Intervention for children with language impairment : findings from the Better Communication Research Programme

1. Intervention for children with language impairment : findings from the Better Communication Research Programme James Law and Sue Roulstone

2. What we have done Part of the �Best Evidence� project within the BCRP; We are bringing together the published evidence and the qualitative evidence from a survey of current clinical practice � using one to inform the other. So there will be a literature and a practice component; We are in the process of constructing a data base which will allow us to test both sets of data; This will lead to a self-help guide to the most appropriate literature to support your evidence based questions.

3. Best evidence - Literature component James Law, Biao Zeng

4. Literature In all, 26 systematic reviews were identified covering the full range of children with SLCN. These reviews drew on 797 ndividual papers (a proportion of which overlapped across reviews). The studies included in these reviews have already been vetted for quality. They include RCT s, quasi experimental group studies and experimental single subject designs. Three reviews had no studies in them and the largest single review had 132 studies (Law et al 1998) covering screening, natural history intervention and prevalence data. All of the 27 reviews have been published in peer reviewed journals or have been peer reviewed as part of the inclusion process in a data base such as the Cochrane or Campbell databases.

5. Literature Models of delivery Universal, targeted and specialist interventions Direct versus indirect interventions Mainstream versus special school intervention

6. Literature International Classification of disability (ICF) framework Dosage Active ingredients Co-morbidity Socio-economic disadvantage Social emotional and behavioural difficulties �

7. What does the literature not give you? The literature ascertained in this way does not give you every intervention study that has ever been published in the field (c10k); It only gives you literature that has been published, the assumption being that only the better material will be published; It does not include grey literature; It is often driven by researchers, reflecting funding sources; Rarely school based; Often provides a very controlled version of current practice.

8. Best evidence: practice component Sue Roulstone, Geoff Lindsay, Yvonne Wren, Ioanna Bakopoulou, Susan Goodlad

9. Aims... to identify range of interventions in use when, where and why they are used the outcomes targeted how the the outcomes are measured Aims: a) to identify the range of current services for children and young people with SLCN and the types of interventions in use, b) explore practitioners� underlying rationale for the use of interventions in a particular context (e.g. with a particular group of pupils) and indications of what outcomes practitioners hoped to achieve with the interventions, and c) investigate how outcomes of these interventions are evaluated in practice at a service level. Aims: a) to identify the range of current services for children and young people with SLCN and the types of interventions in use, b) explore practitioners� underlying rationale for the use of interventions in a particular context (e.g. with a particular group of pupils) and indications of what outcomes practitioners hoped to achieve with the interventions, and c) investigate how outcomes of these interventions are evaluated in practice at a service level.

10. How did we do it? Interviews 14 areas SLTs, educational psychologists, school improvement teams (n=46) Survey Cascaded via RCSLT managers and other networks 576 responses Mixed method, qualitative first to establish the range of depth of data, quantitative second to understand relationships bwteen programmes , targets and outcomes Qualitative 14 different areas: six shire counties, seven urban and one inner London Local Authorities (Las). In total, ten Educational Psychology Services (EPS) were interviewed and thirteen NHS Speech and Language Therapy Services (SLT) of which ten are matching. T Individual or group interviews 46 practitioners were interviewed: 12 Educational Psychologists, 25 Speech and Language Therapists, 3 Advisory Teachers for SLCN, 1 Head of Sensory Service, 2 Advisory Support Team Managers, 1 Learning Support Team Manager, 1 Communication and Interaction Team Manager, 1 Integrated Disability Service Manager. Quantitative The 27 who did not work with children were taken immediately to the last screen after they had completed the information about their work which thanked them for participating. The 13 who provided training only completed the questions on training only (not analysed yet) Mixed method, qualitative first to establish the range of depth of data, quantitative second to understand relationships bwteen programmes , targets and outcomes Qualitative 14 different areas: six shire counties, seven urban and one inner London Local Authorities (Las). In total, ten Educational Psychology Services (EPS) were interviewed and thirteen NHS Speech and Language Therapy Services (SLT) of which ten are matching. T Individual or group interviews 46 practitioners were interviewed: 12 Educational Psychologists, 25 Speech and Language Therapists, 3 Advisory Teachers for SLCN, 1 Head of Sensory Service, 2 Advisory Support Team Managers, 1 Learning Support Team Manager, 1 Communication and Interaction Team Manager, 1 Integrated Disability Service Manager. Quantitative The 27 who did not work with children were taken immediately to the last screen after they had completed the information about their work which thanked them for participating. The 13 who provided training only completed the questions on training only (not analysed yet)

11. Interviews Define SLCN Define universal, targeted, special What interventions are used Who with, and why What outcomes are targeted How are outcomes measured asking respondents to talk about how they defined groups of children with SLCN and also how they defined the terms �Universal�, �Targeted� and �Specialist�. They were then asked to list the interventions they use with children with SLCN in categories dependent on whether the intervention was targeting communication skills, language skills or speech skills. They were then asked to identify one intervention from each list to describe in detail. When time allowed, respondents were also asked to talk through a series of case examples to illustrate how a child with a a particular type of need might receive some of the interventions on offer. collecting documentation Interviewees were also asked to supply any policy documents relating to intervention and provision/prioritisation that might be relevant. asking respondents to talk about how they defined groups of children with SLCN and also how they defined the terms �Universal�, �Targeted� and �Specialist�. They were then asked to list the interventions they use with children with SLCN in categories dependent on whether the intervention was targeting communication skills, language skills or speech skills. They were then asked to identify one intervention from each list to describe in detail. When time allowed, respondents were also asked to talk through a series of case examples to illustrate how a child with a a particular type of need might receive some of the interventions on offer. collecting documentation Interviewees were also asked to supply any policy documents relating to intervention and provision/prioritisation that might be relevant.

12. Survey Clinical practice Caseload Interventions � published programmes, intervention activities, principles/approaches Outcomes � broad and specific, measurement and data collection Delivery of intervention Training and outcomes Types of question Clinical practice � asked about whether they worked directly with children or not, and if not, whether they delivered training to the children�s workforce Caseload � asked about age, SEN category (with SLCN split into SLCN � with speech as major difficulty, or language or communication), and setting of most typical chlid at this point in the survey, respondents were told � �so your most typical is (e.g.) a child aged 5-7 with SLCN with language as the main difficulty in a mainstream school� Interventions � split into these three broad types of intervention. Respondents were asked how frequently they used each intervention for the most typical child as they had previously identified in the survey. Respondents were then presented with a list of interventions which they had indicated they used most frequently and then were asked which intervention was the one they used the most out of the list presented. They were asked to respond to the next set of questions for this single most used intervention. Outcomes � they were asked which broad outcomes (speech, language, communication, fluency, other) they targeted when using this intervention (could tick as many as they wanted) They were then asked which specific outcomes they were targeting (e.g. under communication, turntaking skills). They were asked how they measured outcomes using this intervention and whether and how outcome data was collected at a service level. They were then asked questions about the delivery of the intervention that they had indicated they used the most (i.e. level of follow up from others, frequency, duration etc). For those who only provided training, they were asked questions about their frequency of use of particular training programmes and the outcomes that they collected from these. (not reported today � still to analyse) Types of question Clinical practice � asked about whether they worked directly with children or not, and if not, whether they delivered training to the children�s workforce Caseload � asked about age, SEN category (with SLCN split into SLCN � with speech as major difficulty, or language or communication), and setting of most typical chlid at this point in the survey, respondents were told � �so your most typical is (e.g.) a child aged 5-7 with SLCN with language as the main difficulty in a mainstream school� Interventions � split into these three broad types of intervention. Respondents were asked how frequently they used each intervention for the most typical child as they had previously identified in the survey. Respondents were then presented with a list of interventions which they had indicated they used most frequently and then were asked which intervention was the one they used the most out of the list presented. They were asked to respond to the next set of questions for this single most used intervention. Outcomes � they were asked which broad outcomes (speech, language, communication, fluency, other) they targeted when using this intervention (could tick as many as they wanted) They were then asked which specific outcomes they were targeting (e.g. under communication, turntaking skills). They were asked how they measured outcomes using this intervention and whether and how outcome data was collected at a service level. They were then asked questions about the delivery of the intervention that they had indicated they used the most (i.e. level of follow up from others, frequency, duration etc). For those who only provided training, they were asked questions about their frequency of use of particular training programmes and the outcomes that they collected from these. (not reported today � still to analyse)

13. Interventions �any action undertaken in an effort to improve a client�s circumstances with respect to a previously diagnosed communication disorder� (Dollaghan, 2007) explicit application of therapeutic/educational techniques intended to modify an individual�s performance in a designated area associated with communication (ie expressive language, attention etc) (Law et al, 1998) Interventions are defined in the literature as actions or techniques or activities or procedures (or indeed combinations of these) that reflect a shared aim to bring about an improvement or prevent a negative outcome related to a child�s speech, language and communication skills and can include the modification of factors that are barriers or facilitators to change. Words such as treatment, therapy, intervention, and remediation are used interchangeably although they carry slightly different connotations, some more medically oriented than othersInterventions are defined in the literature as actions or techniques or activities or procedures (or indeed combinations of these) that reflect a shared aim to bring about an improvement or prevent a negative outcome related to a child�s speech, language and communication skills and can include the modification of factors that are barriers or facilitators to change. Words such as treatment, therapy, intervention, and remediation are used interchangeably although they carry slightly different connotations, some more medically oriented than others

14. Interventions identified Published Programmes Intervention Activities Principles or Approaches to Intervention Service Developed Programmes Resources Training Models or Theories of Intervention Targets of Intervention

15. tell us about the age group of children (% OF RESPONDENTS) that they most frequently work with, the category of special educational need that they work with most, and the setting they most frequently work in. tell us about the age group of children (% OF RESPONDENTS) that they most frequently work with, the category of special educational need that they work with most, and the setting they most frequently work in.

16. Types of SEN

17. Setting

18. Interventions � published programmes For these questions, respondents were asked to answer in relation to the most typical child on their caseload, as identified from the caseload questions (for example � a child aged 5-7 with SLCN (language) in mainstream school). The data has not been analysed in relation to types of client yet but we do have information on frequencies of use of different types of intervention generally. Respondents were initially asked to indicate whether or not they used a particular intervention. If they indicated that they did use it they were asked whether they used it rarely, sometimes or frequently. The table here shows only the responses relating to the most frequently used interventions for published programmes. The table shows the top 15 out of a total of 40 in the list of published programmes presented in the survey. N of respondents = 536. Amongst the most frequently selected were �service developed programmes� (126 different programmes mentioned by 112 respondents)� i.e. programmes which were not published but which had been developed by their own service � and therefore were unlikely to have been subject to rigorous investigation for reasons of funding, resources for research and also bias as it would most likely be tested by those who developed it. Many of those service developed programmes listed used components of other therapy approaches (e.g. phonological awareness activities) and these aspects would have been investigated in other studies. The service developed programme ranged from fully developed packages with their own titles to comments such as �I make my own programmes�. Given the number of published programmes available, the high number of service developed programmes, and the descriptions of these service developed programmes, suggests a lot of overlap between them. I.e. a lot of people seem to be spending a lot of time developing new packages of intervention which perhaps share many features. Regarding other published programmes, 96 people mentioned 162 other published programmes. However the comments included resources (e.g. Black Sheep Press materials, color cards, Earobics, Lexion), training materials (e.g. Elklan), therapy approaches/strategies rather than published programmes (e.g. PGSS, Cued artic) and provision (e.g. Early Bird). At this stage, respondents were not aware of the subsequent questions in which they would have been able to select some of these options. However it is of interest to see how people classify interventions and to see that there is some discrepancy in how individuals use the term. I.e. is a resource an intervention in itself � when in fact there are numerous ways in which you could use that resource to deliver different interventions. This highlights the need to be cautious in how we interpret people�s comments on the content and delivery of their interventions as two people who say they use Black Sheep Press to work with chidlren with language impairment could be doing very different things. For these questions, respondents were asked to answer in relation to the most typical child on their caseload, as identified from the caseload questions (for example � a child aged 5-7 with SLCN (language) in mainstream school). The data has not been analysed in relation to types of client yet but we do have information on frequencies of use of different types of intervention generally. Respondents were initially asked to indicate whether or not they used a particular intervention. If they indicated that they did use it they were asked whether they used it rarely, sometimes or frequently. The table here shows only the responses relating to the most frequently used interventions for published programmes. The table shows the top 15 out of a total of 40 in the list of published programmes presented in the survey. N of respondents = 536. Amongst the most frequently selected were �service developed programmes� (126 different programmes mentioned by 112 respondents)� i.e. programmes which were not published but which had been developed by their own service � and therefore were unlikely to have been subject to rigorous investigation for reasons of funding, resources for research and also bias as it would most likely be tested by those who developed it. Many of those service developed programmes listed used components of other therapy approaches (e.g. phonological awareness activities) and these aspects would have been investigated in other studies. The service developed programme ranged from fully developed packages with their own titles to comments such as �I make my own programmes�. Given the number of published programmes available, the high number of service developed programmes, and the descriptions of these service developed programmes, suggests a lot of overlap between them. I.e. a lot of people seem to be spending a lot of time developing new packages of intervention which perhaps share many features. Regarding other published programmes, 96 people mentioned 162 other published programmes. However the comments included resources (e.g. Black Sheep Press materials, color cards, Earobics, Lexion), training materials (e.g. Elklan), therapy approaches/strategies rather than published programmes (e.g. PGSS, Cued artic) and provision (e.g. Early Bird). At this stage, respondents were not aware of the subsequent questions in which they would have been able to select some of these options. However it is of interest to see how people classify interventions and to see that there is some discrepancy in how individuals use the term. I.e. is a resource an intervention in itself � when in fact there are numerous ways in which you could use that resource to deliver different interventions. This highlights the need to be cautious in how we interpret people�s comments on the content and delivery of their interventions as two people who say they use Black Sheep Press to work with chidlren with language impairment could be doing very different things.

19. Interventions � intervention activities In terms of intervention activities, i.e. discrete activities which might be used as part of a therapy programme but which are not part of published programme and neither are they strategies which are required to be used with a child as part of everyday interaction with them. This table has the complete list of activities which were presented to respondents, again only the figures relating to �use frequently� are shown. Of �other intervention activities�, 109 people mentioned 133 intervention activities. These covered a very wide range of activities but included programmes, some of which had been listed in the previous question (e.g. nuffield, TEACCH, the listening programme), resources (e.g. semantic links) theories (e.g. psycholinguistic framework), and some non-specific responses (e.g. language activities, group work, �I devise my own�) In terms of intervention activities, i.e. discrete activities which might be used as part of a therapy programme but which are not part of published programme and neither are they strategies which are required to be used with a child as part of everyday interaction with them. This table has the complete list of activities which were presented to respondents, again only the figures relating to �use frequently� are shown. Of �other intervention activities�, 109 people mentioned 133 intervention activities. These covered a very wide range of activities but included programmes, some of which had been listed in the previous question (e.g. nuffield, TEACCH, the listening programme), resources (e.g. semantic links) theories (e.g. psycholinguistic framework), and some non-specific responses (e.g. language activities, group work, �I devise my own�)

20. Outcome measurement Respondents were asked what sort of measurement tools are typically used to measure outcomes for their given intevrention. They were invited to select all that applied. The two most frequently selected methods of outcome measurement were subjective. Objective assessments were selected by just under half of all respondents. Two-thirds (66% or 181 of the responding 536 SLTs) said that they did not submit data on outcomes to their head of service for service level outcome measurement, compared to just over a third (34% or 181/536). Of the third that did, 157 specified which measures they used. The most frequently cited was EKOS or EKOS based systems (64 mentions). Respondents were asked what sort of measurement tools are typically used to measure outcomes for their given intevrention. They were invited to select all that applied. The two most frequently selected methods of outcome measurement were subjective. Objective assessments were selected by just under half of all respondents. Two-thirds (66% or 181 of the responding 536 SLTs) said that they did not submit data on outcomes to their head of service for service level outcome measurement, compared to just over a third (34% or 181/536). Of the third that did, 157 specified which measures they used. The most frequently cited was EKOS or EKOS based systems (64 mentions).

21. Delivery of intervention -pattern Respondents were asked questions about how their most frequently used intervention was typically delivered to the most typical child on their caseload. The most selected option for pattern of delivery was that the respondent delivered the intervention regularly but that others delivered if more frequently between their visits. Typically it was either a parent or teaching assistant who assisted in delivering the intervention and they were expected to deliver the intervention either throughout the day or two or three times a week. Respondents were asked questions about how their most frequently used intervention was typically delivered to the most typical child on their caseload. The most selected option for pattern of delivery was that the respondent delivered the intervention regularly but that others delivered if more frequently between their visits. Typically it was either a parent or teaching assistant who assisted in delivering the intervention and they were expected to deliver the intervention either throughout the day or two or three times a week.

22. Delivery of intervention - frequency In terms of how frequent the respondent typically saw their client, almost half were seeing the most typical child on their caseload for delivery of their most typical intervention on a weekly basis. (this surprised me � especially as the most typical child was a child aged 5-7 with SLCN (language) in mainstream school � in Bristol it would be more typical to see a child like this once a term or once a double term � arguably either better or worse � dependent on your view an the evidence for the given intervention)In terms of how frequent the respondent typically saw their client, almost half were seeing the most typical child on their caseload for delivery of their most typical intervention on a weekly basis. (this surprised me � especially as the most typical child was a child aged 5-7 with SLCN (language) in mainstream school � in Bristol it would be more typical to see a child like this once a term or once a double term � arguably either better or worse � dependent on your view an the evidence for the given intervention)

23. Delivery of intervention - duration However although typically a chlid would be seen weekly, the most selected duration was one term suggesting that children might be seen weekly but only for six weeks (less than the 8 weeks minimum recommended duration/frequency from the evidence). A substantial number of respondents did report seeing their most typical clients for longer than this. However although typically a chlid would be seen weekly, the most selected duration was one term suggesting that children might be seen weekly but only for six weeks (less than the 8 weeks minimum recommended duration/frequency from the evidence). A substantial number of respondents did report seeing their most typical clients for longer than this.

24. Key programme elements

25. Key programme elements: PECS Applied Behaviour Analysis Complex � Pyramid approach to education Why, what and how of learning What and why? Functional objectives Powerful reinforcement system Communication and social skills Preventing inappropriate behaviours How? Generalisation Designing effective lessons Specific teaching strategies Minimizing and correcting errors Overall approach comes from applied behaviour analysis � behaviour is lawfully related to environmental factors; PECS has as its central tenet: pyramid approach to education � science of learning (why), the what � goals and the how (designing lessons) What and why? Functional objectives (ie meaningful communication as the goal and meaningful materials) Powerful reinforcements systems (meaningful to the student, natural to the situation, timely, making deals) Communication and social skills (involves speaker and listener, a social outcome of communication, initiation vs responding vs imitation) Preventing and reducing contextually inappropriate behaviours How? Generalisation � changing goals and expectations by �just noticeable differences� Designing effective lessons (relevant to the type of lesson and goal) Specific teaching strategies (prompts, cues, shaping) Minimizing and correcting errors (4 step error correction procedure) Overall approach comes from applied behaviour analysis � behaviour is lawfully related to environmental factors; PECS has as its central tenet: pyramid approach to education � science of learning (why), the what � goals and the how (designing lessons) What and why? Functional objectives (ie meaningful communication as the goal and meaningful materials) Powerful reinforcements systems (meaningful to the student, natural to the situation, timely, making deals) Communication and social skills (involves speaker and listener, a social outcome of communication, initiation vs responding vs imitation) Preventing and reducing contextually inappropriate behaviours How? Generalisation � changing goals and expectations by �just noticeable differences� Designing effective lessons (relevant to the type of lesson and goal) Specific teaching strategies (prompts, cues, shaping) Minimizing and correcting errors (4 step error correction procedure)

26. Thinking about the evidence base Should we look at evidence that evaluates PECS as a system? Should we look for evidence that evaluates the components of PECS?

27. The development of user friendly database of the �best evidence� Next stage is to fuse the two sources of information � what we know about effectiveness and what people do in schools and clinics Start with a template of key feature s which we can apply to both sets of data; Enter in the intervention studies and the programmes and practice features which SLTs and researchers think are useful

28. The structure of the data base

30. Other possibilities We could create a WIKI site where individuals can post papers which they have found especially helpful or programme where there is an emerging evidence base; We could develop a series of summaries around specific issues � computerised interventions for language impairment, parent/child interaction interventions for young children who stammer etc. Would this be interesting and sustainable? Would there be value in having free text searching � ie searching for evidence about specific programme? Who would use it?

32. Acknowledgements Thank you to all the teachers, educational psychologists and therapists for participating in this research programme