Treating children with speech and language impairments

Aligned or misaligned: Are public funding models for speech-language pathology reflecting recommended evidence? An exploratory survey of Australian speech-language pathologists

Government subsidised funding arrangements serve as an essential medium for families to access private speech-language pathology (SLP) services in Australia. This study aimed to investigate whether, from a provider perspective, contemporary public funding models (PFMs) align with best-available scientific evidence for management of children and young persons with swallowing and communication disorders within Australian private-practice settings. This exploratory study was distributed to paediatric speech-language pathologists throughout Australia via an online survey. A total of 121 valid surveys were completed by Australian speech-language pathologists with divergent career experiences. In comparing three familiar PFMs using mixed effects logistic regression models to estimate odds ratios, results indicated that perceived congruence with recommended scientific evidence for SLP management varied across PFMs: the odds of failing to align with scientific evidence was 4.92 times higher for Medicare's Chronic Disease Management Plan (MBS_CDMP) than for the National Disability Insurance Scheme; and 7.40 times higher in comparison to Medicare's Helping Children with Autism initiative. This study is the first to report on (in)congruence between PFMs that provide access to independent Australian SLP services for children and young persons and best available scientific evidence to inform clinical practice. Participants identified that: (a) four out of seven contemporary PFMs were unfamiliar to speech-language pathologists; and (b) MBS_CDMP initiative failed to align with the evidence-base for best scientific SLP management.

'Turning up and tuning in'. Factors associated with parental non-attendance and non-adherence in intervention for young children with speech, language communication needs

BACKGROUND

When parents bring their child to appointments and then adhere to agreed speech and language therapy (SLT) recommendations, there is the potential to increase the intensity of the intervention, support generalization and improve outcomes. In SLT, however, little is known about factors that may promote attendance or adherence. Studies in other clinical areas such in medicine, psychology and physiotherapy have identified risk factors for non-attendance or non-adherence that are multifactorial and variable dependent on, for example, population and intervention.

AIMS

To identify rates of non-attendance and non-adherence, and to identify parent or child factors associated with parent involvement in intervention for children under 5 years of age receiving SLT.

METHODS

Parents completed questionnaires at two time points assessing the domains of parents' beliefs (problem perceptions, self-efficacy), personal circumstances (socio-demographics, family functioning), treatment experience and child factors. Predictors of parent attendance and adherence were identified through multiple regression analyses. Non-attendance rates were identified via local health records and non-adherence ascertained using a specific parent-reported measure within the treatment experience domain.

RESULTS

Participants (N = 199) were predominantly mothers, and were ethnically and socio-economically diverse, speaking a wide range of languages. Their children presented with a range of speech, language communication needs (SLCN). The rate of non-attendance was 25% and the main predictors of non-attendance were maternal age, education level and two factors within the parent beliefs domain. This model explained 40% of the variance in attendance. The rate of non-adherence in this cohort was 26% with parental rating of the importance of a recommendation and self-efficacy beliefs predicting adherence; this explained 56% of the variance in adherence to SLT recommendations at home.

CONCLUSIONS & IMPLICATIONS

Our research has provided preliminary evidence of the influence of parents' beliefs, personal circumstances and treatment experiences on their involvement in their child's therapy. Speech and language therapists should consider factors impacting attendance and adherence to treatment and explore parental perceptions of their child's SLCN before embarking on an intervention, a foundation for collaborative practice. A possible limitation of this study is that the levels of attrition in our sample led to generally high measured rates of participation, which should be considered in future studies. Future research should explore adherence in treatments with varying doses, with different types of SLCN or interventions and in different settings.

WHAT THIS PAPER ADDS

What is already known on the subject It is acknowledged that parent involvement in their child's therapy, such as attending and adhering to recommendations, is important but little is known about the rates of involvement and what factors may be associated with attendance and adherence in SLT. Qualitative research has explored parental involvement suggesting that beliefs about an intervention may be pertinent. Extensive research in other clinical areas suggest multiple and varied factors are influential and further exploration of particular populations and interventions is necessary. What this paper adds to the existing knowledge This study identified rates of parental non-attendance and non-adherence in a cohort of predominantly mothers of children under the age of 5 years. It is the first study to measure parent adherence in SLT and identify factors that are associated parental adherence to SLT recommendations. It adds to the small body of SLT specific research in understanding risk factors for non-attendance. What are the potential or actual clinical implications of this work? This study highlights the need for a speech and language therapist to consider and explore parents' perspectives of their child's SLCN as a part of achieving collaboration with a parent in order to achieve the best outcomes. It provides a foundation for further systematic research into parent involvement with the ultimate aim of enhancing outcomes for children with SLCN.

Harnessing automatic speech recognition to realise Sustainable Development Goals 3, 9, and 17 through interdisciplinary partnerships for children with communication disability

PURPOSE

To showcase how applications of automatic speech recognition (ASR) technology could help solve challenges in speech-language pathology practice with children with communication disability, and contribute to the realisation of the Sustainable Development Goals (SDGs).

RESULT

ASR technologies have been developed to address the need for equitable, efficient, and accurate assessment and diagnosis of communication disability in children by automating the transcription and analysis of speech and language samples and supporting dual-language assessment of bilingual children. ASR tools can automate the measurement of and help optimise intervention fidelity. ASR tools can also be used by children to engage in independent speech production practice without relying on feedback from speech-language pathologists (SLPs), thus bridging the long-standing gap between recommended and received intervention intensity. These innovative technologies and tools have been generated from interdisciplinary partnerships between SLPs, engineers, data scientists, and linguists.

CONCLUSION

To advance equitable, efficient, and effective speech-language pathology services for children with communication disability, SLPs would benefit from integrating ASR solutions into their clinical practice. Ongoing interdisciplinary research is needed to further advance ASR technologies to optimise children's outcomes. This commentary paper focusses on industry, innovation and infrastructure (SDG 9) and partnerships for the goals (SDG 17). It also addresses SDG 1, SDG 3, SDG 4, SDG 8, SDG 10, SDG 11, and SDG 16.

Predicting Which Children Will Normalize Without Intervention for Speech Sound Disorders

PURPOSE

The speech of some children does not follow a typical normalization trajectory, and they develop speech sound disorders (SSD). This study investigated predictive correlates of speech sound normalization in children who were at risk of SSD.

METHOD

A prospective population cohort study of 845 Cantonese-speaking preschoolers was conducted over 2.5 years to examine (a) children who resolved nonadult realizations of consonants (normalized) and (b) those who had persisting speech sound difficulties (did not normalize). From these 845, a sample of 82 participants characterized as having SSD (1.25 SDs below the mean in a standardized speech assessment, with a delay in initial consonant acquisition or with one or more atypical errors) was followed for 2 years at 6-month intervals or until the completion of their initial consonant inventory. Data from 43 children who did not receive speech-language pathology services were analyzed with survival analysis to model time to normalization while controlling for covariates. The target event (outcome) was the completion of their initial consonant inventory.

RESULTS

Under the no-intervention condition, the estimated median time to normalization was 6.59 years of age. Children who were more likely to normalize or normalized in a shorter time were stimulable to all errors and more intelligible as rated by caregivers using the Intelligibility in Context Scale. Those who showed atypical error patterns did not necessarily take longer to normalize. Similarly, expressive language ability was not significantly associated with speech normalization.

CONCLUSIONS

Stimulability and intelligibility were more useful prognostic factors of speech normalization when compared to (a)typicality of error patterns and expressive language ability. Children with low intelligibility and poor stimulability should be prioritized for speech-language pathology services given that their speech errors are less likely to resolve naturally.

Frequency of Early Intervention Sessions and Vocabulary Skills in Children with Hearing Loss

BACKGROUND

A primary goal of early intervention is to assist children in achieving age-appropriate language skills. The amount of intervention a child receives is ideally based on his or her individual needs, yet it is unclear if language ability impacts amount of intervention and/or if an increased frequency of intervention sessions results in better outcomes. The purpose of this study was to determine the relationship between the frequency of early intervention sessions and vocabulary outcomes in young children with hearing loss.

METHODS

This was a longitudinal study of 210 children 9 to 36 months of age with bilateral hearing loss living in 12 different states. Expressive vocabulary skills were evaluated using the MacArthur-Bates Communicative Development Inventories.

RESULTS

A higher number of intervention sessions reported at the first assessment predicted better vocabulary scores at the second assessment, and more sessions reported at the second assessment predicted better scores at the third assessment. For each increase in the number of sessions reported, there was a corresponding, positive increase in vocabulary quotient. In contrast, children's vocabulary ability at an earlier time point did not predict intervention session frequency at a later point in time.

CONCLUSIONS

A significant prospective effect was apparent with more therapy sessions resulting in improved vocabulary scores 9 months later. These findings underscore the importance of early intervention. Pediatricians and other health care professionals can help apply these findings by counseling parents regarding the value of frequent and consistent participation in early intervention.

Assessment of caregivers' perspectives regarding speech-language services in Saudi Arabia during COVID-19

Background

As a consequence of stay-at-home and other lockdown measures, such as social distancing, all health care service provisions during the COVID-19 pandemic have been affected, including the provision of speech therapy. Telehealth services can play a major role in maintaining access to health care, help speech and language pathologists (SLPs) overcome physical barriers by providing patients and caregivers with access to health care, and limit the discontinuity of patient care. To have a better understanding of the changes that have occurred in these services during COVID-19, this research was conducted to explore the nature and current situation of speech-language services in Saudi Arabia based on caregivers’ perspectives. It also investigated whether changes have occurred in these services during the COVID-19 lockdown. The study also determined the perception of caregivers in delivering SLS sessions remotely.

Method

A cross-sectional study was conducted with 385 caregivers in Saudi Arabia. An online survey asked whether children were experiencing any SLS problems and if they had received any intervention. The survey also assessed the perception of changes in service during the COVID-19 lockdown and the perceptions, acceptance, and willingness of the caregivers to deliver telehealth speech services in Saudi Arabia.

Results

About 50% of the respondents had or were suspected to have a child with SLS problems, and just over half of them had accessed SLS services. Most of the respondents reported suspension of therapy sessions as a response to the COVID-19 pandemic. While the respondents had little experience using telehealth prior to the pandemic, they generally showed a willingness to use telehealth in therapy sessions, expressing a preference for video calls over other options.

Conclusion

The study revealed that SLS services in Saudi Arabia are limited and that accessing these services is challenging. Alternative service delivery using remote services could help caregivers overcome such challenges. When telehealth was introduced as an option for service delivery, the caregivers showed welcoming responses, particularly with video calls.

The Influence of Quantitative Intervention Dosage on Oral Language Outcomes for Children With Developmental Language Disorder: A Systematic Review and Narrative Synthesis

Purpose The aim of this study was to examine the degree to which quantitative aspects of dosage (dose, dose frequency, and total intervention duration) have been examined in intervention studies for children with developmental language disorder (DLD). Additionally, to establish the optimal quantitative dosage characteristics for phonology, vocabulary, and morphosyntax outcomes. Method This registered review (PROSPERO ID CRD42017076663) adhered to PRISMA guidelines. Search terms were included in seven electronic databases. We included peer-reviewed quasi-experimental, randomized controlled trial or cohort analytical studies, published in any language between January 2006 and May 2020. Included articles reported on participants with DLD (M = 3-18 years); oral language interventions with phonology, vocabulary, or morphosyntax outcomes; and experimental manipulation or statistical analysis of any quantitative aspect of dosage. Studies were appraised using the Cochrane risk-of-bias tool. Results Two hundred forty-four articles reported on oral language interventions with children with DLD in the domains of interest; 13 focused on experimentally/statistically manipulating quantitative aspects of dosage. No article reported phonological outcomes, three reported vocabulary, and eight reported morphosyntax. Dose frequency was the most common characteristic manipulated. Conclusions Research is in its infancy, and significant further research is required to inform speech-language pathologists in practice. Dosage characteristics are rarely adequately controlled for their individual effects to be identified. Findings to date suggest that there is a point in vocabulary and morphosyntax interventions after which there are diminishing returns from additional dosage. If dose is high (number of learning opportunities within a session), then the literature suggests that session frequency can be reduced. Frequent, short sessions (2/3 × per week, approximately 2 min) and less frequent, long sessions (1 × per week, approximately 20 min) have yielded the best outcomes when composite language measures have been used; however, replication and further research are required before clinicians can confidently integrate these findings into clinical practice. Supplemental Material https://doi.org/10.23641/asha.13570934.

Randomized controlled trial comparing Parent Led Therapist Supervised Articulation Therapy (PLAT) with routine intervention for children with speech disorders associated with cleft palate

BACKGROUND

A total of 68% of pre-school children with cleft palate have speech problems requiring speech therapy. There is a lack of access to regular targeted therapy. Parent training leads to positive outcomes in early communication skills in cleft palate and non-cleft speech disorders. Connected health has been used to address inadequate access to therapy, providing intervention to those who would not otherwise receive therapy.

AIMS

To evaluate the speech, activity and participation outcomes of Parent Led, Therapist Supervised, Articulation Therapy (PLAT) compared with routine speech therapy intervention in parent-child dyads.

METHODS & PROCEDURES

A total of 44 children, aged 2.9-7.5 years, were included in a two-centre, two-phase randomized controlled trial. Informed consent and assent were obtained. Participants and speech and language therapists (SLTs) were unblinded to the groups. Parents, in the parent-trained group (n = 23), attended 2 days' training, received a detailed speech therapy programme, and undertook intervention over 12 weeks supported by the cleft specialist SLT using FaceTime and one face-to-face session. In the control arm (n = 21), parent-child dyads received six therapy sessions over 12 weeks with a research SLT, comparable with usual care. Speech recordings were undertaken pre- and post-intervention. Percent consonant correct (PCC) was analysed by external SLTs blinded to the time and group. Activity and participation were measured using the Intelligibility in Context Scale (ICS) and Focus on Outcomes for Children Under Six (FOCUS) questionnaire.

OUTCOMES & RESULTS

There was no evidence of an interaction between Time and Group or an overall statistical difference between groups for PCC scores. There was a statistically significant difference over time for both groups (words: p < 0.002; confidence interval (CI) = 9.38-16.27; d = 0.57; sentences: p < 0.002; CI = 16.04-25.97; d = 0.23). Effect sizes were medium for words and small for sentences. For intelligibility and participation, there was no evidence of an interaction between Time and Group or an overall statistical difference between groups. A statistically significant difference over time was found for intelligibility (F = 29.97, d.f. = 1, 42, p < 0.001, 95 % CI = 1.45-3.15 d = 0.46) and for participation (F = 14.19, d.f. = 1, 41, p < 0.001 95% CI = 7.63-25.03; d = 0.36) with FOCUS results indicating clinically meaningful (parent-led group) and significant (control group) change in participation.

CONCLUSIONS & IMPLICATIONS

PLAT can be as effective as routine care in changing speech, activity and participation outcomes for children with cleft palate, when supported by a specialist cleft SLT using connected health. What this paper adds What is already known on this subject Over 50% of children with cleft palate require speech therapy. However, there is a lack of timely, accessible speech therapy services in the UK and Ireland. Previous studies have shown that parents can deliver therapy effectively, and that connected health can support the delivery of speech therapy. This study aims to provide evidence that parent-led therapy with the supervision of a specialist cleft therapist using FaceTime is effective. What this paper adds to existing knowledge This randomized controlled trial indicates that parents can be trained to deliver therapy for children with cleft palate speech disorders, under the supervision of an SLT. This approach results in improved speech, activity and participation outcomes similar to routine care. What are the potential or actual clinical implications of this work? This study indicates that both parent-led articulation therapy and routine care showed meaningful gains in speech, activity and participation, and that parent-led articulation therapy when supported by a cleft SLT using connected health could be an additional service delivery model for children with cleft palate speech disorders.

Waiting for speech-language pathology services: A randomised controlled trial comparing therapy, advice and device

Purpose: To compare children's speech, language and early literacy outcomes, and caregivers' empowerment and satisfaction following provision of 12 sessions of direct intervention (therapy), or face-to-face advice or a purpose-built website (device) while waiting for therapy.Method: A four-stage randomised controlled trial was undertaken involving three- to six-year-old children referred to speech-language pathology waiting lists at two Australian community health centres over eight months (n = 222). Stage 1 (screening): 149 were eligible to participate. Stage 2 (pre-assessment): 117 were assessed. Stage 3 (intervention): 110 were randomised to advice (33), device (39) or therapy (38). Stage 4 (post-assessment): 101 were re-assessed by a speech-language pathologist blinded to the intervention condition.Result: After controlling for baseline levels, children's speech (percentage of consonants correct) was significantly higher in the therapy group compared to the advice and device conditions. Caregivers' satisfaction was also significantly higher in the therapy condition compared to the device condition. There were no significant differences between the three conditions for children's intelligibility, language and early literacy or caregivers' empowerment.Conclusion: Therapy resulted in significantly higher speech outcomes than the advice and device conditions and was associated with significantly greater caregiver satisfaction. Provision of a website containing evidence-based material or a single session of advice may be a viable alternative while children wait for therapy targeting intelligibility, language and early literacy, and to empower caregivers.

Enabling New Articulatory Gestures in Children With Persistent Speech Sound Disorders Using Ultrasound Visual Biofeedback

Purpose This study evaluated ultrasound visual biofeedback treatment for teaching new articulations to children with a wide variety of speech sound disorders. It was hypothesized that motor-based intervention incorporating ultrasound would lead to rapid acquisition of a range of target lingual gestures with generalization to untreated words. Method Twenty children aged 6-15 years with a range of mild to severe speech disorders affecting a variety of lingual targets enrolled in a case series with replication. Of these, 15 children completed the intervention. All of the children presented with a variety of errors. We therefore employed a target selection strategy to treat the most frequent lingual error. These individual speech targets were treated using ultrasound visual biofeedback as part of ten to twelve 1-hr intervention sessions. The primary outcome measure was percentage of target segments correct in untreated wordlists. Results Six children were treated for velar fronting; 3 children, for postalveolar fronting; 2 children, for backing alveolars to pharyngeal or glottal place; 1 child, for debuccalization (production of all onsets as [h]); 1 child, for vowel merger; and 2 children, for lateralized sibilants. Ten achieved the new articulation in the 1st or 2nd session of intervention, despite no children being readily stimulable for their target articulation before intervention. In terms of generalization, effect sizes for percentage of target segments correct ranged from no effect (5 children), small effect (1 child), medium effect (4 children), and large effect (5 children). Conclusions Ultrasound visual biofeedback can be used to treat a wide range of lingual errors in children with various speech sound disorders, from mild to severe. Visual feedback may be useful for establishing new articulations; however, generalization is more variable.

Implementation fidelity of a computer-assisted intervention for children with speech sound disorders

BACKGROUND

Implementation fidelity refers to the degree to which an intervention or programme adheres to its original design. This paper examines implementation fidelity in the Sound Start Study, a clustered randomised controlled trial of computer-assisted support for children with speech sound disorders (SSD).

METHOD

Sixty-three children with SSD in 19 early childhood centres received computer-assisted support (Phoneme Factory Sound Sorter [PFSS] - Australian version). Educators facilitated the delivery of PFSS targeting phonological error patterns identified by a speech-language pathologist. Implementation data were gathered via (1) the computer software, which recorded when and how much intervention was completed over 9 weeks; (2) educators' records of practice sessions; and (3) scoring of fidelity (intervention procedure, competence and quality of delivery) from videos of intervention sessions.

RESULT

Less than one-third of children received the prescribed number of days of intervention, while approximately one-half participated in the prescribed number of intervention plays. Computer data differed from educators' data for total number of days and plays in which children participated; the degree of match was lower as data became more specific. Fidelity to intervention procedures, competency and quality of delivery was high.

CONCLUSION

Implementation fidelity may impact intervention outcomes and so needs to be measured in intervention research; however, the way in which it is measured may impact on data.

Involvement of parents in intervention for childhood speech sound disorders: a review of the evidence

BACKGROUND

Internationally, speech and language therapists (SLTs) are involving parents and providing home tasks in intervention for phonology-based speech sound disorder (SSD). To ensure that SLTs' involvement of parents is guided by empirical research, a review of peer-reviewed published evidence is needed.

AIMS

To provide SLTs and researchers with a comprehensive appraisal and analysis of peer-reviewed published intervention research reporting parent involvement and the provision of home tasks in intervention studies for children with phonology-based SSD.

METHODS & PROCEDURES

A systematic search and review was conducted. Academic databases were searched for peer-reviewed research papers published between 1979 and 2013 reporting on phonological intervention for SSD. Of the 176 papers that met the criteria, 61 were identified that reported on the involvement of parents and/or home tasks within the intervention. These papers were analysed using a quality appraisal tool. Details regarding the involvement of parents and home tasks were extracted and analysed to provide a summary of these practices within the evidence base.

MAIN CONTRIBUTION

Parents have been involved in intervention research for phonology-based SSD. However, most of the peer-reviewed published papers reporting this research have provided limited details regarding what this involved. This paucity of information presents challenges for SLTs wishing to integrate external evidence into their clinical services and clinical decision-making. It also raises issues regarding treatment fidelity for researchers wishing to replicate published intervention research.

CONCLUSIONS & IMPLICATIONS

The range of tasks in which parents were involved, and the limited details reported in the literature, present challenges for SLTs wanting to involve parents in intervention. Further high-quality research reporting more detail regarding the involvement of parents and home tasks in intervention for SSD is needed.

Mapping speech pathology services to developmentally vulnerable and at-risk communities using the Australian Early Development Census

PURPOSE

The Australian Early Development Census (AEDC) is a population-based measure of children's development across five domains in the first year of formal schooling. In this study, the AEDC data from two domains (Language and Cognitive Skills and Communication Skills and General Knowledge) were used to explore the extent and distribution of vulnerability in communication skills among children in Australian communities. Speech Pathology Australia (SPA) membership data were then used to explore the accessibility of services within those communities.

METHOD

The 2012 AEDC data were accessed for 289,973 children, living in 577 communities across Australia. The number of children identified as "at risk" (10-25(th) percentile) or developmentally "vulnerable" (< 10(th) percentile) in each of the domains was calculated, then the location of communities with high proportions (> 20%) of these children was determined. These data were mapped against the location of paediatric speech-language pathologists (SLPs) to identify the number of communities with little to no access to speech-language pathology services.

RESULT

Across Australia, there were 47,636 children (17.4%) identified as developmentally vulnerable/at risk in Language and Cognitive Skills and 69,153 children (25.3%) in Communication Skills and General Knowledge. There were 27 communities with > 20% of children identified as developmentally vulnerable/at risk in Language and Cognition in their first year of formal schooling. Of those, none had access to speech-language pathology services, according to current SPA membership data. There were also 27 local government areas with > 20% of children identified as developmentally vulnerable/at risk in the Communication Skills and General Knowledge domain. Of these, three had access to SLP(s) and these were in regional/metropolitan areas.

CONCLUSION

The AEDC provides a means of identifying communities where children are performing well and communities which may benefit from population-based prevention or intervention. Given the number of communities within Australia without access to SLPs, there is a need to reconsider how such population-based services could be delivered, particularly in the communities with higher levels of vulnerability in communication development.

Optimal intervention intensity

Empirical evidence exists for many of the different interventions in speech-language pathology. However, relatively little is known about the optimal intensity of those interventions. In order for speech-language pathology services to be both effective and efficient speech-language pathologists need to know how to faithfully administer ideal doses of the active ingredients of interventions, in what forms, how often and for how long. This is the lead paper to a scientific forum on this fundamental yet under-studied issue of clinical practice. Borrowing from the work of Warren, Fey, and Yoder, the concept of intervention intensity is described. Issues involved in establishing the optimal intensity of interventions are identified, including what and how intervention goals are targeted. Given that speech-language pathology interventions can involve the delivery of therapeutic inputs (e.g., conversational recasts, questions) and/or clients carrying out an act (e.g., speech production, voice production, comprehending, naming, swallowing), a framework is proposed for measuring all potential inputs and acts that might contribute to the calculation of an intervention intensity. Client-, clinician-, condition-, and service-related variables that could influence the investigation and practical application of an optimal intervention intensity are also discussed.

Characterizing optimal intervention intensity: the relationship between dosage and effect size in interventions for children with developmental speech and language difficulties

Although Warren, Fey and Yoder (2007) have described the key components of "dosage", one needs to go beyond description if one is to understand "optimal" dosage, specifically one needs to relate the characteristics of the intervention to the size of the intervention effect. This study examines the association between dose, intensity, and effect size in 20 randomized controlled studies taken from a few systematic reviews focusing on interventions aiming to ameliorate vocabulary, phonology, and syntax. Reporting of dosage characteristics is an important issue. Our analysis shows that "teaching episodes" and "dose form" are rarely reported in the included studies. The other dosage characteristics are present but not always reported in a transparent fashion. Session length and cumulative intervention intensity is lower for phonology interventions than it is for vocabulary intervention. Dosage, however defined, is not directly associated with outcome, although the level of association varies across the three interventions, for example appearing stronger for vocabulary and phonology than syntax. Taking the three interventions together the dosage components are related to the intervention effects size, but the sample is small and the association is not statistically significant. This study concludes that, while the framework suggested by Baker (2012) and adapted from Warren et al. (2007) is useful but without reference to the effect size of a study, it can only ever tell half the story. One needs to be able to relate dosage to outcome, asking questions about the relationship between the different dosage characteristics and the intervention effect size. Given the available data, it is not, at this stage, possible to make recommendations about optimal dosage.

Paediatric speech-language pathology service delivery: an exploratory survey of Australian parents

Consideration of client values and preferences for service delivery is integral to engaging with the evidence-based practice triangle (E(3)BP), but as yet such preferences are under-researched. This exploratory study canvassed paediatric speech-language pathology services around Australia through an online survey of parents and compared reported service delivery to preferences, satisfaction, and external research evidence on recommended service delivery. Respondents were 154 parents with 192 children, living across a range of Australian locations and socio-economic status areas. Children had a range of speech and language disorders. A quarter of children waited over 6 months to receive initial assessment. Reported session type, frequency, and length were incongruent with both research recommendations and parents' wishes. Sixty per cent of parents were happy or very happy with their experiences, while 27% were unhappy. Qualitative responses revealed concerns such as; a lack of available, frequent, or local services, long waiting times, cut-off ages for eligibility, discharge processes, and an inability to afford private services. These findings challenge the profession to actively engage with E(3)BP including; being cognisant of evidence-based service delivery literature, keeping clients informed of service delivery policies, individualizing services, and exploring alternative service delivery methods.

Quality of life of children with language delays

We investigated health-related quality of life (HRQOL) of children with language problems and controls. Data on language development (Language Screening Instrument 3-years-olds, Van Wiechen items) and HRQOL by means of the TNO-AZL Pre-school children Quality of Life-questionnaire (TAPQOL) were collected at age 3 in a population-based cohort by parental questionnaire (n = 8877, response 78%; mean age 39.1 months (SD 2.0), 4347 were girls). Cronbach's alpha (internal consistency) ranged between 0.63 and 0.85. Dependent on the definition of language problem, 131 to 316 children appeared to be language impaired. Receiver Operating Characteristic analyses (ROC-curves) to assess the discriminative ability of six TAPQOL scales revealed that the Communication scale and Social Functioning scale discriminated best between children with language problems and children without these problems. Language-impaired children had significantly lower scores on the Communication scale and Social Functioning scale as compared to children without language problems (p < 0.01). The findings indicate that language problems at age three can have an impact on children's social life. These results provide additional evidence for the importance of monitoring the language development and its consequences during childhood.

Evaluation of a structured test and a parent led method for screening for speech and language problems: prospective population based study

OBJECTIVE

To evaluate two methods for identifying speech and language problems in preschool children.

DESIGN

Prospective population based study.

SETTING

Inner London.

PARTICIPANTS AND METHODS

37 health visitors were randomly assigned to use a structured screening test (18) or a parent led method (19). Of 623 eligible children aged 30-36 months, the parents of 582 agreed to participate (353 using the structured test and 229 the parent led method).

MAIN OUTCOME MEASURES

Children were assessed by a speech and language therapist blinded to the test result, using the Reynell developmental language scales. Children were classified as having "severe language problems" if the Reynell score was below the third centile for receptive language and as "needing therapy" if the Reynell score was below the seventh centile for receptive or expressive language and clinical opinion.

RESULTS

Reference assessments and usable scores were obtained for 458 (97%) of the 474 children screened. 98 (21%) children had severe language problems and 131 (29%) needed therapy. The sensitivity and specificity for the structured screening test were 66% (95% confidence interval 53% to 76%) and 89% (85% to 93%) respectively for severe language problems and 54% (43% to 65%) and 90% (85% to 93%) for those needing therapy. The sensitivity and specificity for referral by the parent led method were 56% (40% to 71%) and 85% (78% to 90%) for severe language problems and 58% (44% to 71%) and 90% (83% to 94%) for those needing speech and language therapy.

CONCLUSIONS

Both approaches failed to detect a substantial proportion of children with severe language problems and led to over-referral for diagnostic assessments. Screening is likely to be an ineffective approach to the management of speech and language problems in preschool children in this population.