SLI in Preschoolers: Which service delivery model?

1. SLI in Preschoolers: Which service delivery model? Paediatric Language Group

2. Paediatric Language Group- a quick update • Change of leadership - thank you to Brooke Butt for all your hard work • New group leaders • Katie Carmody (Sydney Children’s Hospital) • Mary Falco (Sydney Children’s Hospital) • Sara Beckett (Bankstown Community Health) • Current members - mainly of community health paediatric speech pathologists and a few private therapists from both metropolitan and rural areas • Cover a broad range of topics

3. The challenges in coming up with a clinical question ….. • Difficulties • Broad topic, language has many theoretical constructs and many clinical elements • Language impairment is a heterogeneous group • There are a huge range of intervention techniques in use, with varying levels of evidence.

4. The challenges in coming up with a clinical question ….. (cont) • Useful to keep in mind: • Start with a broad clinical question that can be answered • Decide on type of question: Diagnostic? Predictive? Comparing types of intervention or service delivery models? • Ensure topic is relevant & motivating to group members and will have implications for clinical practice

5. Current Question: • In children 0-6 years, which service delivery models are effective in treating Specific Language Impairment?

6. Current Question (cont) • Reasoning for question: significant variation in how children with language impairment are treated -group therapy -direct therapy (SP) -individual therapy -indirect therapy (non SP) -parent training • Type of service delivery model has implications on the efficacy of services.

7. Searching the evidence • Search terms • specific language impairment • language therapy/intervention/outcomes, • individual therapy, • group therapy, • direct therapy, • indirect therapy • ……………………and a mix of all terms

8. Searching the evidence (cont) • Results, 11 articles matched search terms and fit the clinical question. • Boyle J, McCartney E, Forbes J, O’Hare A. A randomised control trial and economic evaluation of direct vs indirect and individual vs group modes of speech and language therapy for children with primary language impairment. Health Technology Assessment 2007: 11 (25) • Boyle et al. (2009). Direct versus Indirect and individual versus group modes of language therapy for children with primary language impairment: principal outcomes from a randomized controlled trial and economic evaluation. International of Journal of Communication Disorders, 44 (6) 826-846 • Dickson et al (2009). Cost analysis of direct versus indirect and individual versus group modes of manual based speech-and-language therapy for primary school-age children with primary language impairment. International of Journal of Communication Disorders, 44 (3) 369 - 381

9. Gallagher & Chiat (2009). Evaluation of speech and language therapy interventions for pre-school children with specific language impairment: a comparison of outcomes following specialist intensive, nursery-based and no intervention. International of Journal of Communication Disorders, 44 (5) • Gibbard (1994). Parental based intervention with preschool delayed children, European Journal of Disorders in Communication, 29, 131-150 • Ward (1999). An investigation into the effectiveness of an early intervention method for delayed language development International of Journal of Communication Disorders, 34 (3) • Baxendale et al (2003). Comparison of the effectiveness of the Hanen Parent Programme and traditional clinic therapy, International Journal Communication Disorders, 38 (4), 397–415

10. Gibbard (2004). Cost-effectiveness analysis of current practice and parent intervention for children under 3 years presenting with expressive language delay, International Journal Language Communication (39)2, 229–244 • Moller et al (2008). Implementation and evaluation of a parent training for language delayed children • Buschman et al (2009). Parent based language intervention for 2 yr old children with specific expressive language delay- a randomised controlled trial Arch Dis Child 2009 94: 110-116 • Law (1997). Evaluation intervention for language impaired children: a review of the literature. European Journal of Communication Disorders (32) 1-14

11. Articles • Boyle J, McCartney E, Forbes J, O’Hare A. A randomised control trial and economic evaluation of direct vs indirect and individual vs group modes of speech and language therapy for children with primary language impairment. Health Technology Assessment 2007: 11 (25)

12. Articles – Boyle et al. (Cont) • Participants: 163 school children aged 6-11yrs in Scotland below 10th percentile on CELF, normal IQ, no comorbidity • Experimental groups split into: • direct individual • direct group • indirect individual • indirect group • Controls received normal community health services

13. Articles – Boyle et al. (Cont) • Treatment group received 20hrs therapy across 15 weeks. Consistent program delivered to all groups (comprehension monitoring, vocabulary development, grammar, narrative therapy). • Results: • no significant difference at 12 months review between any of the groups • indirect group therapy was most cost-effective, but authors warn caution as this was reliant on high level of training and support for therapy aides in program

14. Articles – Boyle et al. (Cont) • Strengths: large RCT • Limitations: noted by authors • “when designing the therapy protocol used there was an overall lack of evidence on therapy effectiveness for this population” • study was unable to reach the intended number of participants for the initial power calculation • “language delay” was heterogenous- mixed receptive/expressive and levels of delay.

15. Articles – Gallagher & Chiat (2009) • Gallagher, A. & Chiat, S. 2009, Evaluation of speech and language therapy interventions for preschool children with specific language impairment: a comparison of outcomes following specialist intensive, nursery-based and no intervention. International Journal of Language and Communication Disorders, 44 (5), 616- 638.

16. Articles – Gallagher & Chiat (2009) (cont) • Participants: 24 preschoolers (3;6 4;1yrs) in London. Delay of 18 months or more (at least 2 standard deviations from the mean) on receptive and/or expressive language scores. No co morbidity. • Controls (n=8): from waiting list of local community health.

17. Articles – Gallagher & Chiat (2009) (cont) • Experimental group: 1) Intensive direct group therapy (n = 8) – with 2 speech pathologists, weekly appointments, 4 hours a week for 24 weeks. Total 96hrs contact with SP. 2) Indirect in class therapy (n = 8) – weekly sessions for 2 blocks of 6 weeks (joint sessions SP/preschool staff), classroom staff trained to continue therapy during break between blocks. Total 12 hrs direct. • Targeted linguistic concepts, grammatical markers, increasing utterance length, vocabulary and attention to adult lead tasks.

18. Articles – Gallagher & Chiat (2009) (cont) • Results: • Intensive treatment group vs. preschool consultation: intensive group showed statistically significant improvement in comprehension of grammar & vocabulary and expressive vocabulary & expressive information compared to psk gp. • Intensive treatment group vs. control: showed significantly more improvement on all language measures. • Preschool vs. control: significant improvements in comprehension of grammar, but not in other areas.

19. Articles – Gallagher & Chiat (2009) (cont) • Strengths: • Control group used (no intervention). Therapy targets & activities matched for both intervention groups. Therapy activities clearly described. • Limitations: • Teasing apart: different outcomes related to dosage, not intervention model? Limited motivation on classroom based staff, training was offered to teachers and carers, but was declined. Classroom staff were inconsistent week to week, which may have affected outcomes.

20. Articles – Gibbard Gibbard, D. (1994). Parental Based intervention with preschool language delayed children. European Journal of Disorders in Communication, 29, 131 -150. Participants – 35 children were recruited from a clinical population at Comm. Health Centre. Aged 2; 3  3;3 and had 30 or less single words. No comorbidity.

21. Articles – Gibbard (continued) • First Experiment- • 18 parents attended parent training sessions at Community Health once per fortnight for 6 months (11 sessions, approx 14 hours of therapy). Traditional language stimulation strategies. (2 groups) • Significant improvements in language skills found on Reynell, RAPT and mothers word lists • Showed consistent results from each group.

22. Articles – Gibbard (continued) • Experiment 2 • 17 children split into three groups • Direct individual Speech therapy • Indirect parental training (speech and language) • Indirect parental group (general cognition/non specific therapy) • No significant difference between direct and indirect language therapy. • Indirect language therapy (group) made significantly more gains than those who were in the non specific group.

23. Articles – Gibbard (continued) • Strengths: • Repeat testing of group model first to see if consistent gains were made from group to group • Community Health Setting • Limitations: • Small sample size

24. Articles – Baxendale & Hesketh (2003) • Baxendale, J. & Hesketh, A., 2003 Comparison of the effectiveness of the Hanen Parent Program and traditional clinic therapy. International Journal of Language and Communication Disorders, 38(4), 397 – 415.

25. Articles – Baxendale & Hesketh (2003) (cont) • Participants: 37 children aged 2:6  3:6 with diagnosed expressive language impairment (scores less than 81 on PLS-3). With or without receptive language impairment. No co-morbidity. English speaking Caucasian background.

26. Articles – Baxendale & Hesketh (2003) (cont) • Experimental group: • 19 children assigned to the Hanen Parent Program, 11 week program (8x 2.25 weekly group sessions and 3x home visits) by two trained SPs. • Control Group: 18 children assigned to traditional individual clinic based therapy with SP (number of sessions matched with Hanen). • Assessed pre-treatment, 6mths, 12mths. No therapy for 6mths following treatment.

27. Articles – Baxendale & Hesketh (2003) (cont) • Results: • At 6 mths: 42% of Hanen participants and 61% of individual therapy participants showed improvement in standard scores on PLS-3. • At 12 mths: 79% Hanen participants and 67% individual therapy participants showed improvement on standard scores. • No significant differences were found between each treatment group for parent interaction measures at 6 or 12 mth post-tx.

28. Articles – Baxendale & Hesketh (2003) (cont) • Results: • Trend: fewer children with expressive-only delay made improvement with Hanen group than children with rec/exp delay (but small numbers). • “Different families benefit from different types of therapy and should be selected accordingly” • Hanen more time/cost intensive (Hanen: 19-28hrs per child; Clinic: 4hrs-9hrs, av 8hrs).

29. Articles – Baxendale & Hesketh (2003) (cont) • Strengths of paper: Number therapy sessions matched for individual and group therapy. • Limitations: No control group, wide ranges of experience level in SP’s delivering individual therapy. Heterogenous language delays.

30. Clinical bottom line • The research reviewed showed gains in language abilities. • No significant difference identified between group and individual therapy. • Some differences identified between direct & indirect therapy, however these were usually related to training and motivation of the SP aides administering therapy (negative and positive effects).

31. Clinical bottom line (cont) • Cost effectiveness of group differed from study to study. Consideration if settings and demographics is required to ensure groups run effectively in the local clinical setting.

32. Current Clinical Practice • Sydney South West Area Health Service Hanen It Takes Two to Talk Quality Improvement Project. • SSWAHS is a very diverse community • High SP referral rates • High levels of global developmental delay and ASD. • High numbers of families with multiple children accessing SP Services • Evaluating the use of Hanen ITTT as a way to create a sustained change in the community.

33. Current Clinical Practice (cont) • Training of all SSWAHS SP’s in Hanen ITTT during 2010 and 2011. • Minimum of three Hanen ITTT groups will be run at each centre during 2010 – 2011. • Data collection on children referred to the service aged 0 – 3;0 • Three clinical pathways • 1) Hanen ITTT • 2) “Traditional” language groups • 3) Individual therapy

34. Current Clinical Practice (cont) • Data is collected on • Parents attitudes to groups (why do they chose to participate or not participate) • Time per client spent on therapy and preparation • Outcomes will be measured at the completion of the group (or equivalent period of time for individual) and eight months post initial assessment

35. Current Clinical Practice (cont) • Pre and post • standardised assessment measure of language • Macarthur Bates Communication Development Inventory. • Hanen Questionnaires • Parent Child Interaction Check • Parent Carer Self Rating Scales • Parent Satisfaction • Clinician Satisfaction

36. Current Clinical Practice • Northern Beaches Community Health – Early Language Playgroups, for preschoolers with language delays. • Focus on language development through parent training, group activities and individual activities. • Playgroup 1 services children aged 1;10  2:9 with less than 30 single words

37. Current Clinical Practice • Playgroup 2 services children 2;0  3;6 with 50 words, but limited two word combinations. • Group involve one parents only training sessions followed by 6 weekly group sessions with parents and children present.

38. Current Clinical Practice (cont) • Collecting pre and post data during 2010 • using first words and verbs checklists • parents use of language stimulation strategies • Preverbal development. (measures developed based on research during group development)

39. Current Clinical Practice (cont) • Data Analysis to date • Preliminary qualitative analysis in July 2010 • Play group 1: increased preverbal ability and increase in vocabulary noted • Playgroup 2: increased preverbal skills, increased vocabulary and increased lengths of utterance to more than two words.

40. Development of a new question • In reviewing the literature on service delivery models group vs. individual & direct vs. indirect was not typically the defining factor of success. • Significant effects may be present based on • Dosage (amount and frequency of therapy) • Motivation and training of therapist and therapists and therapy aides/assistants

41. Development of a new question • Articles reviewed also raised questions regarding the timing of intervention and the longitudinal maintenance of therapy gains (i.e. more than 12 months post therapy)

42. Where to from now…. • Next year, our meetings will be at • Bankstown Community Health Centre • Sydney Children’s Hospital Randwick • Please contact Sara Beckett: sara.beckett@sswahs.nsw.gov.au Ph: 9780 2772 if you are interested in joining us in our literature reviews.