Speech, Language and Communication Training for Health Visitors

1. Speech, Language and Communication Training for Health Visitors Developed by the Institute of Health Visiting in partnership with; ESRC Centre for Language and Communicative Development (LuCiD), TCT, ICAN, The National Literacy Trust, Representatives from RCSLT; Language for Life / Nottinghamshire NHS Trust, Worcestershire Health Care NHS Trust, “Time to Talk “/ South Warwickshire NHS Foundation Trust, Salford Royal NHS Foundation Trust, PHE Expert Advisory Group. Second version – May 2019

2. Background • The project is part of the Department for Education Social Mobility Action Plan: Unlocking Talent, Fulfilling Potential (2017) • Public Health England (PHE) are leading a programme of work including: • Training health visitors • Provision of an early assessment tool and its evaluation • Guidance to Local Authorities to support the development of evidence-based SLCN pathways • The Institute of Health Visiting has been commissioned to deliver the training to 1,000 health visitors over 2019, who will cascade the training to their workforce. • The programme will be fully evaluated for PHE using a range of methods PHE Speech, Language and Communication Training for Health Visitors

3. Aim of the training • To equip health visitors with additional skills and knowledge to support families in promoting early language acquisition in the home learning environment, to support improved health and wellbeing outcomes including school readiness • This will include clarity regarding timely and appropriate referrals and pathways for children when speech, language and communication needs are identified PHE Speech, Language and Communication Training for Health Visitors

4. Learning outcomes • To increase your knowledge of; • Typical /non-typical speech, language and communication development in all children • The impact of speech, language and communication needs on long-term health and wellbeing outcomes for children • Application of evidence-based strategies to promote speech, language and communication development with all children and families DHE Speech, language & Communication workshop for Health Visitors

5. Learning outcomes • Be confident and able to: • Identify risk factors for speech, language and communication needs (SLCN) through your assessment • Use evidence-based strategies to support families when a SLCN is identified and consider methods to demonstrate impact of the interventions • Identify and refer children with SLCN to speech therapy and/or local evidence based services PHE Speech, Language and Communication Training for Health Visitors

6. Why Health Visiting? • Health visitors; • Lead the Healthy Child Programme and work across 4 levels of service to meet needs • Deliver a universal service to all families • Have specialist public health knowledge and skills in assessing need • Have opportunities to promote language development with families • Can offer timely interventions through established relationships with families • Work within the home and can promote this as a learning environment. • What is the need for additional training? • In a national survey 96% of Health Visitors told us you would like more training on SLC, Specifically you wanted more on the evidence to support your role and approaches to work effectively with families to promote early language acquisition. PHE Speech, Language and Communication Training for Health Visitors

7. Why does SLC matter? 3x more 81% 1 in 4 1.4 million 10% up to 50% 60% 2x more “Communication is crucial to children’s life chances”Bercow (2018) “Reducing income-related learning gaps therefore requires a comprehensive approach, providing age appropriate support to all levels of need” (EIF, 2018) PHE Speech, Language and Communication Training for Health Visitors

8. Headlines from policy and research • The Home Learning Environment (DfE, National Literacy Trust, 2018) - • importance to narrow the word gap, Chat, Play, Read • Language as a Child Wellbeing Indicator (EIF, 2017)evaluates the link between language acquisition and life chances • High Impact Area 6, (PHE, 2018) - wellbeing and development of the child aged 2: Ready to learn, narrowing the word gap; health visitors leading • Bercow 10 Years On, (2018)services are inaccessible and inadequate; SLCNs unidentified; need for early identification; need for training • “Things, people, numbers and words” (EIF, 2018) the importance of early intervention to develop children’s understanding including supportive factors and the importance of the caregivers and child-directed speech PHE Speech, Language and Communication Training for Health Visitors

9. Universal level of service PHE Speech, Language and Communication Training for Health Visitors

10. Speech, language and communication • Speech, language and communication are central life skills. They are linked to social and emotional development, learning, attainment, behaviour, as well as mental health and wellbeing. • So what are we talking about when we say: Language Speech Communication PHE Speech, Language and Communication Training for Health Visitors

11. The Tree of Language Respond Listen Fruit literacy Leaves saying words clearly Branches using words and sentences Trunk understanding Roots attention and listening Soil play and interaction PHE Speech, Language and Communication Training for Health Visitors

12. Early language development Early language can follow different trajectories of development Single words develop into sentences. Complex sentence structure and abstract thought come later Babbling and single sounds Pointing is a significant milestone Crying and cooing form the basis of early communication Language development starts before birth: babies are born ready to communicate Speech, language and communication provide a foundation for children to be understood, learn, develop, build relationships and socially interact with others PHE Speech, Language and Communication Training for Health Visitors

13. Communication skills develop from birth (P.O.Svanberg 2010) PHE Speech, Language and Communication Training for Health Visitors

14. Key components of language development • Social communication and use of language – child realises they can use language to communicate; interested in stories, can talk about feelings • Attention and listening– developed gradually, vital in turn-taking for communication and to develop auditory sequential memory • Understanding– receptive language develops understanding of who, what, where, why and how • Talking – expressive language – gradually increases vocabulary, using nouns, adjectives and verbs to help development of sentence structure. • By 3 yrs should be using 300+ words; By 5 yrs should have 3000 to 5000 • words! • The quality of input that children receive is likely to be more important than the quantity • Reference www.thecommunicationtrust.org.uk/universally.speaking PHE Speech, Language and Communication Training for Health Visitors

15. The ages and stages of language development – related to health visitor universal contacts. • From 24 weeks gestation Children’s language development begins in the womb at approximately 24 weeks gestation, the unborn child can first hear and discriminate the sounds of their family’s voices • From birth - 8 weeks Babies respond to faces and mirror expressions; make noises to get attention; quiet alert state, bright face; wide-eyed, with still body (refer to Baby states) • From 9-12 months Babble strings of sounds; point and show toys; start to understand ‘bye-bye’ and use gesture; recognise familiar words and name; use talking sounds to respond or get attention • From 1- 2 years: Use 50 or more single words; join two words; understand between 200-500 words; enjoy pretend play; become frustrated when cannot communicate feelings • For all stages please refer to: DfE Home Learning Environment table 2, ECAT Speech, Language and Development chart child monitoring tool and play ideas or at:www.talkingpoint.org.uk PHE Speech, Language and Communication Training for Health Visitors

16. English as an additional language • Bilingualism and multilingualism are assets • Families /carers need to speak to children in the home language, which helps the child learn other languages • Children learning a new language often go through ‘the silent phase’ of 2-3 months. This is a normal part of development. • It can take up to 2 years to develop conversational English • There is NO evidence to suggest that learning English as an additional language will cause delay in the development of speech, language or communication • 10% of ALL children will have long-term SLCN, children with EAL are as likely to have these needs as those with English as the first language. Assessment should be in the home language using an interpreter PHE Speech, Language and Communication Training for Health Visitors

17. Strategies to support language development PHE Speech, Language and Communication Training for Health Visitors

18. Foundations of child development (EYFS,2017) PHE Speech, Language and Communication Training for Health Visitors

19. Importance of the Home Learning Environment • ..the child’s communication environment was a more important predictor of language development at two, and school entry ‘baseline’ scores at 4 than socio-economic background. • Roulstone et al (2011) PHE Speech, Language and Communication Training for Health Visitors

20. The Home Learning Environment 0-6 months: • Connect to Wifi • CTRL & Click on the hyperlink below • https://youtu.be/EgelYRuhIJE PHE Speech, Language and Communication Training for Health Visitors

21. The Home Learning Environment 2-3 years: • Connect to Wifi • CTRL & Click on the hyperlink below • https://youtu.be/11Kauf2far0 PHE Speech, Language and Communication Training for Health Visitors

22. The Home Learning Environment (HLE) • The Department of Education and the National Literacy Trust (2018) advocate a behavioural approach to encourage families to chat, play and read more. Capability Chat: encourage talking but crucially, reciprocal communication; Play: language thrives when children interact and explore in a playful and creative manner; Read: sharing books, parents and children talking together. Opportunity Behaviour Motivation (Michie et al,2014) PHE Speech, Language and Communication Training for Health Visitors

23. The Home Learning Environment (HLE) • Connect to Wifi • CTRL & Click on the hyperlink below • https://youtu.be/z073fQLaIuA PHE Speech, Language and Communication Training for Health Visitors

24. Importance of child/adult relationships • Relationship and responsiveness of adult – to early gestures; serve and return, contingent talk • “Parentese” – Rhythm and repetition are important factors across all languages for babies to develop word pattern and engage in communication • Child directed speech - Maximising talk during everyday routines to provide opportunities for their child to hear language used in clear and predictable ways is the most important factor for language development • Gesture– holding out gestures and pointing gestures should be used widely by 8-12 months; and are closely associated with early language learning • Attunement – recognising baby’s attempts to communicate and turn-taking • Mind-mindedness – the ability to see things from the child's perspective • NB: References in pack PHE Speech, Language and Communication Training for Health Visitors

25. What’s it like to be a small person? • In pairs : activity • Selected person to talk for one minute to their partner about something they are excited about PHE Speech, Language and Communication Training for Health Visitors

26. The importance of face-to-face Eye contact Attunement Responsiveness Mirroring PHE Speech, Language and Communication Training for Health Visitors

27. Encourage early gesture development Talk to baby using gesture to link words to actions From 9 months, babies use intentional gesture More early gestures can lead to more words later Babies gesture more with encouragement With thanks LuCiD Ref: Cameron-Faulkner et al. (2015, Infancy), and Colonnesi et al. (2010, Dev Review), McGillion et al. (2013, IEEE) PHE Speech, Language and Communication Training for Health Visitors

28. Joint Attention: engaged with both toy and infant. Toy Attention: engaged with toy only. “Are you showing me the toy? That’s fantastic!” “Wow you’re good at shaking that toy!” “This toy is red and grey and makes a good noise!” “Wow there’s lots of colours and shapes!” Infant Attention: engaged with infant only. Ignore: ignored with non-contingent utterances. “You are doing a great job sitting in the highchair!” “Wow you’re in a good mood today!” “I really must check my emails after this!” “Wow what lovely weather outside!” Boundy et al. (2018, Infancy) PHE Speech, Language and Communication Training for Health Visitors

29. What helps? Child-directed language Children who hear language directed towards them specifically go on to make more gestures and have a wider vocabulary Adults are role models of eye contact and turn-taking and communication and listening Maximising talk during everyday routines to provide opportunities for their child to hear language used in clear and predictable ways (Shneidman, Arroyo, Levine, Goldin-Meadow, 2013) PHE Speech, Language and Communication Training for Health Visitors

30. Strategies - on to words and sentences Copy and add on Comment Questioning Labelling EIF(2017) PHE Speech, Language and Communication Training for Health Visitors

31. Summary of evidence-based strategies • Chat, play and read at every opportunity with consideration of the following: • Sharing experiences in the home learning environment • Quality of the conversations with a child • Sensitivity to the child’s language level • Baby cues and baby states • Importance of gesture • Contingent responses of the adult to the child, serve and return • Mind-mindedness • Infant directed speech, parentese • The importance of play and shared attention • Managing distractions • Opportunities for interaction with other children - promotion of the 2 year offer • Adapted from Gross,J (2018); EIF (2018) PHE Speech, Language and Communication Training for Health Visitors

32. Key strategies to support development Pregnancy: • Connect to Wifi • CTRL & Click on the hyperlink below • https://youtu.be/ODTY-iYYJNU PHE Speech, Language and Communication Training for Health Visitors

33. Key strategies to support development From birth • Connect to Wifi • CTRL & Click on the hyperlink below • https://youtu.be/PZcdPhQp2W8 PHE Speech, Language and Communication Training for Health Visitors

34. Key strategies to support development As they develop • Connect to Wifi • CTRL & Click on the hyperlink below • https://youtu.be/XIQ6e37rnyc PHE Speech, Language and Communication Training for Health Visitors

35. Universal Plus and Partnership Plus PHE Speech, Language and Communication Training for Health Visitors

36. Children with Speech, Language and Communication Needs (SLCN) 7.6% Specific SLCN • SLCN is the most under-identified SEN, but the most common,10% of children have long term SLCN that needs support. Robust, early identification is essential. Developmental language disorder (7.6%), Other conditions including: Cleft lip & palate; autism, dyspraxia, hearing impairment; speech difficulties such as stammering (2.3%) 3-5% Associated developmental delay Children with language delay associated with developmental delay, usually requiring SLT advice and monitoring but language can only improve at the same rate as their general development Vulnerable Children with a complex combination of home environment and within-child factors. Some require general advice and some more intensive and some SLT Up to 50% of children starting school in the most disadvantaged areas PHE Speech, Language and Communication Training for Health Visitors

37. Developmental Language Disorder SLCN Learning Difficulties Dyslexia ADHD Dyspraxia SLCNs - a summary Language Disorder Speech Disorder Dysarthria (cerebral palsy) Verbal dyspraxia Articulation difficulties Cleft Palate Grammar Word finding Vocabulary Social skills phonology ASD stammering voice disorders PHE Speech, Language and Communication Training for Health Visitors

38. What is DLD? PHE Speech, Language and Communication Training for Health Visitors

39. PHE, Speech, Language and Communication Training for Health Visitors (Law J, in EIF (2017) Language as a Child Wellbeing indicator)

40. Risk factors (Asmussen, Law et al 2018) PHE Speech, Language and Communication Training for Health Visitors

41. Supportive factors associated with SLCN PHE Speech, Language and Communication Training for Health Visitors (Asmussen, Law et al 2018)

42. Factors related to difficulties in speech, language and communication Access to enriching Early years provision Quality of parent child interaction Learning disabilities Inherited/ biological factors Environmental factors Socio-economic status Developmental language delay Access to resources: books, toys educational experiences Preterm birth “Word gap” -exposure to fewer quality conversations Being a boy Sensori-neural losses The right environmental support can make a real difference to how a child learns language Early Language: An indicator of child well being

43. Flags for review Adapted from Ebbels et al (2019) and CATALISE, (2016) PHE Speech, Language and Communication Training for Health Visitors

44. Supporting SLC development • Consider what helps and what might get in the way of speech language and communication development group activity ??? PHE Speech, Language and Communication Training for Health Visitors

45. No shortage of theories Dummies Mobile phones Screen time Adapted from slide courtesy of Jean Gross (2017)

46. Assessment as a tool • Assessment needs to be integrated into all contacts and part of core practice • The best assessments are seen as part of a conversation with a family and carried out in partnership • Really important to consider - what you are assessing? • Parent-child interactions • Developmental progress in line with milestones (DfE table 2, ICAN Wall Chart, The Communication Trust progress checker) • Family use of strategies for SLCD • Risk factors • Flags for review PHE Speech, Language and Communication Training for Health Visitors

47. The importance of effective communication in building a therapeutic relationship • Effective interpersonal skills are essential to forming successful relationships to support your work in partnership with the family • Relationship factors are one of the strongest predictors of positive outcomes from the interventions and advice you offer • It is important that you draw upon your effective communication strategies • O.A.R.S. (O = Open Questions A = Affirmations R = Reflective Listening S = Summarising) is a skills-based model which uses motivational interviewing principles. Both verbal and non-verbal skills need to be modified in order to be culturally sensitive PHE Speech, Language and Communication Training for Health Visitors

48. Asset-based approaches – Universal Plus and Partnership Plus • A need is identified, how can you help and what should you do next? • Ask the parent what they think - have they any concerns – consider how and when to do this • Consider what is working already set shared goals with the parents • Consider who else can offer support as part of the early years offer – what is available in your area • Consider local services and support including SLT • Consider how you continue to work with the family alongside the referral process to continue to support the strategies we talked about earlier • Ensure you have consent for information sharing with other agencies PHE Speech, Language and Communication Training for Health Visitors

49. Sources of support for SLCN • National and local pathways, including the new National Pathway being developed • Local partner providers including; speech and language therapists, voluntary groups, early education and child care providers, children's centre • The family and the community • Colleagues in your organisation • National organisations including; ICAN, TCT; National Literacy Trust, RCSLT PHE Speech, Language and Communication Training for Health Visitors

50. Your local provision • In your slide set for your training you will find this blank template for you to personalise with your own local resources for children with SLCN • Consider SLT, Early years and Children Centres, Voluntary Sector Providers all of whom can offer support and activities for families PHE Speech, Language and Communication Training for Health Visitors