Paediatric Language Therapy: Cheese on toast or chocolate cake?

1. Paediatric Language Therapy: Cheese on toast or chocolate cake? Paediatric Language Group

2. Paediatric Language Group: Recap • Last year we looked at service delivery ie: group vs individual direct vs indirect • Outcomes: Therapy is good, but no clear difference between service modes (eg some studies group therapy was cheaper, other studies group therapy more expensive) • Differences in outcome of therapy related to: intensity of therapy what kind of therapy rather than service delivery.

3. Question for this year was: • In children 0-6 years, what is the optimum intensity of treatment in treating Specific Language Impairment?

4. Current Question - Literature Search Cirrin, Frank M; Gillam, Ronald B. (2008): Language Intervention Practices for School-Age Children With Spoken Language Disorders: A Systematic Review Language, Speech & Hearing Services in Schools 39. 1 110-37. Mendelsohn, Alan L; Mogilner, Leora N; Dreyer, Bernard P; Forman, Joel A; et al (2001). The impact of a clinic-based literacy  intervention  on language development in inner-city preschool children Pediatrics107. 1: 130-4.  Gillam, Ronald B; Loeb, Diane Frome; Hoffman, LaVae M; Bohman, Thomas; Champlin, Craig A; et al. (2008): The Efficacy of Fast ForWord Language Intervention in School-Age Children With Language Impairment: A Randomized Controlled TrialJournal of Speech, Language, and Hearing Research51. 1 97-119. 

5. Current Question - Literature Search Swanson, Lori A; Fey, Marc E; Mills, Carrie E; Hood, Lynn S. (2005) Use of Narrative-Based Language Intervention With Children Who Have Specific Language Impairment American Journal of Speech - Language Pathology 14. 2 : 131-43.  Warren, Steven F; Fey, Marc E; Finestack, Lizbeth H; Brady, Nancy C; Bredin-Oja, Shelley L; et al. (Apr 2008) A Randomized Trial of Longitudinal Effects of Low-Intensity Responsivity Education/Prelinguistic Milieu TeachingJournal of Speech, Language, and Hearing Research51. 2 451-70. 

6. Current Question - Literature Search Brinton, Bonnie; Fujiki, Martin. (2006)  Social Intervention for Children With Language Impairment: Factors Affecting Efficacy Communication Disorders Quarterly28. 1: 39-41,62.   Paul, Diane; Roth, Froma P. (2011) Guiding Principles and Clinical Applications for Speech-Language Pathology Practice in Early InterventionLanguage, Speech & Hearing Services in Schools (Online)42. 3 : 320-330A. 

7. Problems • Definitions of dosage/ intensity different in different articles. • Not many articles directly looking at intensity/dosage • Generally only mentioned as part of other investigations. • Many different treatment types targeting SLI

8. Current Question • 3 review articles • Dosage in language therapy • Narrative intervention summary • Dosage & distribution in morphosyntax intervention summary

9. Article • Warren S, Fey M, & Yoder P. Differential treatment intensity research: a missing link to creating optimally effective communication interventions. Mental Retardation and Developmental Disabilities 2007: 13, 70-77 • research review & discussion paper • noted that in general therapy is effective • general consensus that early intervention is effective • in medical research dosage is clearly defined, in communication research it is not • different definitions for treatment intensity eg: • quality and quantity of services in a given time • number of hours of intervention in specific time period • level of participation in a service offered over time • ratio of adults: children in intervention context • number of specific teaching/therapeutic episodes per unit of time

10. no consensus on unit of measurement used across time • argument for standardising terminology (similar to medical fields) • 4 factors proposed to consider when defining “cumulative intervention intensity”: (multiply these together) • dose: the number of properly administered teaching episodes during a single session of intervention X • dose form: ‘active ingredient’ ie typical task or activity within which the teaching episodes are delivered eg structured drills, prompts for imitation X • dose frequency: number of times a dose of intervention is provided per day and per week X * • total intervention duration: time period over which a specified intervention is presented X * • *usually well defined in research • studies of each intervention type should look to define “cumulative intervention intensity”

11. Morphosyntax Intervention • Proctor-Williams, K. (2009) Dosage and distribution in morphosyntax intervention: current evidence and future needs. Topics in Language Disorders, 29, 294-311 • Review article • Outlines & evaluates dose forms and intervention contexts used to facilitate morphosyntactic acquistion. • Evaluates research outcomes and provides examples of dosage components • Identifies lack of systematic comparisons of dosage forms and measurement in research

12. Dose forms • Techniques: • Time delay/slow rate • Model • Recast • Expansion • Imitation/mand • Imitation/feedback • Question • Direct instruction

13. Dose forms cont… • Procedures: • May combine 2 or more techniques • Effects may be additive or may negate effectiveness of one another • Order of presentation of techniques within procedure may be important to efficacy • Intervention contexts: • Child centred • Hybrid • Clinician directed

14. Dosage • Distribution within session • Dose frequency: • eg optimal frequency of recasts. • occur 3.5 times more frequently in therapy than available in child’s typical environment. • children whose parents used higher rates of recasts showed greater gains. • parents had difficulty sustaining high rate of recasts as children’s language improved

15. Hoffman, LM Narrative Language Intervention Intensity and dosage (2009). Topics in Language Disorders 29 (4), 329-343 • Responded to Warren, Fey and Yoder’s (2007) article by beginning to define the “active ingredients” in Narrative Intervention • Proposed further investigations into the teaching of • Episodic Structure • Reading & Interest Levels • Genre • Discourse Level Teaching and Performance • Inference/moral/culture • Suggested we need to further clarify the “potent point” or active ingredients before we are able to monitor dosage.

16. Massed or Distributed Practise? Riches, NG, Tommasello, M, Conti-Ramsden, G. Verb Learning in Children with SLI: Frequency and Spacing Effects. Journal of Speech Language and Hearing Research 2005: 48, 1397-1411 Experimental group : 24 children with SLI (mean age 5;6) -1SD on CELF-P & normal intelligence Control group: 24 children with typically developing language & intelligence (mean age 3;4) All excluded hearing loss, social and emotional difficulties & Bilingualism No significant difference in MLU, “Talkativeness”, British Picture Vocabulary Test. SLI group performed slightly better on the Expressive Vocabulary Test

17. Riches et al 2005 continued • Modelled three novel verbs for a range of actions in play sessions • “Look, it’s VERBing! See, it VERBs!” • 2x2 experimental design combining 2 training regimes (massed and spaced) • (a) Massed 12, with 12 exposures on a single day, • (b) Massed 18, with 18 exposures on a single day, • (c) Spaced 12, with 12 exposures spread over 4 days (3 per day), and • (c) Spaced18, with 18 exposures spread over 4 days (4,5,4,5).

18. Riches et al 2005 continued • Post Test (immediately after final presentation) & • Retention Test (one week after final presentation) • No significant difference between Control and experimental groups overall • Significantly better post test learning in children in the spaced trials • Retention was significantly lower in the SLI group • But: • Significantly better retention in Spaced groups • Spaced practices made a bigger difference in learning for the SLI group.

19. Riches et al 2005 continued • Clinical Bottom Line • Distributed practise leads to better learning and retention in all children (for verb learning), but it is particularly important for children with SLI

20. Clinical bottom line • Therapy is good • Distributed practice is more effective than massed practice • Active ingredients not clearly enough defined in the literature

21. Clinical practice • Surveys of clinicians also indicate therapists are not able to clearly define their active ingredient • Everyone is doing a good job, kids are achieving goals but we are not good at explaining what we are doing when we say ‘we are doing language therapy’ • Language therapy isn’t simple like cheese on toast, it’s complicated like chocolate cake. We need to be better at explaining HOW we made our chocolate cake so that other people can also make fantastic chocolate cake too!!