outcomes in our sample.

CONCLUSIONS & IMPLICATIONS

The results are consistent with the majority of Communicative Development Inventory (CDI) studies, and support the psychometric eligibility of the instrument for screening purposes between 30 and 50 months. As certain regions of Hungary are characterised by a high prevalence of low-SES families, more research is needed to adapt the screening procedure and subsequent measures to their needs.

WHAT THIS PAPER ADDS

What is already known on the subject Difficulties in language development are related to lower social and academic outcomes and lower quality of life from childhood to adolescence. These grave consequences might be significantly reduced by timely identification and professional support. Structured parent report forms such as the MacArthur-Bates CDI are widely accepted methods for screening children with LD. What this paper adds to existing knowledge This study reports the Hungarian adaptation and norming of the CDI-III form. Statistical analyses revealed appropriate psychometric properties of most of its sections. Language outcomes were affected by age, gender and parental education on all main outcome variables in children between 2 and 4 years of age. What are the potential or actual clinical implications of this work? The results support the psychometric eligibility of the HCDI-III instrument for screening purposes. The introduction of the screening procedure in clinical practice is expected to improve early support of children with language difficulties and reduce risks of developmental problems related to language disorders.

Systemic support for learners with developmental language disorders in Zimbabwe and South Africa

Background

Teachers play a significant role as early identifiers of learners with developmental language disorder (DLD). They provide important information to other professionals for further specialist support of such learners. Professionals, such as educational psychologists, speech–language therapists (SLTs) and learning support therapists are involved in assisting learners with DLD; hence, inter-professional collaboration (IPC) amongst these professionals is of paramount importance in meeting the needs of learners.

Objectives

This study aimed to examine systemic support strategies available to learners with DLD.

Method

This was a multiple case study of Zimbabwe and South Africa. Purposive sampling was used to select participants. The study consisted of 56 participants: 5 teachers, 2 SLTs, a learning support therapist, an educational psychologist and 47 learners. A qualitative research approach was employed and data were collected using interviews, focus group discussions and classroom observations. The data were analysed thematically and categorised.

Results

Support strategies employed by teachers include remedial lessons and promoting a culture of reading for leisure to enhance learners’ vocabulary and narrative skills. The SLTs and the learning support therapist use speech–language programmes and assistive technologies. Limited IPC and the absence of SLTs in District Based Support Teams were some of the challenges identified. The results also indicate that SLTs receive referrals mostly from primary schools compared with secondary schools.

Conclusion

Raising awareness of DLD in schools and communities is deemed essential. Inter-professional collaboration is recommended to support learners with DLD as it increases the exchange of ideas and mutual acknowledgement of expertise amongst professionals.

Allocation and funding of Speech and Language Therapy for children with Developmental Language Disorders across Europe and beyond

BACKGROUND

Children with Developmental Language Disorder (DLD) have a significant deficit in spoken language ability which affects their communication skills, education, mental health, employment and social inclusion.

AIM

The present study reports findings from a survey by EU network COST ACTION 1406 and aims to explore differences in service delivery and funding of SLT services for children with DLD across Europe and beyond.

METHODS AND PROCEDURES

The survey was completed by 5024 European professionals. COST countries were grouped into Nordic, Anglo-Saxon, Continental, Mediterranean, Central/Eastern and Non-European categories. The use of direct, indirect and mixed interventions, and their relationship to funding available (public, private or mixed) were considered for further analysis.

OUTCOMES AND RESULTS

The results revealed that for direct therapy, there were more cases than expected receiving private funding. For indirect therapy, fewer than expected received private and more than expected public funding. For mixed therapy, fewer cases than expected received private funding.

CONCLUSIONS AND IMPLICATIONS

The results implies that other factors than evidence-based practices, practitioners experience, and patient preferences, drive choices in therapy. More research is needed to gain a better understanding of factors affecting the choice of therapy.

Addressing implementation considerations when developing universal interventions for speech, language and communication needs in the ordinary classroom: a protocol for a scoping review

Background: Understanding the factors that influence the implementation of health interventions in the context of education is essential to improving outcomes for children and young people with speech, language and communication needs (SLCN). Yet implementation considerations have not been adequately addressed when developing interventions for this context. The aim of this paper is to present a protocol for a scoping review of existing implementation frameworks that might guide SLCN intervention research in schools.  Methods: In accordance with scoping review guidelines, the proposed study will be conducted in  phases: (1) identifying potentially relevant studies, (2)  screening and selection of studies, (3) charting and extracting data from identified frameworks, (4) collating, summarising and reporting the results and (5) consulting with stakeholders. Two reviewers will conduct the screening and the data extraction phases independently. Identified frameworks will be collated, and described, and constructs from the frameworks will be categorised using domains from the Consolidated Framework for Implementation Research. A draft implementation science model will be proposed based on the findings of the scoping review. Conclusions: The findings of this review will provide guidance for researchers to begin to address implementation considerations when developing and facilitating the uptake of universal interventions for SLCN in the ordinary classroom, and ultimately can contribute towards improving outcomes for this vulnerable childhood population.

Perspectives of International Experts on Collaborative Tiered School-Based Physiotherapy Service Delivery

AIMS

The purpose of this Phase II study is to identify the perceived strengths and weaknesses of a collaborative tiered school-based physiotherapy (PT) service delivery model, considering its core attributes and tiered interventions identified in the first phase of the study (Phase I), and explore the potential facilitators and barriers to implementing the model internationally.

METHODS

Three focus group discussions were conducted with international experts (n = 16) Discussions focused on the core attributes and tiered interventions of the model in Phase I. Data were analyzed using a framework approach and SWOT (strengths, weaknesses, opportunities, and threats) analysis.

RESULTS

Themes surrounding the perceived characteristics of the model included comprehensiveness, guiding document, collaborative approach, and inclusiveness. Additional themes were related to the implementation that included governance, professional roles, workload, implementation in different countries, advocacy, and available opportunities. A framework table was tabulated to present the strengths and weaknesses of the service delivery model and available opportunities, and potential barriers to implementation.

CONCLUSIONS

This study revealed international perspectives regarding a proposed collaborative tiered school-based PT service delivery model and presented a framework to guide clinicians, researchers, and policymakers for the implementation of tiered approaches.Relationships between health and education have been more pronounced in recent years, and interactions between healthcare and the education system have evolved (Zajacova & Lawrence, 2018). Recent recommendations of the World Health Organization (WHO) and UNESCO suggest that "every school should be a health-promoting school", and provided intervention guidelines for the global standards for health-promoting schools (WHO., 2021a). In the meantime, education sectors in different countries have shifted inclusive education policy, with a focus not only on students with disabilities, but all students (Whitley & Hollweck, 2020). In conjunction with the changes in both education and school health services (WHO., 2021b), researchers in the field of speech-language therapy (SLT), occupational therapy (OT) (Camden et al., 2021), and physiotherapy (PT) (Cinar et al., 2021), have been exploring tiered approaches to delivering services in schools, and searching for collaborative strategies to encourage interaction between stakeholders in health and education sectors.

Understanding the Diversity of Pharmacotherapeutic Management of ADHD With Co-occurring Autism: An Australian Cross-Sectional Survey

OBJECTIVES

Attention deficit hyperactivity disorder (ADHD) frequently co-occurs with other neurodevelopmental diagnoses, such as autism spectrum disorder (autism), which can make clinical decision making around symptom management challenging for clinicians. There is a paucity of research examining pharmacotherapeutic management of children who have ADHD with co-occurring diagnoses. We aimed to report on the co-occurring diagnoses and symptom profile of children, and report on medication use, stratified by ADHD, autism and ADHD + autism diagnoses.

METHODS AND MATERIALS

Caregivers of 505 children (2-18 years) with ADHD (n = 239), autism (n = 117), and co-occurring ADHD + autism (n = 149) completed a questionnaire on current medication use and clinical rating scales about their child's symptoms, as part of a broader project investigating diagnosis and management of symptoms in children with ADHD or autism.

RESULTS

The parents of the ADHD group reported a higher proportion of their children had learning disorders (17.15%) and speech and language disorders (4.60%) compared to the parents of the autism and ADHD + autism groups. Parents of the ADHD + autism group reported higher proportions of intellectual disability (5.37%), oppositional defiant disorder (20.13%), anxiety (38.93%), depression (6.71%) and genetic conditions (3.36%) in their children, in comparison to the parents of the ADHD and autism groups. Children with ADHD were reported to be taking a higher proportion of psychotropic medication (90%), followed by ADHD + autism (86%) and autism (39%). The parents of children with ADHD + autism reported a higher proportion of non-stimulant ADHD medication (25.5%), antipsychotic (18.79%), antidepressant (22.15%) and melatonin (31.54%) use by their children, compared to the parents of the ADHD and autism groups.

CONCLUSIONS

A similar proportion of children with ADHD + autism and ADHD were reported to be taking medication. However, the types of medication taken were different, as expected with reported co-occurring diagnoses. The complexity of symptoms and diagnoses in ADHD + autism warrants targeted research to optimize management and therapeutic outcomes.

Reflective practice across speech and language therapy and education: a protocol for an integrative review

Effective co-practice is considered a linchpin of inclusive education. Speech and language therapists (SLT), in collaboration with teachers, are amongst the professionals who have a role in ensuring inclusion for students. The challenges of collaboration are well documented, with communication considered a potential antidote. Proposals for how collaborative communication can take place often align with models of reflection. Uncertainty around a shared language for reflection within and across the professions of teaching and SLT may pose a barrier to it occurring. Reflection has long been documented as a strategy used by effective clinicians to improve practice. Hence, teachers and SLTs reflecting together could be considered 'a port of entry' for effective collaborative practice. This study aims to synthesise literature and knowledge on the phenomenon of reflective practice across the professions to facilitate collaboration for inclusive education. The method of qualitative evidence synthesis will be an integrative review. A systematic search will be conducted to extract empirical studies, reviews and theoretical papers on the topic of reflection across both professions.  An adapted version of the PRISMA reporting guidelines will be used in the development, design and reporting of this review. Four databases will be searched: CINAHL, SCOPUS, Education Source and ERIC. A web-based search will also be conducted to retrieve relevant policy documents. Included literature will be appraised using the M-MAT and an adapted checklist from the Joanna Briggs Institute. Deductive content analysis will endeavour to determine if a shared language exists about reflection, across the professions of teaching and speech and language therapy. Establishing a shared language represents a first step towards the development of a framework for collaborative reflection between teachers and SLTs. This is turn serves to inform future research, policy and practice regarding how speech and language therapist can work collaboratively with teachers in schools.

Opportunities to Enhance Children's Communication Development at School in Underserved Communities

PURPOSE

Alternative service delivery approaches are required to provide support for children with communication difficulties in underserved communities. Schools have a unique set of assets that can be utilized to provide this support. This study explored what the education sector and classrooms in the early years of schooling offer as support for children with communication difficulties in an underserved Majority World country, the Maldives. The objective was to identify opportunities to enhance support provided for these children.

METHOD

A qualitative multimethod approach was used involving (a) 520 min of classroom observational data from four remote schools, (b) interviews with four special education needs teachers, and (c) an interview with a Ministry of Education official. Classroom observational data were analyzed using the Communication Supporting Classroom Observation Tool. Deductive content analysis was used to analyze the interview data.

RESULTS

The support system aimed to reflect the Inclusive Education Policy of the Maldives. The Ministry of Education official and teachers raised concerns regarding lack of allied health services such as speech-language therapy in schools. Teachers frequently used certain communication supporting interactions such as imitation in classrooms. Missed opportunities to enhance communication were observed, including limited use of some interaction features such as modeling language, limited planned opportunities for children to interact in class, and limited resources in the environment to develop communication in Grade 1 and 2 compared to preschool.

CONCLUSION

Findings suggest building capacity among teachers and training teachers on identified classroom communication support areas to enhance support for children with communication difficulties. Supplemental Material https://doi.org/10.23641/asha.17003980.

Addressing implementation considerations when developing universal interventions for speech, language and communication needs in the ordinary classroom: a protocol for a scoping review

Background: Understanding the factors that influence the implementation of health interventions in the context of education is essential to improving outcomes for children and young people with speech and language needs (SLCN). Yet implementation considerations have not been adequately addressed when developing interventions for this context. The aim of this paper is to present a protocol for a scoping review of existing implementation frameworks that might guide SLCN intervention research in schools.  Methods: In accordance with scoping review guidelines, the study will be conducted in six phases: (1) identification of the research question, (2) identification of potentially relevant studies of Implementation Science frameworks, (3) study screening and selection, (4) charting and extracting data from identified frameworks, (5) collating, summarising and reporting the results and (6) consultation with stakeholders. Two reviewers will conduct the screening and extraction stages independently. Identified frameworks will be collated, and described, and constructs from the IS frameworks will be categorised using domains from the Consolidated Framework for Implementation Research. A draft implementation science model will be proposed based on the findings of the scoping review. Conclusions: The findings of this review will provide guidance for researchers to begin to address implementation considerations when developing and facilitating the uptake of universal interventions for SLCN in the ordinary classroom, and ultimately can contribute towards improving outcomes for this vulnerable childhood population.

Optimising existing speech-language therapy resources in an underserved community: A study of the Maldives

BACKGROUND

People living in Majority world countries face complex challenges regarding speech-language therapy services. As traditional individualised service delivery approaches may not suit the needs of the population, customised solutions are needed.

AIM

This study explored speech-language therapy and related resources available in the Maldives, a Majority world country, as seen by local government representatives and service providers. The goal was to identify service delivery approaches for children with communication difficulties that could yield the most out of existing resources.

METHOD

Semi-structured interviews were conducted with six service providers (three speech-language therapists (SLTs), three representatives from Non-Governmental Organisations (NGOs) related to disabilities) and six local government representatives (atoll councillors) of the Maldives. Interview questions related to services available for children with communication difficulties. The data were analysed via deductive content analysis.

RESULTS

SLTs predominantly delivered traditional individualised and rehabilitative therapy. Services were unevenly distributed across the Maldives with some atolls receiving no services. Support was available from community groups and atoll councillors in some atolls, for instance to access aids provided by the government. Some NGOs were trialling alternative service delivery approaches by conducting programs for parents and teachers in atolls. Participants suggested several possible measures including increasing awareness of speech-language therapy and communication difficulties amongst communities, engaging active community groups to support interventions and allowing less qualified professionals to provide services. The costs related to access and provide services were noted as a challenge.

CONCLUSION

While this study discovered limitations, the existing resources that were identified can be better directed to reach more children who require services in the Maldives. The following potential alternative service delivery approaches were derived from the results: focusing on prevention, using public health approaches to train families and teachers, creating awareness, building capacity within the community, and adopting cost-effective approaches to provide services.

Clinical practices of speech-language pathologists working with 12- to 16-year olds in Australia

Purpose: The current landscape of speech-language pathology (SLP) services for 12- to 16-year olds in Australia remains largely unchartered. Implementing the Speech Pathology 2030 vision necessitates mapping current services, and gaps in services, provided by speech-language pathologists (SLPs). However, the last survey of Australian SLPs' practices with young people was conducted in 2005. The aim of this study was to bridge the service delivery information gap.Method: Ninety-six SLPs working with 12- to 16-year olds in Australia completed an anonymous online survey consisting of binary choice, multiple choice, and Likert scale questions. A theoretical approach to service delivery based on response to intervention models underpinned question design.Result: SLP clinical practices remain traditional, following an impairment/diagnostic model. Additionally, there is an inequitable provision of SLP services across states/territories of Australia, according to whether or not there is government provision for SLP services in public schools.Conclusion: The results suggest a need for standard government provision of SLP services across Australia to ensure equity of access. These findings inform our understanding of contemporary assessment and intervention practices of SLPs working with 12- to 16-year olds in Australia.

RETRACTED: Allocation and funding of Speech and Language Therapy for children with Developmental Language Disorders across Europe and beyond

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of Authors and Editor-in-Chief. Whilst conducting further analyses for a companion paper in June 2021 using the survey data reported in this study, it came to the authors' attention that unfortunately there were errors in the data used in the analyses for this paper. The authors believe this to be either human error in data entry or coding or a technical error whilst recoding a variable. They therefore reran their analyses with the correct data for the paper to understand if and how the results differed from those published, and they did indeed change the findings. As soon as this came to the authors' attention (July 2021), they contacted the Editorial office. All authors on the paper are in agreement with this retraction. A new revised article with the correct data, analysis and results is now available: 10.1016/j.ridd.2021.104139.

Addressing implementation considerations when developing universal interventions for speech, language and communication needs in the ordinary classroom: a protocol for a scoping review

Background: Understanding the factors that influence the implementation of health interventions in the context of education is essential to improving outcomes for children and young people with speech and language needs (SLCN). Yet implementation considerations have not been adequately addressed when developing interventions for this context. The aim of this paper is to present a protocol for a scoping review of existing implementation frameworks that might guide SLCN intervention research in schools.  Methods: In accordance with scoping review guidelines, the study will be conducted in six phases: (1) identification of the research question, (2) identification of potentially relevant studies of Implementation Science frameworks, (3) study screening and selection, (4) charting and extracting data from identified frameworks, (5) collating, summarising and reporting the results and (6) consultation with stakeholders. Two reviewers will conduct the screening and extraction stages independently. Identified frameworks will be collated, and described, and constructs from the IS frameworks will be categorised using domains from the Consolidated Framework for Implementation Research. A draft IS model will be proposed based on the findings of the scoping review. Conclusions: The findings of this review will provide guidance for researchers in addressing implementation considerations when developing universal interventions for SLCN in the ordinary classroom, and ultimately will contribute towards improving outcomes for this vulnerable childhood population.

A classroom intervention targeting working memory, attention and language skills: a cluster randomised feasibility trial

Background

International debate around the best models of speech and language therapy provision for children with language disorders has highlighted the need for research into classroom-based approaches and intervention dosage. Working memory (WM) is a cognitive skill linked to attention and language. ‘Recall to Enhance Children’s Attention, Language and Learning’ (RECALL) is a novel, 6-week, classroom-based intervention delivered by health professionals (HPs) and teachers. It is designed to target WM and enhance attention and language skills in 4–5 year olds.

Methods

A cluster randomised feasibility trial was conducted to investigate aspects of the feasibility of a definitive trial to evaluate RECALL: (i) recruitment and sampling procedures; (ii) compliance and fidelity; (iii) the acceptability of RECALL to HPs and teachers; (iv) the appropriateness of the outcome measures. Six classes of 4–5 year olds participated: two received RECALL, two received an existing intervention targeting attention skills (not underpinned by WM theory), and two received education as usual (no intervention). Ten children in each class (n = 60) were sampled to assess the appropriateness of the outcome measures. Classroom observations were conducted to measure fidelity and semi-structured interviews with HPs, and teachers explored the acceptability of RECALL.

Results

The recruitment targets were met, and all six schools completed the trial, but the sampling procedures require modification. Compliance was good (95% of RECALL sessions were delivered), but fidelity to the intervention protocol varied between 76% and 45% across the two schools. This was influenced by large class sizes, child factors, and facilitator factors, e.g., their understanding of the theory underpinning the intervention. The lack of fidelity reduced the dose (number of practice items) accessed by individual children, particularly those most at risk. There were mixed findings regarding the acceptability of RECALL and the appropriateness of the outcome measures.

Conclusions

The trial protocol could be easily scaled-up in a future definitive trial, with an amended sampling procedure. RECALL should be repackaged as a small group intervention to enhance the fidelity of its delivery and its acceptability to HPs and teachers. This study highlights the need for thorough training for professionals who deliver classroom-based interventions for children with language disorders.

Trial registration

ISRCTN13633886. Registered on 7 September 2018

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00771-w.

Why Clinicians Choose Their Language Intervention Approach: An International Perspective on Intervention for Children with Developmental Language Disorder

<b><i>Purpose:</i></b> Considerable progress has been made in recent years in generating external evidence underpinning interventions for children with developmental language disorder (DLD), but less is known about the practitioner decision-making process underpinning such interventions and whether such decisions are context specific or are internationally generalizable. <b><i>Methods:</i></b> An online survey about clinical practice was developed by members of COST Action IS1406, an EU-funded research network, which included representation from 39 countries. The participants were 2,408 practitioners who answered questions in relation to their decision making for a specific child of their choosing with DLD. Analysis of open-ended questions was undertaken, and data were converted into codes for the purpose of quantitative analysis. <b><i>Results:</i></b> Although a wide range of intervention approaches and rationales were reported, the majority of responses referenced a client-centred approach. Level of functioning was used as a rationale only if a child had severe DLD. Practitioners with university level education or above were less likely to report basing intervention on client-centred factors. A number of differently named interventions with variable theoretical and empirical underpinnings were used in different countries. <b><i>Conclusions:</i></b> Specific client and practitioner characteristics have an impact on the intervention approaches and rationales adopted across countries. A limited number of practitioners reported use of external scientific evidence, which suggests that there should be more initiatives in basic training of practitioners and continuing professional development to encourage the uptake of scientific evidence-based practice.

The complexity of early diagnostic decision making: A follow-up study of young children with language difficulties

BACKGROUND & AIMS

Due to the complexity of early diagnostic decision making, we examined the predictive value of an early diagnostic classification and early abilities on later best estimate diagnosis for 22 clinically referred children with language difficulties.

METHODS AND PROCEDURES

Four years after initial evaluation (Time 1), the clinical files of these children were reviewed. A best-estimate (BE) diagnosis of language disorder (LD), intellectual disability (ID), or autism spectrum disorder (ASD) was established, with ASD being most common.

OUTCOMES AND RESULTS

Early clinical classifications were relatively unstable or difficult to establish at a young age. The magnitude of children's cognitive and receptive language delay was a significant predictor of a later BE diagnosis of ID and LD respectively. A BE diagnosis of ASD, by contrast, could not be predicted from children's early social communication problems nor the presence of restricted and repetitive behaviors and interests.

CONCLUSIONS

Taken together, the results of this study suggest that language difficulties can be an early marker of a neurodevelopmental disorder which is often not identified at the age of first referral.

IMPLICATIONS

Eligibility for treatment should, therefore, be based on biopsychosocial case formulation rather than DSM or ICD diagnostic classification.

WHAT THIS PAPER ADDS?

In this study a dimensional approach was used to characterize the abilities of young children referred with mild to profound receptive and/or expressive language difficulties. Later on, a categorical approach was adopted to establish best estimate diagnoses. Our clinical, broadly defined sample reflects the heterogeneous intake of young children referred for diagnostic assessment. Other studies on diagnostic stability often only focus on one diagnostic category (and are explicitly excluding children with specific other diagnoses), not taking into account the difficulties of early differential diagnostic decision making and stability across different categories over time. Investigations of differential diagnosis within a clinical group, instead of only differentiating children with a specific diagnosis from typically developing children, may be more informative for clinicians.

Supporting language development in Lebanese preschools: SLT and pre-KT practice and perception of roles

BACKGROUND

Speech and language therapists (SLTs) are increasingly engaging in school-based interventions targeting children with language difficulties. Collaborative work between teachers and SLTs has shown to be beneficial in fostering language development in all children. Both groups of professionals have different but complementary roles in offering language support, according to children's needs. Effective collaboration between SLTs and teachers requires both parties to understand their roles and practices in schools. However, little is known about language support practices in Lebanese preschools and the roles of SLTs in these contexts.

AIMS

(1) To explore the perceptions and reported practices among preschool teachers (pre-KTs) to support language development; (2) to investigate the current practices of SLTs in preschools; and (3) to understand pre-KTs' and SLTs' perceptions of the SLTs' role in Lebanese preschools.

METHOD & PROCEDURES

Using a quantitative method, the study reports the results of two questionnaires (one for pre-KTs and one for SLTs) that were developed based on a review of the academic literature and adapted to the contextual realities. Questionnaires were completed in hard or soft copy by pre-KTs and through an online survey by SLTs.

OUTCOMES & RESULTS

The questionnaires were completed by 1259 out of 1442 pre-KTs from 175 Lebanese preschools, and by 200 out of 391 SLTs from across Lebanon. First, the findings show that both professional groups recognize they have a role in supporting language development. Second, differences in reported practices were identified regarding language strategies for children with communication needs. In particular, pre-KTs reported less use of specific language strategies targeting children with language difficulties, while SLTs reported that their practices in schools remain primarily focused on children with communication needs. Finally, the analysis of perceptions showed a lack of acknowledgement of the SLTs' role in the prevention of communication and language disorders among all children.

CONCLUSIONS & IMPLICATIONS

This study provides an overview of the perceptions and reported practices of language development support in Lebanese preschools. The majority of SLTs and pre-KTs acknowledge their role in supporting language development. However, the slight differences in perceptions of SLT roles in prevention interventions highlight the necessity for SLTs to promote their active involvement in services targeting all children. Future research will investigate how SLTs are beginning to reconceptualize their role in intervention for preschool children. This will help to better define SLTs' roles and responsibilities in educational settings and foster effective professional collaboration. What this paper adds What is already known on the subject Collaboration between teachers and SLTs has been shown to be beneficial in supporting language among all children. The way SLTs and pre-KTs view each other's roles could result in more effective professional collaboration. The SLT profession in Lebanon emerged about 20 years ago, yet SLTs are still struggling to define a framework for the scope of their practice in Lebanese preschools and to increase awareness of the relevance of their intervention in language. What this paper adds to existing knowledge The results revealed that there are major agreements between pre-KTs and SLTs concerning the support of language development in preschools. However, the findings highlight slight differences in the perception of the SLTs' role in the prevention of communication, language and literacy disorders in educational settings. It seems that their role is more commonly acknowledged for children with identified language and communication needs. Moreover, despite the strong agreement between both professionals on the role of the SLT to target all children, SLTs' practices in preschools are still mostly limited to meeting only referred and diagnosed needs in children. What are the potential or actual clinical implications of this work? This study's findings contribute to a better understanding of the perceptions regarding the roles and practices of both groups of professionals in language development. The differences in how the SLTs' roles are perceived could lead to a more difficult implementation of collaborative language practices in preschools. It is therefore necessary to ensure a better understanding of the roles played by professionals, who could receive the relevant training in undergraduate education programmes. There is also a pressing need to provide a clearer definition of SLTs' roles in educational settings by reconceptualizing them into a preventive approach in collaboration with teachers.

What families really think about the quality of early intervention centers: a perspective from mixed methods

Background

Families are a fundamental aspect in the current perspective of Early Intervention, and knowing their opinion with quantitative and qualitative research is necessary for its improvement. The objective of this research was to evaluate the quality of the service perceived in Early Intervention Centers and its relationship with satisfaction and future intention, as well as to identify factors that are associated with the perception of users.

Methods

A measurement model of 50 items and an open question to gather qualitative information was used in a sample of 233 participants. A confirmatory factor analysis and a regression analysis were conducted. Regarding the qualitative data, the information was subjected to a thematic content analysis in order to delve into the perception of the participants.

Results

The model showed a satisfactory fit and the regression analysis indicated that treatment rooms (β =  − 0.28) and adaptation of activities (β = 0.27) have greater weight with respect to satisfaction, whereas for future intention, the factors of greater weight were adaptation of activities (β = 0.23) and location (β = 0.20). The qualitative analysis showed three themes: facilitators, barriers and suggestions for improvement. Within facilitators, the participants were satisfied with the Early Intervention professionals, and they made improvement suggestions for the detected barriers to improve the facilities and the follow-up of the child.

Conclusions

The study offers a wide perspective of the perception of the service with an active participation of families in the treatment within the Early Intervention service. This will allow professionals in Early Intervention, service providers and researchers to consider the families as intervention agents capable of providing their opinion and making decisions, and not only as passive elements.

A meta-analysis on the effectiveness of intervention in children with primary speech and language delays/disorders: Focusing on China and the United States

The purpose of this meta-analysis was to investigate the immediate and long-term effects of intervention for children with primary speech and language delays/disorders and to explore whether some characteristics of interventions, specifics of the study and research participants moderate the magnitude of the effectiveness of interventions. Using the random effect model, we pooled the effect size and conducted a publication bias evaluation, a moderating effect analysis in CMA 2.0. Results of a random effects model analysis demonstrated a moderate immediate effect (g = 0.70), whereas the long-term efficacy was small (g = 0.23). Additionally, type of measure, language of intervention, parental involvement, intervention content and study quality, as well as the duration of intervention, significantly moderated the effect size of intervention effectiveness.

Promoting Reading Achievement in Children With Developmental Language Disorders: What Can We Learn From Research on Specific Language Impairment and Dyslexia?

Purpose Specific language impairment (SLI; see also developmental language disorder) and dyslexia are separate, yet frequently co-occurring disorders that confer risks to reading comprehension and academic achievement. Until recently, most studies of one disorder had little consideration of the other, and each disorder was addressed by different practitioners. However, understanding how the two disorders relate to each other is important for advancing theories about each disorder and improving reading comprehension and academic achievement. The purpose of this clinical focus article is to integrate research on SLI and dyslexia as well as advocate for the consideration of comorbidities in future research and clinical practice. Method The first section reviews definitions as well as inclusionary and exclusionary criteria for SLI and dyslexia. The second section reviews research demonstrating that SLI and dyslexia are different disorders that often co-occur. Studies examining language, working memory, and academic achievement in children with separate versus co-occurring SLI and dyslexia are reviewed. The final section compares and contrasts school identification frameworks for children with SLI and dyslexia and considers the potential benefits of incorporating broad language skills into response to intervention (RTI) assessment frameworks. Conclusions Children with weak language skills are at a high risk of experiencing reading problems, but language difficulties are often hidden from view. Directly addressing language skills within school RTI frameworks can help improve the identification and treatment of children with SLI and dyslexia as well as support improved reading comprehension and academic achievement for all students. Presentation Video https://doi.org/10.23641/asha.13063793.

Evaluation of a parent preference-based outcome measure after intensive communication intervention for children with social (pragmatic) communication disorder and high-functioning autism spectrum disorder

BACKGROUND/OBJECTIVES

Children with Social (Pragmatic) Communication Disorder (SPCD) or High-Functioning Autism Spectrum Disorder (HFASD) have persistent deficits in language structure and language use (pragmatics). This feasibility study evaluated a novel parent preference-based outcome measure and secondary outcomes associated with the Social Communication Intervention Programme (SCIP).

METHODS

15 UK speech and language practitioners identified 20 children aged 5-11 years with pragmatics/language needs. Practitioners received SCIP training and supervision. Children received 20 SCIP therapy sessions. Primary endpoint was a goal attainment scale (SCIP-GAS). Before intervention (T1), parents provided three prioritised communication goals, refined into a series of steps. After intervention (T2) parents and practitioners rated each goal compared to T1 and parents provided a narrative on outcomes.

SECONDARY OUTCOMES

Children's Communication Checklist-2, Social Language Development Test (SLDT), and observational ratings of conversational interaction (TOPICC-2).

RESULTS

All children except one progressed on T2 SCIP-GAS parent outcomes. All children progressed on practitioner SCIP-GAS ratings. 82.5 % of parent comments supported their own SCIP-GAS ratings. Secondary outcomes measures: Only SLDT Making Inferences scores and TOPICC-2 ratings showed improvement at T2.

CONCLUSIONS

A preference-based social communication measure showed feasibility as an outcome measure following social communication intervention for children who have HFASD or SPCD.

Development of Computer-Aided Semi-Automatic Diagnosis System for Chronic Post-Stroke Aphasia Classification with Temporal and Parietal Lesions: A Pilot Study

Survivors of either a hemorrhagic or ischemic stroke tend to acquire aphasia and experience spontaneous recovery during the first six months. Nevertheless, a considerable number of patients sustain aphasia and require speech and language therapy to overcome the difficulties. As a preliminary study, this article aims to distinguish aphasia caused from a temporoparietal lesion. Typically, temporal and parietal lesions cause Wernicke’s aphasia and Anomic aphasia. Differential diagnosis between Anomic and Wernicke’s has become controversial and subjective due to the close resemblance of Wernicke’s to Anomic aphasia when recovering. Hence, this article proposes a clinical diagnosis system that incorporates normal coupling between the acoustic frequencies of speech signals and the language ability of temporoparietal aphasias to delineate classification boundary lines. The proposed inspection system is a hybrid scheme consisting of automated components, such as confrontation naming, repetition, and a manual component, such as comprehension. The study was conducted involving 30 participants clinically diagnosed with temporoparietal aphasias after a stroke and 30 participants who had experienced a stroke without aphasia. The plausibility of accurate classification of Wernicke’s and Anomic aphasia was confirmed using the distinctive acoustic frequency profiles of selected controls. Accuracy of the proposed system and algorithm was confirmed by comparing the obtained diagnosis with the conventional manual diagnosis. Though this preliminary work distinguishes between Anomic and Wernicke’s aphasia, we can claim that the developed algorithm-based inspection model could be a worthwhile solution towards objective classification of other aphasia types.

Re-Evaluating Evidence for Best Practice in Paediatric Speech-Language Pathology

BACKGROUND

Systematic reviews of treatment trials for children with speech and language difficulties often exemplify the limited clinical usefulness of the evidence base, reflecting recent literature in evidence-based medicine. Other studies report that clinicians often fail to seek information about best practice, across the health professions. Consequently, clinical researchers, including those in speech-language pathology, have sought alternative methodologies for determining best practice.

SUMMARY

Some approaches focus on "pragmatic trials," usually as part of existing health services. Others place case management of individuals at the centre of intervention presenting studies of one or more cases, including N-of-1 randomized controlled trials and cross-over group designs. Clinical case studies can provide important theoretical data contributing to our understanding of the development of typical and atypical communication. Precision medicine (also known as personalized medicine) is an emerging approach to building the clinical evidence base that acknowledges the importance of individual genetic and environmental differences between people. With increasing knowledge of aetiological heterogeneity, even within children presenting with the same diagnosis (e.g., childhood apraxia of speech), data reinforce the edict that children are not all born equal. Key Message: This review argues that to understand response to treatment, it is critical to examine child-related factors as well as the variables of the intervention itself.

A Comparison of the Prevalence Rates of Language Impairment Before and After Response-to-Intervention Implementation

Purpose This research note presents a secondary data analysis of language impairment (LI) prevalence rates of children in public schools before and after a statewide mandate for response-to-intervention (RTI) implementation. Method Statewide and district-level LI prevalence rates were compared across 10 school years. Prevalence data from 67 school districts located in 1 state in the United States are reported as the proportion of the general student population (students ages 3-21 years) who were identified with a primary disability of LI. Results The mandated implementation of RTI within special education prereferral, evaluation, and eligibility processes coincided with significant changes in LI prevalence as a primary disability for most of the school districts. The majority of school districts experienced an increase in LI prevalence within 1 school year following RTI implementation. However, the degree and direction of change in prevalence rates varied across some of the school districts. Similar degrees of change were not evident across the other years of prevalence data review, suggesting the systemic change that occurred via RTI requirements coincided with fluctuations in the LI prevalence rates for the majority of school districts in the state. Conclusion A causal relation between RTI and LI prevalence cannot be established with the current data; however, this study establishes a temporal connection between the timing of RTI implementation and changes in LI prevalence in public schools of 1 very large state. Implications are presented for further research investigating the potential impact of systemic mandates on the identification of school-age children with LI. Supplemental Material https://doi.org/10.23641/asha.8968676.

The Contribution of Bilingualism, Parental Education, and School Characteristics to Performance on the Clinical Evaluation of Language Fundamentals: Fourth Edition, Swedish

Assessment of bilingual children in only one language fails to acknowledge their distributed linguistic competence and has been shown to overidentify language disorder in bilingual populations. However, other factors, sometimes associated with bilingualism, may also contribute to low results in language assessments. Our aim was to examine the impact of these factors on language abilities. We used the Clinical Evaluation of Language Fundamentals - Fourth Edition, Swedish (CELF-4) to investigate core language abilities of 224 7- to 8-year-old children. Results showed 30 and 80% of monolinguals and bilinguals, respectively, performing more than 1 SD below the normative sample mean, calling into question the clinical utility of the test. However, participant and school characteristics provided a deeper understanding of the skewed results. In isolation, bilingualism predicted 38% of the variance in the CELF-4 Core scores. With level of parental education entered the variance explained by the model increased to 52%, but the unique contribution of bilingualism was reduced to 20%. Finally, with information added on school characteristics and enrollment in the school's recreation center the model explained an additional two percent, with the unique contribution of bilingualism further reduced to 9%. The results indicate an increased risk for low results on the CELF-4 Core when children present with multiple risk factors. This highlights the need to look beyond bilingualism in language assessment of bilingual children and adolescents and to consider other explanations to academic struggle. Available interventions must be considered and applied proportionately to their respective impact on the individual's development.

A classroom-based intervention targeting working memory, attention and language skills in 4-5 year olds (RECALL): study protocol for a cluster randomised feasibility trial

BACKGROUND

There is international recognition of the need for creative, classroom-based interventions to support children at risk of low academic achievement and well-being, due to poor attention and language skills on school entry. Working memory (WM) is a cognitive skill that is strongly associated with attention and language skills. There has been speculation that WM training, embedded within typical educational activities, may improve children's WM skills and produce transfer effects to real-world skills such as attention and language. However, little is known about the effectiveness of this approach.'Recall to Enhance Children's Attention, Language and Learning' (RECALL) is a novel, 6-week, classroom-based intervention targeting WM, attention and language skills in 4-5 year olds. RECALL was co-produced with health professionals, teachers and parents. This protocol describes the rationale, methods and analysis plan for a proposed cluster randomised feasibility trial of this RECALL programme.

METHODS

This is a three-arm, cluster randomised feasibility trial comparing RECALL to an existing programme (active control), and no-intervention (education as usual). We will recruit six schools in socially disadvantaged areas in one region of the UK. Two schools will be randomly allocated to each arm of the trial. In each school, one class of children (ages 4-5 years) of approx. 30 children will be involved in this study. Ten children in each class will be sampled purposefully for outcome measurement including: standardised assessments of WM, language and attention skills; teacher ratings of attention; and parent ratings of functional communication skills. These will be administered at baseline and 1-week post-intervention in order to test the acceptability of the measures. A process evaluation using semi-structured interviews with participants will explore the acceptability of RECALL and the procedures employed in this trial.

DISCUSSION

This feasibility study will explore the acceptability of RECALL to the health professionals and teachers who will deliver it and inform the optimal design of the programme. The inclusion of an active control group and the blinding of outcomes assessors enhance rigour in this study. The findings will determine whether this study can be scaled-up into a definitive cluster randomised trial to evaluate the effectiveness of RECALL.

TRIAL REGISTRATION

ISRCTN13633886. Registered 7 Sept 2018.

Evaluating 'enhancing pragmatic language skills for young children with social communication impairments' (E-PLAYS): protocol for a feasibility randomised controlled trial study

Background

A number of children experience difficulties with social communication and this has long-term deleterious effects on their mental health, social development and education. The proposal presented in this article describes a feasibility study for a trial to test an intervention (‘E-PLAYS’) aimed at supporting children with social communication impairments. E-PLAYS harnesses technology in the form of a novel computer game in order to develop collaborative and communication skills. Preliminary studies by the authors show that when E-PLAYS was administered by the research team, children with social communication impairments showed improvements on communication test scores and on observed collaborative behaviours. The study described here is a pragmatic trial to test the application of E-PLAYS delivered by NHS speech and language therapists together with schools.

Methods

This protocol outlines a two-arm feasibility cluster-randomised controlled trial of the E-PLAYS intervention with treatment as usual control arm, with randomisation at the level of the speech and language therapist. The aim of this study is to ascertain whether it will be feasible to progress to running a full-scale definitive trial to test the effectiveness of E-PLAYS in an NHS setting. Data relating to recruitment and retention, the appropriateness of outcomes and the acceptability of E-PLAYS to participants will be collected.

Speech and language therapists will select suitable children (ages 4–7 years old) from their caseloads and deliver either the E-PLAYS intervention (experimental group) or treatment as usual (control group). Assessments will include blinded language measures and observations, non-blinded teacher-reported measures of peer relations and classroom behaviour and parent-reported use of resources and quality of life. There will also be a qualitative process evaluation.

Discussion

The findings of this study will inform the decision as to whether to progress to a full-scale definitive randomised controlled trial to test the effectiveness of E-PLAYS when delivered by speech and language therapists and teaching assistants within schools. The use of technology in game form is a novel approach in an area where there are currently few available interventions.

Trial registration

ISRCTN 14818949 (retrospectively registered).