resource manual for commissioning and planning services

© RCSLT 2009

Resource Manual for Commissioning and Planning Services for SLCN Professor Pam Enderby Dr Caroline Pickstone Dr Alex John Kate Fryer Anna Cantrell Diana Papaioannou

Resource Manual for Commissioning and Planning Services for SLCN

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Acknowledgements The RCSLT and the Project Team would like to thank all those who assisted in drafting this guidance. We have received valuable advice from many reviewers from within the speech and language therapy profession who have given up their time generously. Experts on particular topic areas from related professions have also been consulted and assisted with detail. Service Commissioners and senior managers have commented on drafts showing patience and fortitude! We would particularly like to thank the many who contributed to the focus groups which helped to shape this document.


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Resource Manual for Commissioning and Planning Services for SLCN CONTEXT The aim of this section is to set out the context for this resource. This work forms part of a range of tools which can support leaders with service planning and delivery, in line with both government and local priorities. It is essential for service providers to demonstrate quality and productivity and to: show value for money be able to provide a strong financial argument for the need to invest in services for

people with speech, language, communication and swallowing needs demonstrate improvements in outcomes for individuals, families and society

Value for money is not about being the cheapest option but about delivering the most return (impact, best outcomes) for a given investment over time. The key drivers for change to services include: 1. The broad context, which can be divided according to the following factors: Political and Legislative factors Economic factors Social factors Technological factors

2. The near or local context, including: Localised policies Addressing local needs Service provision Workforce The evidence base

THE BROAD CONTEXT (MACRO-ENVIRONMENTAL ANALYSIS): FACTORS FROM THE WIDER WORLD The Macro-environmental analysis commonly takes the form of a PEST analysis: Political and legislative factors Economic factors Social factors Technological factors Political and legislative drivers Devolution has resulted in changes to the powers of the different institutions across the UK. The government in power at Westminster maintains responsibility for policy and legislation in relation to key areas including: tax, benefits, foreign affairs, international development,


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trade and defence for the four countries of the UK. Government in Westminster is also responsible for health, social care and education in England, but these areas are devolved for Northern Ireland, Scotland and Wales. As a result of devolution, each country of the UK may have different parties in power, with the possibility of increasing powers in the future. The impact of this is the diversification of policy and direction of travel. Legislative drivers The main areas of UK-wide legislation that are relevant include the following themes: Human Rights Disability Discrimination Equality

Though there is different local interpretation, these far-reaching legal instruments define the rights and responsibilities of people and those commissioning and providing services for them. Public protection has also been strengthened through the introduction of registration of professionals, for example, through the Health Professions Council. There is separate legislation relating to health, education and social services in each of the devolved administrations in England, Northern Ireland, Scotland and Wales. Economic The current challenging economic backdrop will have a significant impact on the financing of public services, with local planners and commissioners prioritising services which are value for money, evidence based and releasing cash through innovation. Social In order to plan and deliver services, it is essential to identify the demographic factors relevant to speech and language therapy (SLT) and the challenges that these bring. The population is aging: people are living longer. The birth rate is falling: most families are having fewer children The infant mortality rate is also falling, with more children surviving premature birth or

health problems or injury in infancy. The urban population is growing. The proportion of the population in employment is falling. The proportion of the population with English as an additional language is increasing,

particularly in urban areas.


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THE NEAR OR LOCAL CONTEXT Localised policies Central to the new reforms is the emphasis on local decision-making within a national framework. Across the four countries of the UK there are requirements to provide services to accord with local need and influence. In England there is a particular focus on increasing the range of potential providers (plurality of provision) with commissioners having a role to stimulate the market. For each country, arrangements have been established to assess whether commissioners are achieving better health outcomes for the local population. Part of this process will be an assessment of how well commissioners are performing against specified competencies/indicators/targets. For example, in Northern Ireland these targets are based upon high-level outcomes linked to local strategies. With the devolution of power to local levels, there is a focus on developing more robust accountability. There is an emphasis on joint working to support integrated commissioning, service planning and provision across health, social care and education. There are different approaches to this development with different structures and commissioning and performance management arrangements being established across the UK. The dominant theme in strengthening accountability is “putting service users at the centre” with respect to: Access and self–referral User voice at strategic to operational to individual case management Population/local engagement Information and advice for users, parents/ carers Patient Rights Self management of conditions

Some localities will be commissioning or planning speech and language therapy services as a single service whilst others will be commissioning integrated services, cutting across traditional boundaries, with health services integrated with education or social services. In many areas, this has already happened for children's services. It is recognised that, often, no single agency can deliver best outcomes for their service users by working in isolation. Joint commissioning is advocated wherever the meeting the needs of individuals requires contributions from a number of agencies. Similarly, some service planners or commissioners will be organising services around disease groups, such as services for persons who have survived a stroke. In either case, it will be important for speech and language therapy managers to liaise with other services to ensure that SLT provision is incorporated in their service plans. Special arrangements are in place for commissioning services for unusual, low incidence or costly interventions. Speech and language therapy managers should identify the specialist commissioning procedures that may be required for individuals requiring


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particular interventions such as costly augmentative communication aids, protracted or intensive interventions. Addressing local needs In general terms, the UK is experiencing a number of long-term demographic changes (some of which are identified above). There is significant local variation within these general trends. It is important to understand what these changes and variations imply in relation to the provision of local SLT services. Other local factors to be taken into consideration include: employment, cost of living, housing, transport and, particularly, levels of deprivation. There are information resources available online from which planners, commissioners and providers can find out more about local and regional demographic factors. Some of these can be found signposted on the RCSLT website www.rcslt.org . Local public health teams will also be able to sign-post local services to relevant data and information for their area. There will also be learning from data collected by services. The RCSLT has developed an online tool called Q-SET, the Quality Self- Evaluation Tool to help you collate local SLT service derived information http://www.rcslt.org/resources/qset . Q-SET should be used alongside national and local data to support service planning and evaluation of service delivery. Through completing Q-SET, provider services can: use the resource every 9-12 months to review progress in meeting action plans and to

demonstrate service enhancement compare their service with other similar service types e.g. urban, rural, acute,

community, adult, paediatric, education, 3rd sector demonstrate that their service meets the needs of the service users identify areas of strength and generate action plans relating to areas of development. submit the results as part of the evidence for a clinical audit retain ownership of the monitoring and development of services ensuring that strong

professional standards are maintained in the context of multi-agency teams Service providers completing Q-SET will support commissioners to: reduce the ‘postcode lottery’ of service availability and quality have high quality information that is relevant and accessible have an overview of developments, trends and initiatives within the service have accurate and timely statistics to support performance management and

monitoring collect data to contribute to the debates on benchmarking. Where benchmarks do not

yet exist Q-SET will enable Commissioners to contribute to this in the future collect examples of good practice to inform other pieces of work and the development

of services as a whole.

http://www.rcslt.org/

http://www.rcslt.org/resources/qset


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Locally derived information will help SLT services to illustrate: the numbers of patients/clients seen sources of referral amount of resource used in providing a service to the client e.g. number of sessions

and skill mix nature and severity of the disorder, disability, psychosocial impact at the onset of

intervention nature and severity of the disorder, disability, psychosocial impact at the completion of

intervention. level of satisfaction with the service.

Service provision Speech and language therapists have a role in delivering specialist and targeted support to clients, carers and their families. Speech and language therapists can also reduce long-term demands on services by addressing immediate needs that arise from circumstance rather than underlying impairment. Providing training for the wider workforce is integral to the speech and language therapists core role, as outcomes for people with speech, language and communication needs SLCN are improved when the whole workforce is able to contribute appropriately to care pathways. SLTs also work with the wider workforce contributing to the public health agenda, promoting health and well-being in respect of communication and swallowing. There is little awareness outside the profession of the role of speech and language therapists in preventing the development of speech and language impairments and the further impact and consequences of different speech, language and communication disorders upon health, education, social integration and employment. The challenges of meeting the speech, language and communication needs (SLCN) of a given population are best understood through a social (participative) model. Key elements of a total service specification will start with: identifying the needs of the service user, parent or carer for support and information identifying/assessing and diagnosing specific SLCN and providing appropriate

intervention. considering needs of service users within the environments they encounter training the wider workforce that interfaces with them to maximise opportunities for

positive outcomes. The balanced system (diagram 1) below illustrates the wider context for how SLTs contribute to this range of activities. The needs of service users should be considered in service specifications. The role of SLTs in supporting the active participation of service users in service planning, adapting the environment and enskilling the workforce is as relevant as the SLT role in identification and intervention.


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Workforce Careful planning of services, including joint commissioning, will help to shape the workforce and inform the skill mix required to deliver high quality services, improve outcomes and support value for money. Because the commissioning and planning of services relies on the evidence base for a given type of SLCN or model of practice, it is essential that clinical and managerial expertise from speech and language therapists is available to support innovation and quality of service design. Speech and Language Therapists, as part of the wider workforce, may be employed by a range of organisations, including the third sector, social care and education or be working as private practitioners. Equal Access to services is of importance to local decision makers. Local demographic profiling will inform workforce requirements. For example, bilingual staff and support workers are required in most areas to meet the needs of diverse communities. The appropriate skill mix should enable services to be family-centred and be culturally and linguistically appropriate and responsive. It may be necessary to consider increasing home delivered services or providing services in unusual locations. The RCSLT also acknowledges the important role that Assistants and Support Workers have in the delivery of effective speech and language therapy services. Assistants and Support Workers are integral members of both speech and language therapy and multi-disciplinary teams, engaged in a wide range of clinical settings with diverse client groups, duties and responsibilities. http://www.rcslt.org/aboutslts/rcslt_statement_v3.pdf

http://www.rcslt.org/aboutslts/rcslt_statement_v3.pdf


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In order to support more effective use of skill mix, SLT services also need to provide education and training of the wider workforce and not be focussed solely on direct patient / client care. For all services, this is critical to secure the appropriate balance of cost-effective universal, targeted and specialist services.

PRACTICAL CONSIDERATIONS Many people involved in strategic planning, commissioning or reviewing services will not be familiar with speech and language therapy, its objectives, the needs of clients requiring speech and language therapy, the principles driving the profession, or the evidence base and the following points may support people. Where possible, draw on the evidence base. Communicate clearly and succinctly. Avoid using acronyms and provide a glossary of terms. Do not assume knowledge of local arrangements or the requirement to interface with

other agencies Set your service in the context of local priorities.

The RCSLT’s Communicating Quality 3 (CQ3) provides clear guidance on care pathways, clinical standards and issues related to quality assurance. This information should be used in submissions to support commissioning quality services. The following guiding principles have been adopted and apply to all client groups. Services are to:


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be family centred and culturally and linguistically appropriate and responsive be comprehensive, coordinated and team based work with and communicate effectively with other services meeting the needs of the

client be evidence based ensure equal access involve the family and carers include training and education of co-workers ensure practitioners continuing professional development and appropriate support.

Evidence of the impact of the service will be important to commissioners and providers. Providers will need to demonstrate the impact of their service, particularly when services are being reviewed. Determining the objectives of the service will support the process of outcome measurement. SLT services will need to provide information on outcomes achieved and levels of client satisfaction. Some of this information can be gathered through use of the RCSLT’s Q-SET tool, as detailed above.

Managers of speech and language therapy services will need to equip themselves to engage effectively and positively with those who are commissioning or monitoring services. They will need to: identify who is commissioning or responsible for overseeing different services. For

example, health commissioners may be working with commissioners for education/head teachers. It is important to identify who is taking the lead for each aspect of the service delivery in the locality.

establish good working relationships and effective communication with those commissioners and planners for their area of responsibility.

be aware of local priorities and commissioning plans and strategies. have a good understanding of the commissioning/planning/monitoring framework for

the locality be equipped with local data, knowledge and evidence to the tendering process be clear of the unique contribution of the service to improving health, employment,

education and social outcomes be able to clarify and demonstrate local working partnerships and collaborations provide data describing the service provided, (numbers and types of patients, numbers

of attendances, health and social outcomes etc). The RCSLT has developed a range of resources to support its members with Continuing Professional Development. CPD is a regulatory requirement for all SLTs and this requires all HPC Registrants to demonstrate how the CPD they have undertaken has sought to enhance service delivery and to be of benefit to service users. The RCSLT has endorsed this requirement through its own CPD standards. http://www.rcslt.org/cpd/resources

http://www.rcslt.org/cpd/resources


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THE EVIDENCE BASE The commissioning and planning of services must be informed by the evidence base of effective practices. This Resource Manual SLCN is based on a synthesis of existing published research. The threshold for inclusion in the syntheses has favoured the most scientifically robust research methodologies which have often reflected medical (impairment) rather than social (participative) models of care. In the section summaries, emerging practices that have not been included in the evidence synthesis, are referred to and should be considered alongside the syntheses. This tension between empirical evidence resulting from robust research, which by definition is retrospective, and the needs to encourage innovation and service re-design to support improvements in outcomes for people with speech, language, communication and swallowing difficulties is natural and unavoidable. Emerging practice will not have the same evidence base and therefore less empirically stringent measures of evidence need to be taken into account for these areas including professional consensus and measures of service user, parent or carer experience. However, because of the value of some emerging innovative practice, they have been included in this resource. An overview of the methodologies employed in identifying practices that are included in this resource accompanies this document. Using these resources Speech and language therapy managers can assist commissioners by understanding their agenda and the objectives that they are to be assessed on. The Royal College of Speech and Language Therapists is providing these resources to assist speech and language therapists in gathering the core data required to support service tendering agreements, service planning, monitoring arrangements and/or where services require specification. Each part of these resources is focused on a specific area. The resources provide: The Contextual Synthesis. This includes definitions, information on the incidence and

prevalence of the disorder, key contribution of speech and language therapists, consideration of the implications and broader consequences of the disorder.

The Synthesis of Key Literature. This summarises the evidence of the impact of speech and language therapy.

Each section within these resources gives succinct information to inform the factual content for any service planning activity. These include: Key points Topic –What is [the condition]? How many people have [the condition]?


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What causes [the condition]? How does this condition affect individuals? What are the aims/objectives of speech and Language therapy interventions for [this

condition]? What is the management for people with [this condition]? What is the evidence for Speech and language therapy interventions in [this

condition]? Studies Assessment methods Speech and language therapy interventions Summary References

This information will need to be put into context, using local information. Other guidance and resource materials It is recognised that service managers may wish to amplify or clarify, an aspect of their service by providing reference to other national or local research of relevance. The RCSLT has a range of resources which can be used to further support and inform the commissioning, planning and provision of services for people with speech, language, communication and swallowing needs. These can be found on the RCSLT website: www.rcslt.org

The RCSLT is grateful to the experts from within the SLT community who contributed to the evidence published in this document.

http://www.rcslt.org/


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METHODOLOGY FOR SYNTHESIS OF LITERATURE Introduction The focus of the interventional synthesis within these briefings is to provide a synopsis on the effectiveness of speech and language therapy interventions for each specific condition. The interventional syntheses are produced by reviewers within the Information Resources Section (within the Health Economic and Decision Science Section) at the School of Health and Related Research (ScHARR). Information specialists/reviewers for this bulletin were Diana Papaioannou and Anna Cantrell. Methodology The interventional syntheses are not intended to be a full systematic review within each topic area. However, they draw upon systematic review techniques to ensure that the syntheses are developed according to systematic, explicit and transparent methods. The intention of the syntheses is to consolidate twenty articles which represent some of the best research for each topic area. Literature searching Systematic literature searches were undertaken to identify a range of evidence for each interventional synthesis. The interventional syntheses do not attempt to consolidate all research within a particular topic area; rather they aim to present a careful selection of the most current research within that field. Therefore, the approach adopted for the literature search aims to be comprehensive reflecting this systematic and explicit approach. Firstly, search terms were selected within the project team drawing on the expertise of four speech language professionals. This involved listing all possible synonyms describing the condition or population (for e.g. children/infant, stuttering/stammering) and combining those with terms to describe speech and language therapy. Terms were used in both free text and thesaurus searching. The following databases were used: ASSIA CINAHL The Cochrane Library (which includes the Cochrane Database of Systematic Reviews,

Cochrane Central Register of Controlled trials, Database of Abstracts of Reviews of Effects, Health Technology Assessment Database and NHS Economic Evaluations Database).

Linguistics and Language Behaviour Abstracts MEDLINE PsycInfo

All references retrieved from the literature searches were entered onto a Reference Manager Version 11 database using appropriate keywords.


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Selecting and obtaining relevant articles Articles for inclusion were selected to illustrate the range of good quality evidence within each topic area. An initial screening of articles was undertaken by the Information specialists/reviewers who adopted the following principles: Articles must be empirical research evaluating the effectiveness of a particular speech

and language therapy intervention Only articles published in English language are included. In general, only the most current (1998-present) literature is included. However,

exceptions were made to this if a particular article was felt to be important to include. Where possible higher level evidence was included (systematic reviews, randomised

controlled trials). However, this research did not always exist in every topic area. Efforts were also made to seek out literature that provided a range of perspectives on

interventions for each topic area, i.e. both quantitative and qualitative research. Following initial screening, the remaining articles were examined by two members of the team; each having considerable speech and language therapy knowledge and experience. Approximately, twenty articles were selected by the two reviewers with disagreements being resolved by a third reviewer. Assessing the quality of relevant articles Formal quality assessment of the articles was not undertaken. Instead, quality assessment involved using checklists as a guide to give an indication of the overall quality of studies and highlight the main good and bad aspects of each study. For each interventional synthesis, the included study designs are listed and the problems with each study design noted. General observations on study quality are made and common errors within the studies, where appropriate, are specifically noted. The checklists used are one for quantitative and one for qualitative studies from the Alberta Heritage Foundation for Medical Research.1 Additionally, when an identifiable study design was used, the appropriate Critical Appraisal Skills Programme (CASP) checklist was selected.2 Syntheses of the twenty articles Each article was read in turn by one of the Information Specialists/reviewers. The key points were summarised including the objective of the study, the participants’ characteristics, the methodology, the intervention, results and limitations. From this, articles were grouped into themes according to the factor being investigated (for e.g., length of intervention, personnel carrying out intervention, family involvement in treatment, nature of disorder). Results were summarised and drawn together within each particular theme and a summary paragraph provided at the end. These syntheses first went out for review by selected individuals, identified by the research team, with particular expertise in the delivery or management of services to the 1 LM Kmet, RC Lee, LS Cook (2004) Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields. Accessed at http://www.ihe.ca/documents/hta/HTA-FR13.pdf (Accessed on 25th September 2008, now no longer available) 2 Critical Appraisal Skills Programme (2007) Appraisal Tools. Accessed at http://www.phru.nhs.uk/Pages/PHD/resources.htm on 9th January 2009.

https://webmail.shef.ac.uk/horde/util/go.php?url=http%3A%2F%2Fwww.ihe.ca%2Fdocuments%2Fhta%2FHTA-FR13.pdf&Horde=d671418123b6f29c44085d4d9d054e27

http://www.phru.nhs.uk/Pages/PHD/resources.htm


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specific client group. Comments were included in the second draft, which was then dispatched to those selected by the Royal College Speech and Language Therapists who were invited to attend a focus group day. These therapists gave detailed consideration to their specialist area and contributed to the more general discussion of one further area. Issues to be captured in the key points were also identified within the focus groups. These comments contributed to the third draft of the syntheses, which again went out to reviewers. In some cases, further work was required in order to modify the wording and reflect discussion. Checklist for service managers involved in commissioning services Have you presented incidence and prevalence figures and local demographic trends for the conditions in your area? Have you provided information on local access and use of services in the context of the number expected and highlighted your approaches to inequalities? Have you consulted systematically with users to inform development of this commissioning proposal? Does your proposal fit/link with local cross agency priorities? Have you outlined the range of services provided including training? Have you made clear how this fits with future planning for your service over the next 3-5 years? Have you stated the assumptions which underpin your thinking in the plan and for future developments? Have you offered predictions about the likely impact of investment in the proposal? Have you made clear where the risks are and what contingency plans you have put in place? Professor Pam Enderby Dr Caroline Pickstone Dr Alex John Kate Fryer Anna Cantrell Diana Papaioannou

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RCSLT RESOURCE MANUAL FOR COMMISSIONING AND PLANNING SERVICES FOR SLCN Speech & Language Impairment

RCSLT RESOURCE MANUAL FOR COMMISSIONING AND PLANNING SERVICES FOR SLCN SLI

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Speech and Language Impairment

1. Key Points for Speech and Language Impairment

1. Speech and language therapists play a unique role in identification and assessment of children with speech and language disorders. The ability to diagnose the specific speech and language disorder as well as retained communication abilities are unique skills of speech and language therapists

2. Improved communication has an impact on literacy, social skills, peer relationships, self-

confidence and behaviour

3. Difficulties with communication are a predominant feature in reducing access to education, employment and social integration

4. Programs simulating sound, vocabulary and language development should be tailored for the

child and shared with parents, nursery nurses, teachers and others.

5. Children with speech and language disorders need regular review and their management , which should be integrated into their educational programme

6. Advisory and educational programs for parents, teachers and carers should be part of speech

and language therapy services

7. Intensive therapy is associated with better outcomes for children with predominantly expressive speech and language disorders

8. The provision of speech and language therapy, supported by speech and language therapy

assistants/teaching assistants has been found to be cost-effective

9. Parent based therapy and group therapy involving parents have been demonstrated to be more effective (but more costly) than conventional therapy

10. There is evidence that early and more intensive speech and language therapy interventions are

more effective

11. As part of all service delivery there is emerging practice and developing roles. Within SLI this might include

working with young offenders and the prison population increasing role within the Child and Adolescent Mental Health Service (CAMHS) team working with children and young people with mental health difficulties exploring service provision for young adults and the transition from education to

employment


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Speech & Language Impairment Synthesis

Speech and language impairments can present as a delay or a disorder, impairments can occur as a primary condition or with secondary conditions, such as, cognitive, autistic, learning, hearing, behaviour and emotional impairments. A developmental delay or impairment may result in a speech and language disorder out of line with cognitive ability. There may be a disruption in one or more parameters of language: sound system (phonology), signalling word endings (morphology), grammar (syntax), meaning (semantics), and/or intended meaning (pragmatics). Speech and Language Disorder is usually described in terms of ‘speech’ referring to phonetic or phonological impairments and ‘language’ referring to specific language impairments there is delay or disorder. Speech and Language Therapists (SLTs) use a number of terms to describe the term speech and language impairments. ‘Speech and language impairments’ frequently co-occur, often one aspect will present as the primary impairment. The primary impairment is usually one relating to ‘Speech impairment’ and ‘Language impairment’. In this synthesis, although inter-linked the occurrence of speech and language impairment will be considered in relation to its occurrence as the primary impairment as Topic 1 – speech impairment and Topic 2 – language impairment.

Speech Impairment/Speech Sound Disorders Synthesis 1A

2. What is speech impairment?

Diagnostic terms for specific speech difficulties vary in the literature depending on the theoretical model adopted. In this synthesis speech impairment is used as a top level term, although Speech Sound Disorder (SSD) is frequently used in the literature. Speech impairment or ‘Speech Sound Disorders’ are generic diagnostic labels. It refers to articulation and phonological impairment that arises from development rather than congenital or syndromic conditions. Children can present with either a developmental speech delay where development is behind but following a normal developmental pattern or disorder of speech if the pattern is very delayed or different from the norm (Stackhouse & Wells, 1997). Speech difficulties are defined by phonemic (sound) or phonological (sound system) descriptors. Clinical terms include articulation, phonemic and phonological delay/disorder and these terms are included in this synthesis. Speech comprises of phonemes (individual sounds) and the phonological system (sound patterns of a language). In order to produce speech, an individual has to have an intact articulatory system and be able to articulate the phonemes and access the phonological system of their language. A distinction is made between phonological disorders (with problems in acquiring the language rules that underlie speech) and articulation disorders (with problems producing or perceiving speech). In children with normal speech development, sounds are learned in a developmental order as a child develops mastery of their neuromusculature. Children acquire the majority of their phonological system by 4 - 4.6 years of age (Grunwell in Fletcher and Hall, 1992), sufficient for their speech to be intelligible to those outwith their immediate social circle. Structural or physiological factors affecting either the articulators (cleft palate, malocclusions) or the production of phonemes (hearing loss, dyspraxia) impact on the ability to produce intelligible speech. These speech disorders are distinct from the functional disorder of phonological impairment which may occur as a primary disorder or comorbid with language impairment (Shriberg et al, 1986). An


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articulation impairment/disorder refers to difficulty in producing the sound itself. Phonological impairment refers to children who have delayed or disordered acquisition of phonological processes with an abnormal development of the sound system of language and the rules that govern those sound combinations. Prosody, the rhythm, intonation and rate of speech delivery, can be affected in children with speech impairment. Table 1: Classification of phonological impairment by Holm, Farrier & Dodd 2008 & Dodd 2005

Phonological impairment

Holm, Farrier, Dodd 2008 Dodd 2005

delayed developmental phonological processing system

the child is using only a few contrasts in their phonological system, resulting in the use of a few sounds in the place of non-developed sounds.

consistent non-developmental phonological processing system

speech which contains unusual sound patterns along with some delayed sound patterns which are used in a consistent manner.

inconsistent phonological processing system

speech has a high degree of variability (40% or more). The child will therefore often produce the same word in different ways.

Developmental verbal dyspraxia (DVD) is a term used to distinguish those children with a severe speech disorder resulting from an underlying impairment of motor planning who have a persistent phonological impairment, characterised by inconsistency which is frequently resistant to traditional therapy approaches (Stackhouse 1992, Davis & Velleman 2000). There is an impairment or immaturity in organisation of movement related to motor planning. DVD can manifest itself in early infancy with difficulty with feeding, sucking, chewing followed by delay in expressive language, difficulty in producing speech, reduced intelligibility of speech, and inconsistent production of sounds in familiar words. 3. How many people have speech impairment? Studies reporting on the epidemiology of speech impairment provide different information to depending on the definitions used. Hence, the figures shown in table 2 need to be interpreted accordingly. In 2007, the number of children recorded as having speech, language and communication needs in school recorded as having either special educational needs or at school action plus, were 4.5% in special schools, 23.8% in maintained primary schools, and 6.9% in secondary schools. In Scotland the figures reported for 2006 for pupils in the public sector with additional support needs shows by gender special school 71.9/1000 female and 74.3/1000 male with significant speech and language support needs while in primary school 2/1000 female and 4.6 male, secondary school 0.6/1000 female and 1.6/1000 male.


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Table 2: Prevalence of speech impairment Incidence Prevalence Country Sex Source

6.4% delayed or disordered live births

UK 2:1 male/ female

Broomfield and Dodd, 2004

1.3% (excluding learning difficulty and developmental delay) of these, males peaked in prevalence at 5 years (6.5%); females peaked at 3–4 year-olds (1.8%).

UK Keating, Turrell, Ozanne, 2001

Estimated 1.5% at 3-5 years 4.6% at 5–7 years 12.6% at 6-12 years 7.3% at 12-14 years Figures for speech delay were highly variable, ranging from 2.3% to 24.6%

UK Law, Boyle, Harris, Harkness, 2000

14% of 3 year olds have speech delay. Prevalence was higher in children with otitis media, male, low socioeconomic group, low parental education, minority group, urban dwelling. 3.8% in 6 year olds

US Shriberg, Tomblin, & McSweeny, 1999

Approximately 10–15% of preschoolers have an articulation and phonological disorders. Approximately 6% of school-age children (K to 12th grade) have an articulation and phonological disorder (Office of Scientific and Health Reports 1988).

US Bleile, 2003

4. What causes speech impairment?

Speech impairment is a heterogeneous condition. Studies have identified risk factors as hearing loss caused by recurrent ear infections, poor sensory or linguistic environment, a positive family history of speech and language difficulties, general immaturity (Law et al 2000, Enderby & Emerson, 2005). While the majority of speech impairments have no known cause, some impairment is a result of specific syndrome, for example, isolated sagittal synostosis (Shripster et al, 2003). DVD has been linked to the biochemical mechanisms which underlie the development of normal speech. A study by Webb et al 2003 identified that approximately half of children with galactosemia, an autosomal recessive disorder, developed verbal dyspraxia. There is no known medical cause of phonological impairment. Studies by Stackhouse & Snowling (1992), Elbro (1993) and Holm et al (2008) suggest specific developmental delays affect the child’s psycholinguistic ability, affecting sound preception, phonological awareness,


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segmentation skills, mental representation of words in the lexicon, processing skills for sound perception and production. 5. How does speech impairment affect individuals?

Young children with a delay early in their speech development are at risk of acquiring speech impairment which affects the intelligibility of their speech, ability to be understood by those in their communicative environment, and may cause concern in parents and upset in the child. It is important at this early developmental stage to assess need in order to promote speech development to ensure the sounds and sound system are acquired in the right way at the right time. If these early difficulties in acquiring speech are not resolved, the child may develop long term sound learning and literacy difficulties. Studies show that speech impairments involving phonological impairments and developmental verbal dyspraxia have long lasting sequellae (Hesketh 2004, Conti-Ramsden et al 2001, Law et al 1998, Stackhouse 1992). Difficulties are in: -

Acquisition of sounds Development of sound system Phonological awareness Phonological processing Development of literacy skills

These difficulties impact on the individual’s ability to access the curriculum. Literacy is affected by problems in early sound learning difficulties, particularly when those difficulties relate to phonological awareness (Holm, Farrier & Dodd, 2008, Raitano et al, 2004). Hesketh (2004) found that phonological awareness difficulties at 3.6-5.0 years were a strong predictor for later literacy difficulties. Long-term studies have shown a risk for behavioural and social difficulties at school age and early adolescence (Conti-Ramsden & Botting 2004, Campbell et al 2003, Fujiki, Brinton, & Todd 1996). Individuals with a history of sound impairment did not perform as well as adults with no history on measures of articulation, and receptive and expressive language. These adults received more remedial services during their schooling and completed fewer years of formal education (Felsenfeld, Broen & McGue, 1994, 1992; Clegg, Hollis, Mawhood & Rutter, 2005; Cantwell & Baker, 1987). Table 3: International Classification of Functioning: levels of impact ICF dimension Impact Impairment Sound production abnormalities. Disordered phonological awareness,

phonological processing, phonological template, segmentation skills, mental representation of words in the lexicon, and disturbed prosody.

Activity Reduced intelligibility of speech, reading and writing skills. Participation Reduced communication skills can affect self-esteem, self-identity,

relationships, educational attainment and work attainment. Well-being Frustration, withdrawal, upset.


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6. What are the aims/objectives of Speech and Language Therapy interventions for

speech impairment? SLT aims to identify the nature of the delay or disorder by assessing the pattern of the articulation and phonological template used by the child. This involves assessment of the phonemes present in the sound system and their pattern of use, assessment of the child’s phonological awareness, and auditory discrimination according to age. SLTs will ascertain the effect any sound impairment will have on the individual’s ability to access the curriculum and advise accordingly. The type of speech pattern will influence the intervention. Studies have shown that those children with phonological planning and those with cognitive-linguistic deficit benefit from different therapeutic approaches (Crosbie, Holm, & Dodd, 2005). Table 4: Aims and objectives of Speech and Language Therapy Intervention in Speech Impairment Age Purpose Source

Infants to 2 years Assess, advise and provide intervention and training as required. SLT may provide input to young children perceived to be at risk. This may be through providing an auditory awareness programme. Children’s Centres’ input Educating/training parents/carers Training relevant staff e.g. nursery/voluntary sector staff Children’s Centres’ Sure Start– development of auditory awareness, listening skills, sound production. Chatterbox – listening and perceptual skills, sound processing and production Advice on transition.

Sure Start I-Can

Pre-school

3-4 years Assessment, advice and training on sounds/phonology development Individual/Groups SLT Phonological awareness Phonological processing (input/output) Sound production Core Vocabulary Advice on transition

SLT programmes


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Age Purpose Source 5-11 years Assessment, advice and training on

sounds/phonology development Individual/Groups SLT Phonological awareness Phonological processing (input/output) Sound production Literacy skills Core Vocabulary Advice on transition

SLT programmes School age

11-16/18 years Assessment, advice and training on sounds/phonology development Individual SLT Phonological awareness Phonological processing (input/output) Sound production Literacy skills Advice on transition

SLT programmes

Adults 17/19 + years Assessment, advice and training on sounds/phonology development Individual SLT Phonological awareness Phonological processing (input/output) Sound production Literacy skills Advice on transition

SLT programmes

7. What is the management for speech impairment?

Speech and Language Therapists carry out work which is preventative, aiming to prevent specific speech impairments developing. SLTs also undertake intervention, and work with children with speech impairments to resolve their difficulties. It is recognised that some groups of children are ‘at risk’ in developing their speech and language. Children need good speech and language models to develop speech. If this is not provided the children are ‘at risk’ of poor speech development, for example, in areas of deprivation or where English is not the first language. Preventative measures aid speech development and facilitate appropriate speech development. Speech and Language Therapists contribute to this preventative work through various strategies. The aim of this work being to identify children who may progress to developing a speech impairment and providing training and advice to parents and child workers. This may include work to develop attention, listening, sound discrimination and good models of production. Speech and Language Therapy services for children with a speech impairment are usually delivered according to age group, preschool and school age children, and parental preferences. The SLT will assess the child, give advice, write detailed reports, review progress, educate, train child key workers, provide programmes of work to meet the child’s needs, provide direct and indirect therapy. Most initial referrals are at the foundation stage of schooling/ early years and at 5-6 years of age with SLT


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involvement continuing through school. There are fewer Speech and Language Therapy interventions in secondary school children with speech impairment in part because earlier difficulties have resolved, though studies have shown children with early speech impairment tend to show weakness on tests of both literacy and phonological processing (Lewis et al 2003, 2000, 1992), and in part because of organisation and funding of services. Studies have highlighted unresolved speech impairments in young offenders (Bryan 2004, Hamilton 1999). Speech and Language Therapists’ work with adults with developmental speech impairment is relatively unusual, not because of a lack of need but because of funding streams. The Children’s workforce works across different health, education, social and voluntary sectors to provide the right input at the right time. Speech and Language Therapists work closely as a part of the Children’s Team from early years, working with various agencies e.g. the Preschool Inclusion teams to provide appropriate input and training, for example, facilitating activities to develop attention, listening skills and sound (phonological development). Training parents/carers and staff to provide regular input to children is a key part of providing the right approaches at the right dose. Management is based on the needs of the child and family. The model shown below describes, by national consensus, what a SLT service can offer at the different levels of care (RCSLT 2009): Referral

Driven Specialist Casework

Creating Capable Specialist Services

Addressing Health Inequalities

within primary and secondary healthcare

Specialist Integrated healthcare pathways for people with a learning disability

Generic

healthcare

Promotion of health and wellbeing at a population level Self directed care


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Speech and Language Therapists work as a member of multidisciplinary teams, these may include the following:- Table 5: Speech and Language Therapist work as a member of multidisciplinary teams

Age Group Teams 0 - 2 years Parents/carers, Children’s Services e.g. Health Visitors and Sure Start

Centre Teams, Health and Mental Health Teams, Social Services, Pre-School Inclusion Teams, Early Years Support settings, Voluntary/Charity Sector e.g. I-Can, Afasic

3 – 4 years Parents/carers, Children’s Services e.g. Health and Social Services, Education teams e.g. Nursery Staff, Reception Staff, Psychology staff, and Voluntary/Charity Sector e.g. I-Can, Afasic

5 and 16/18 years Parents/carers, Children’s Services, Education teams and Voluntary/Charity Sector e.g. I-Can, Afasic

17/19 + years upwards

Parents/carers, Health and Mental Health Team, Further education, Higher Education Teams, Adult Literacy Team, Social Services, Prison/Young Offenders Staff, Voluntary/Charity Sector

Speech and Language Therapists will promote methods of speech and language encouragements to facilitate development and to prevent future difficulties. This includes training and advice to referral agencies, parents and carers; produce and disseminate input to health promotion; working with colleagues on developing appropriate individual education plans; providing care plans and programmes appropriate to areas and levels of difficulty. The communication difficulties and problems of social interaction encountered in childhood can continue into adulthood and vulnerable individuals need care and support to cope in society. Augmentative and Alternative Communication Augmentative and Alternative Communication (AAC) refers to any system of communication that is used to supplement or replace speech, to help people with speech, language and communication impairments to communicate and develop speech and language. While AAC covers a range of high technology (such as computer and voice output communication aids), there are low technology systems (such as, those involving no equipment signing and picture systems) which are used in aiding communication and speech development. AAC methods often include Makaton sign system, Paget Gorman sign system, Picture Exchange Cards (PECS) and Boardmaker pictures. Cultural diversity Individuals who are bilingual and have a speech impairment may need help to access services and once seen it will be important to ascertain a full speech and language profile. An interpreter may be required to conduct the SLT assessment to ensure it is both accurate and reliable and to facilitate understanding of therapy and implementation of treatment strategies. There are time and cost implications when working with interpreters/co-workers for example, in taking a case history, completing a full assessment in all languages spoken by the child and family. Timings of services need to be culturally sensitive, for example, not offering appointment times which coincide with religious observations (Communicating Quality 3).


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Speech and Language Therapists as part of a multidisciplinary team The Speech and Language Therapist will be working as part of multidisciplinary team, including people from health, education, social and voluntary organisations. They will also be including within the management process the individual’s family members and others in their communication environment. There are time implications for the education and training that SLT’s provide to other professionals and family members. Working as part of a multidisciplinary team necessitates taking on team roles and attending meetings which also have time implications. The paper 'Healthy Lives, Brighter Futures: The Strategy for Children and Young People's Health ' (DoH 2009) is a cross government strategy for bringing together the Department of Health and the Department for Children, Schools and Families. The paper establishes the responsibility for the provision of care as a priority in Health Services and clarifies how to implement the intentions stated within the Bercow Review (2008) by strengthening the need for joint commissioning of children's services. 8. What is the evidence for Speech and Language Therapy interventions? Evidence for interventions is discussed at section 8 of the following synthesis on language impairment, as the evidence needs to be viewed together. 9. References Cited

1. Bercow, J 2008 Better Communication: An Action Plan to Improve Services for Children and Young People with Speech, Language and Communication Needs Department of Health.

2. Bowen, C., & Cupples, L. (1999a). Parents and children together (PACT): A collaborative

approach to phonological therapy. International Journal of Language and Communication Disorders. 34, 1, 35-55.

3. Broomfield, J. and Dodd, B. (2004) Children with speech and language disability: caseload

characteristics. International Journal of Language and Communication Disorders, 39, 1-22.

4. Bryan, K. Preliminary study of the prevalence of speech and language difficulties in young offenders, 39, 3, 391-400.

5. Campbell, T. F, Dollaghan, C. A, Rockette, H. E., Paradise, J. L., Feldman, H. M., Shriberg, L.

D., Sabo, D. L., & Kurs-Lasky, M. (2003). Risk factors for speech delay of unknown origin in 3-year-old children. Child Development, 74, 2, 346- 357.

6. Cantwell, D. P., & Baker, L. (1987). Clinical significance of childhood communication disorders:

Perspectives from a longitudinal study. Journal of Child Neurology, 2, 4, 257-264.

7. Clegg, J., Hollis, C., Mawhood, L., & Rutter, M. (2005). Developmental language disorders - a follow-up in later adult life. Cognitive, language, and psychosocial outcomes. Journal of Child Psychology and Psychiatry, 46, 2, 128-149.

8. Conti-Ramsden, G., & Botting, N. (2004). Social difficulties and victimization in children with SLI

at 11 years of age. Journal of Speech, Language, and Hearing Research, 47, 145-161.

http://www.dcsf.gov.uk/slcnaction/downloads/Better_Communication_Final.pdf



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9. Davis, B.L. & Velleman, S.L. (2000). Differential Diagnosis and Treatment of Developmental

Apraxia of Speech in Infants and Toddlers. Infant Toddler Intervention: The Trans-disciplinary Journal, 10, 3, pp. 177 - 192.

10. Department of Health (2009) Healthy lives, brighter futures - The strategy for children and young

people's health. www.dh.gov.uk

11. Dodd, B. (2005). Differential diagnosis and treatment of children with speech disorder (2nd Ed.). London: Whurr.

12. Elbro, C. (1993). Dyslexic reading strategies and lexical access. In R. Joshi & C. Leong (Eds),

Reading Disabilities: diagnosis and component Processes, London: Kluwer, 239-251.

13. Enderby, P. & Emerson, J. (1995) Does speech & language therapy work? London: Whurr.

14. Felsenfeld, S., Broen, P. A., & McGue, M. (1994). A 28-year follow-up of adults with a history of moderate phonological disorder: educational and occupational results. Journal of Speech and Hearing Research, 37, 6, 1341-1353.

15. Felsenfeld, S., Broen, P., & McGue, M. (1992) A 28-year follow-up of adults with a history of

moderate phonological disorder: linguistic and personality results. Journal of Speech and Hearing Research, 35, 1114-1125.

16. Fujiki, M., Brinton, B., & Todd, C. (1996) Social skills of children with specific language

impairment. Language, Speech and Hearing in the Schools, 25, 195-202.

17. Gierut, J.A. (1998) Treatment efficacy: Functional phonological disorders in children. Journal of Speech, Language, and Hearing Research, 41, 85-100.

18. Grunwell, P. (1992) Principled decision making in the remediation of children with neurological

disorders. Cht in Speech and Language Disorders in Children. Eds. Fletcher, P. & Hall, D., Whurr: London.

19. Grunwell, P., (1987) Clinical Phonology, Second Edition. (London: Chapman & Hall)

20. Hamilton, J. (1999) Speech Language and communication Therapy: a perspective from HMYOI

Polmont. Internal Report (Forth Valley Primary Care NHS Trust).

21. Hesketh, A. (2004) Early literacy achievement of children with a history of speech problems. International Journal of Language & Communication Disorders, 39, 4, 453 – 468.

22. Holm, A., Farrier, F., Dodd, B. (2008) Phonological awareness, reading accuracy and spelling

ability of children with inconsistent phonological disorder. International Journal of Language & Communication Disorders, 43, 3, 300-322.

23. Keating D.; Turrell G.; Ozanne A. (2001) Childhood speech disorders: Reported prevalence,

comorbidity and socioeconomic profile. Journal of Paediatrics and Child Health, 37, 5, 431-436.

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_094400



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24. Law, J., Boyle, J., Harris, F., Harkness, Nye, C., (2000) Prevalence and natural history of

primary speech and language delay: Findings from a systematic review of the literature. International Journal of Language & Communication Disorders, 35, 2, 165–188.

25. Lewis, B. (2007). Short- and long-term outcomes for children with speech sound disorders.

Encyclopaedia of Language and Literacy Development (pp. 1-6). London, ON: Canadian Language and Literacy Research Network. Retrieved 16/0708 from http://www.literacyencyclopedia.ca/pdfs/topic.php?topId=23

26. Lewis, B., Freebairn, L & Taylor, H. 2000 Academic outcomes in children with histories of

speech sound disorders. Journal of Communication Disorders, 33, 11-30.

27. Lewis, B. & Freebairn, L. 1992. Residual effects of preschool phonology disorders in grade school, adolescence, and adulthood. Journal of Speech and Hearing Research, 35: 819-831,

28. Raitano, N. A., Pennington, B. F., Tunick, R. A., Boada, R., & Shriberg, L. D. (2004). Pre-literacy

skills of subgroups of children with speech sound disorders. Journal of Child Psychology and Psychiatry, 45, 821-835.

29. Rvachew, S & Grawburg, M. (2006) Correlates of phonological awareness in preschoolers with

speech sound disorders Speech, Language and Hearing Research, 49, 74–87.

30. Royal College of Speech and Language Therapists (2003) Communicating Quality 3. RCSLT: London.

31. Shriberg, L. D., Tomblin, B. J., & McSweeny, J. L. (1999). Prevalence of speech delay in 6-year-

old children and comorbidity with language impairment. Journal of Speech, Language, and Hearing Research, 42, 6, 1461-1481.

32. Shriberg, L, Kwiatkowski, J., Best, S., Hengst, J., Terselic-Weber, B. (1986) Characteristics of

children with phonological disorders of unknown origin. Journal of Speech and Hearing Disorders, 51, 140-161.

33. Shipster, C., Hearst, D., Somerville, A, Stackhouse, J., Hayward, R., Wade, A (2003) Speech,

language, and cognitive development in children with isolated sagittal Synostosis. Developmental Medicine & Child Neurology, 45, 34–43.

34. Stackhouse, J. (1992), Developmental verbal dyspraxia I: A review and critique. International

Journal of Language & Communication Disorders, 27, 1, 19–34.

35. Stackhouse, J. & Snowling, M. (1992) Barriers to literacy development in two cases of developmental verbal dyspraxia. Cognitive Neuropsychology, 9, 273-299.

36. Stackhouse, J. & Wells, B. (1997) Children’s Speech and Literacy Difficulties: a psycholinguistic

framework. Whurr: London.

http://www.literacyencyclopedia.ca/pdfs/topic.php?topId=23


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37. Stow, C & Dodd, B. (2003) Providing an equitable service to bilingual children in the UK: a review. International Journal of Language & Communication Disorders, 38, 4, 351 – 377.

38. Pascoe, M., Stackhouse, J., & Wells, B. (2005). Phonological therapy within a psycholinguistic

framework: Promoting change in a child with persisting speech difficulties. International Journal of Language and Communication Disorders, 39, 1-32.

39. Ward, S. (1999) An investigation into the effectiveness of an early intervention method for

delayed language development in young children. International Journal of Language & Communication Disorders, 34, 3, 243-264.

40. Webb, A, Singh, R, Kennedy, M., Elsas, L, (2003) Verbal Dyspraxia and Galactosemia.

Pediatric Research, 53, 3, 396-402.

http://www.informaworld.com/smpp/title~content=t713393930~db=all~tab=issueslist~branches=38#v38

http://www.informaworld.com/smpp/title~content=g713746093~db=all


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Synthesis 1B – Language Impairment

10. What is Language Impairment? Language Impairment is a developmental disorder affecting the development of expressive and receptive ability resulting in functional communication impairment. There are various definitions of language impairment based on linguistic, medical or statistical models. Specific language impairment (SLI) is considered to be on a spectrum where cognitive ability is within the normal range (performance IQ greater than 85), where verbal difficulties are greater than non-verbal difficulties and the composite language measure falls more than 1.25 SD below the mean (equivalent to <10th percentile) (Tomblin et al 1997). The International Classification of Diseases -10 (ICD -10) defines SLI as occurring when a child's language skills fall more than 2 SD below the mean and are at least 1 SD below non-verbal skills. The impairment may involve the form (sounds (phonology)), grammar (syntax) & word endings (morphology), content (meaning (semantics)), and use of language (intended meaning (pragmatics)) to differing degrees. Language initially presents as a delay in the child’s developmental language milestones. This delay can resolve with maturation, respond to intervention or the impairment can be evident in the emerging pattern of involvement in respect of form, content or use and these can change with age and development. Table 6: Type of language delay/impairment and difficulty experienced

Type of Language

Impairment

Description of language impairment

Comprehension Difficulties in understanding language (spoken, signed, gestural, reading) or in interpreting appropriately social situations

Expression Difficulties in expression in formulating sentences for speech, writing, signing or using appropriate language in a social setting.

11. How many people have language impairment? There are various figures reported for different ages. Generally language impairment affects more boys than girls (prevalence estimate for boys was 8% and for girls 6%Tomblin 1997). Table 7: Incidence and prevalence Incidence in UK Prevalence in UK Age Sex Source 14.6% primary speech & language live births 4.5% receptive language 3.7% expressive language

85000-90000 cases estimated as referred to SLT per year

2-6 years 3:1 male/female. Receptive language impairment 75% male/25% female Expressive language

(Broomfield & Dodd 2004)


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Incidence in UK Prevalence in UK Age Sex Source impairment 78% male/22% female Speech & Language 70.4% male/29.6% female

5.9%, median prevalence estimate

Birth to 7 years (Law et al 1998)

968/ 100,000 aged 3-9 years estimated to need SLT

(Enderby, P. & Emerson 1995)

18 – 31% 20 – 24 months in disadvantaged community

(Pickstone 2004)

12. What causes language impairment? There are differing theories on the causes of Specific Language Impairment (SLI). Studies show a positive family history of language impairment and environmental factors (Conti-Ramsden 2001). Environmental factors and deprivation are associated with language delay. Given its heterogeneity, it is hypothesised that different subtypes of SLI exist, with variable specificity and different underlying causes (van der Lely, 2005). There appear to be underlying deficits which affect the child’s ability to deal with abstract linguistic understanding across modalities (Marshall 2006), that is understanding at different levels. Additional studies have shown evidence that visuospatial skills are also impaired (Bishop 1992). Structural neuroimaging studies have indicated the presence of atypical patterns of asymmetry of the language cortex, white-matter abnormalities, along with evidence of cortical dysplasia. (Webster & Shevell 2004) 13. How does language impairment affect individuals? Children with language impairment have specific difficulties in learning language form, content and use. The difficulties experienced can be in comprehension and or expression affecting all modalities – spoken language, reading, writing, signing, and social use of language. Deficits can be also evident in verbal short-term, in working memory and in visuospatial short-term memory (Archibald & Gathercole 2006). Each child is affected in different ways and to varying degrees depending on the combination of difficulties in language learning experienced (Bishop & Clarkson 2003). The pattern of language impairment alters with age. Initially, the impairment may be in the form of a delay with slow emergence of language milestones. As language skills are acquired throughout childhood so the type of presenting difficulty changes both with development of the child’s language skill and also with the demands and opportunities that schooling and society places on the child. If a delayed pattern of language development persists, it commonly affects the child’s ability to communicate or interact with those around them causing frustration and isolation.


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Language impairment impacts on the child’s ability to reach their full potential. It affects the child’s ability to communicate effectively, access the school curriculum, and has emotional and social sequellae which affects participation and well-being. Research has shown children with language impairment under perform and under achieve on national assessments with lower exams results. Language impairment has a cost and implications for adults in later life in what they can achieve (ICAN Cost to the Nation 2006). The communication difficulties and problems of social interaction encountered in childhood can continue into adulthood and vulnerable individuals need care and support to cope in society. Studies have shown that children with language impairment are at risk of long term learning difficulties with problems in accessing the curriculum, suffer low self-esteem and anxiety which have a negative impact on the quality of life of affected adults and substantial economic and health-care costs (Jerome et al 2002, Young et al 2002, Johnson et al 1999). There is an emotional cost to the individual and their families with the need for long term support (ICAN 2006). Table 8: Description of language impairments

Type of Language

Impairment

Description of language impairment

Phonology Impaired development of phonological system for language and literacy.

Syntax Impaired development of rules governing grammatical relations between words and other units within a sentence.

Morphology Impaired development of the structure and construction of word forms.

Semantics Impaired development of associating meanings to words and sentences.

Pragmatics Impaired development of the ability to use the combination of language components (phonology, morphology, syntax, and semantics) in functional and socially appropriate ways.

Table 9: International Classification of Functioning: impact of language impairment

ICF Dimension Impact Impairment Functional comprehension and expression impaired.

Reading and writing impaired Activity Ability to understand and express.

Ability to communicate Ability to use symbolic and sequential play Behaviour may not be appropriate to social setting

Participation Interaction with others affected by reduced ability to communicate. Self-esteem affected. Difficulty in forming friendships because of communication difficulties, may be rejected by peer group, may withdraw from communicative situations,


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inappropriate behaviour in certain social settings. Behaviour may not be appropriate to social setting and affect ability to interact and participate with peers

14. What are the aims/objectives of Speech and Language Therapy interventions for

language impairment? Speech and language intervention is targeted both at preventing language impairment developing and in working to develop language skills appropriate to age in those with a delay or impairment. Full and comprehensive assessments are needed to identify language development and areas of impairment and how this has affected communication, social participation and well-being. Early screening forms part of the process (Klee et al 1998, Klee et al 1995) as well as identifying need at each stage in development and particularly at transition points from home to nursery, to primary school, secondary school, higher education, life needs. The model of intervention described in speech impairment applies equally to language impairment. The model exemplifies the different levels of care (RCSLT 2009):

Referral Driven

Specialist Casework

Creating Capable Specialist Services

Addressing Health Inequalities within primary and secondary healthcare

Specialist Integrated healthcare pathways for people with a learning disability

Generic healthcare

Promotion of health and wellbeing at a population level Self directed care


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It is recognised that some groups of children are ‘at risk’ in developing their speech and language. Children need good language models to develop language as a paucity of good models affects language development. Preventative measures facilitate language development. The Children’s workforce works across different health, education, social and voluntary sectors to provide the right input at the right time. SLT contributes to this work through various strategies. Speech and Language Therapists work closely as a part of the Children’s Team from early years, working with various agencies e.g. the Preschool Inclusion teams to provide appropriate input and training, for example, facilitating activities to develop cognition, language and communication skills. Training parents/carers and staff to provide regular input to children is a key part of providing the right approaches at the right dose. Management is based on the needs of the child and family. Interventions can be through those in most contact with the individual (indirect intervention) or by the Speech and Language Therapist (direct intervention). Table 10: Aims and objects in interventions

To provide appropriate input to ‘at risk’ groups to develop language skills To advise on bilingual matters related to language development To train relevant staff on language development, strategies to develop language, timing

of interventions To identify early communication difficulties. To evaluate language abilities To counsel and advise parents and carers about speech and language development To plan a programme of work to promote development of language To identify target areas for work – directly by SLT, by SLT assistant, by others To work with other professionals to identify work areas To provide input to the individual education plan for the child To work with and through others to raise the competencies, knowledge and skill of the

children’s workforce. To provide monitor and report progress to parents/carers and interested professionals To write advice for statutory assessments, annual reviews, Statements of Need and Co-

ordinated Support Plans To provide assessment, advice and detailed reports To training parents/carers in approaches to develop language To train education staff working with individuals in approaches to developing language To develop augmentative and assistive (AAC) methods of communication in those with

severe difficulties The speech and language therapist will provide programmes/interventions packages which are aimed at developing specific dimensions. For example, in school age children the packages of care aim to help the child better access the curriculum and develop appropriate social skills and provide advice and support on social interaction in different settings in and out of school.


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Table 11: International Classification of Functioning: aims/objectives by dimension

Develop comprehension ability for language – phonological, syntactic, semantic, pragmatic abilities

Impairment

Develop expressive ability for language – phonological, syntactic, semantic, pragmatic abilities

Develop ability to communicate Develop ability to understand and use language appropriate to the

communicative situation

Activity

Develop effective communicative interactions with others Develop ability to integrate socially with others Develop ability to behave appropriately in social settings Develop self-esteem as a communicator

Participation

Develop appropriate social behaviour Develop social skills 15. What is the management for language impairment? Speech and Language Therapists work closely with the families and carers of children to ensure that the communication needs of the child are met. As the child develops, the team members will include a number of different professionals. Children’s Centre teams incorporate Health, Local authority and Voluntary /Charity Sectors. SLTs work with differing team members at different times including those in the private, voluntary and independent sectors (PVI). Table12: Speech and Language Therapists as members of multidisciplinary teams may include Age Group Teams 0 - 2 years Parents/carers, child minders, Children’s Services’ teams e.g. Health

Visitors and Sure Start Centre Teams, Health and Mental Health Teams, Social Services, Pre-School Inclusion Teams, Early Years Support settings, Voluntary/Charity Sector e.g. I-Can, Afasic

3 – 4 years Parents/carers, child minders, Children’s Services’ teams e.g. Health and Social Services, Education teams e.g. Nursery Staff, Reception Staff, Psychology staff, and Voluntary/Charity Sector e.g. I-Can, Afasic

5 and 16/18 years Parents/carers, child minders, Children’s Services’ teams, Education teams and Voluntary/Charity Sector

17/19 + years Adults

Parents/carers/partners, Health and Mental Health Team, Higher Education Teams, Adult Literacy Team, Social Services, Prison/Young Offenders Staff, Voluntary/Charity Sector

Within Speech and Language Therapy Services there are specialist services providing second opinions or assessment, intervention and intensive courses, e.g. The Nuffield Speech and Language Centre, specialist Speech and Language Therapist in language units, providing intensive therapy and out reach services to schools and specialist Speech and Language Therapist working with parents and education within mainstream schools. In the Voluntary/Charity sector, specialist Speech and Language Therapist work in Specialist Schools (such as Dawn House and Moor House) providing intensive intervention. Programmes of intervention are run by Speech and Language Therapists to facilitate language learning working with and through others e.g. Nuffield, Derbyshire Language. Results of interventions are best


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when the timing, duration and intensity of input match the child’s needs (Hart et al 1995, Rescorla et al 1997). Adults with language impairment difficulties may be seen for individual work. Studies have highlighted language impairments in young offenders who have responded to targeted language work (Bryan 2004, Hamilton 1999). Augmentative and Alternative Communication Augmentative and Alternative Communication (AAC) refers to any system of communication that is used to supplement or replace speech, to help people with speech, language and communication impairments to communicate and develop speech and language. While AAC covers a range of high technology (such as computer and voice output communication aids), there are low technology systems (such as, those involving no equipment signing and picture systems) which are used in aiding communication and speech development. AAC methods often include Makaton sign system, Paget Gorman sign system, Picture Exchange Cards (PECS) and Boardmaker pictures. Cultural diversity Individuals who are bilingual and have a language impairment may need help to access services and once seen it will be important to ascertain a full speech and language profile. An interpreter may be required to conduct the SLT assessment to ensure it is both accurate and reliable and to facilitate understanding of therapy and implementation of treatment strategies. There are time and cost implications when working with interpreters/co-workers for example, in taking a case history, completing a full assessment in all languages spoken by the child and family. Timings of services need to be culturally sensitive, for example, not offering appointment times which coincide with religious observations (Communicating Quality 3). Speech and Language Therapy as part of a Multidisciplinary Team The paper 'Healthy Lives, Brighter Futures: The Strategy for Children and Young People's Health ' (DoH 2009) is a cross government strategy for bringing together the Department of Health and the Department for Children, Schools and Families. The paper establishes the responsibility for the provision of care as a priority in Health Services and clarifies how to implement the intentions stated within the Bercow Review (2008) by strengthening the need for joint commissioning of children's services. Bercow’s key themes included: � Communication is crucial as a key life skill at the heart of every social interaction and vital to children’s successful development; � Early identification and intervention is essential to maximise each child’s chance of overcoming their communication need and succeeding; � A continuum of services designed around the family is needed for children with SLCN; � Joint working is critical to deliver services that provide effective support; � The current system is characterised by high variability and a lack of equity The papers emphasise that there will have to be demonstrable stronger and joined up support for early years of life care. For example, close working between Health Visitors and Speech and Language


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Therapists. Speech and Language Therapists will be working as part of multidisciplinary team, including people from health, education, social and voluntary organisations. They will also be including within the management process, the individual’s family members and others in their communication environment. There are time implications for the education and training that Speech and Language Therapists provide to other professionals and family members and the work undertaken as part of a multidisciplinary team, taking on team roles and attending meetings. Commissioners will also be aware of their responsibilities under 'Every Child a Talker ' programme which characterised the importance of language needs of all children. That, along with, the child health strategy, reminds all providers about the complexity of the needs of disabled children and the need to reduce barriers between commissioners and providers. 16. What is the evidence for Speech and Language Therapy interventions for language

impairment? A comprehensive literature search was undertaken on key health and social care databases. Twenty key papers were identified and summarised in the table below followed by the synthesis of individual papers which are summarised in more detail. All of these studies consider speech and language interventions or practices for children aged 0-11 years. The majority of studies consider pre-school age children. Studies were excluded that examined autistic spectrum disorders, fluency/stuttering, hearing problems/deafness, cerebral palsy, attention deficit hyperactivity disorder (ADHD), traumatic brain injury, specific speech disorder and cleft palate. Studies relating to some of these conditions will be discussed in other briefings. Details of studies All studies were published in English, with the earliest being published in 1986. Nine studies were conducted in the UK, five in the USA, two in New Zealand and one in Canada. Two studies were systematic reviews and synthesised results from studies worldwide (Law, J (2003, 2004). The number of children who took part in the studies ranged from 20 to 216 children. The studies covered a range of interventions and associated factors including type of speech/language impairment, timing of interventions, delivery of interventions, acceptability of treatment and computer-based interventions. Study quality Generally, the quality of the 20 studies was good. The two systematic reviews (Law, J (2003, 2004) were of excellent quality. Cochrane reviews are generally considered to be high quality examples of the systematic review methodology. The randomised controlled trials (RCTs) were of good/excellent quality. Common errors in the RCTs were failure to disclose methods of randomisation and small numbers of children taking part in the studies. The clinical trials were of fair quality. The results from these studies need to be interpreted with caution due to the limitations of all clinical trials i.e. lack of randomisation introducing bias. It is worth noting that the findings from the non-UK papers need to be interpreted cautiously due to generalisability of findings to the UK population.


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Considerations of Speech Language Therapy interventions The studies examined a range of components of Speech and Language Therapy (SLT) interventions and their effect on outcomes. This included intensity of intervention, timing of intervention, watch and wait vs. intervention, whom to deliver interventions and computer-based interventions Intensity of intervention All studies gave specific details of the intensity of SLT interventions which generally appeared well-organised and consistently delivered. Two studies (Barrett, J 1992, Boyle, J, 2007) focused on how increasing the intensity of therapy programmes can influence speech and language outcomes. Barrett, J (1992) compared the benefits of intensive individual SLT with more traditional once weekly sessions in a group of forty-two 2-5 years old demonstrating speech delay. The intense programme of therapy consisted of 40 minute sessions, 4 days per week for 3 weeks in each 3 month period (maximum of 24 sessions over 6 months). The comparison group in this study received the same number of sessions but once weekly over a 6 month period. Therapy took place in the child’s nursery. Both groups demonstrated similar improvements in comprehension, whilst the intense therapy group showed significantly greater gains in expression scores. Boyle et al (2007) investigated four treatment modalities for 6-11 year old children with primary language impairment; to determine whether outcomes were affected by who delivered therapy and whether this was done so in group or individual sessions. Whilst no differences were found between the four treatment modalities, their intense nature compared very favourably against standard treatment on standardised scores for expressive language. The four different treatment modalities involved 3 sessions per week as opposed to standard weekly sessions. Timing of intervention and intervention vs. “watch and wait” Two studies (Robertson, S B, 1999, Almost, D, 1998) examined the benefits of carrying out SLT interventions earlier in children with speech delay and severe phonological disorder, respectively. Glogowska (2000) investigated whether a watch and wait approach is indicated for toddlers presenting with speech delay. Robertson, S B et al (1999) carried out a small scale study in which 11 late-talking toddlers were given 12 weeks of two weekly appointments, each lasting 75 minutes. The same speech language therapist saw the child at each appointment and used techniques to encourage use of language. A comparison group of 10 children received no therapy. The children receiving the therapy made significant gains in both language and social skills. Almost, D (1998) examined the effect of early treatment on thirty children less than six years old with severe phonological disorder. Children were randomly split into two groups, one receiving the intervention (twice weekly half hour one-to-one sessions with a speech language therapist) for four months, the other receiving no treatment. After the initial four month period, the children swapped groups i.e. those who had not received the intervention now did so and the children who had initially received the intervention received no further therapy. At the four month half way point, children receiving therapy had made significant language gains in comparison to the non-therapy children. Once both groups of children had received therapy, the groups were examined again. The children who had


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received therapy earlier made greater gains in conversational speech intelligibility and expressive language skills than the later treatment group. Glogowska (2000) carried out a RCT to determine whether the provision of community speech and language therapy for early speech language delay in 159 children aged less than 3.5 years is necessary. The children were randomised to receive either immediate SLT or assigned to a 12 month “watchful waiting” period before therapy. At the end of the trial, 70% of children still had substantial speech and language deficits. SLT appears not to have had an effect. However, the failure for speech delay to resolve naturally in this time period indicates these children do need some kind of therapy. This raises questions about the appropriateness, timing, nature and intensity of SLT in the preschool population. Delivery of SLT interventions? A number of studies have looked at the appropriateness of who should administer SLT. This includes speech language therapists (SLTs), speech language therapy assistants (SLTAs), parents and teachers. Boyle, J (2007) conducted a study examining the treatment efficacy and cost effectiveness of providing SLT via SLTs or SLTAs. In addition, the study investigated the relative merits of providing this therapy as group or individual sessions. The intervention was intense incorporating 2-3 sessions per week over a 15 week period. All four therapies proved to be equally effective with no therapy modality resulting in greater gains. When taking costs into account, provision of treatment via group sessions administered by SLTAs was least costly. Individual treatment provided by SLTs proved the most costly option.

Cole, K (1986) looked specifically at classroom SLT interventions to see whether direct language instruction or an interactive style of intervention was more appropriate. Direct teacher-led instruction was provided for 19 children (aged 3-6 years) and was characterised by predetermined language goals, specific reinforcement procedures and eliciting imitation. Interactive instruction (n=25) used specific individualised language goals, no structured reinforcement procedure and a natural style of language learning where children were encouraged to initiate language production. Whilst both types of intervention resulted in significant and substantial language gains at 8 months, there were no differences between the groups in any measure. However, this study demonstrates a teacher-led intervention can be successful. Baxendale, J (2003) examined the effectiveness of directly involving parents in an intervention programme. The Hanen Parent Programme (HPP), a parent-based SLT intervention was compared with a traditional SLT clinic for thirty-seven 4-6 year olds. The HPP group received 8 weekly parent-only group sessions and 3 home visits, where the focus was on the parents’ language and interaction with their child. The traditional SLT group received 8-12 weekly individual sessions where the speech language therapist interacted directly with the child and demonstrated techniques for the parent to practice at home, consequently the emphasis was on the child’s language. The study results indicated that over a 12-month period, the majority of children demonstrated significant improvements in their language ability. No differences were detected between the HPP and traditional SLT clinical-based groups. Both therapies taught parents successful ways of interacting with their child, with the focus on being less talkative and letting the child do the talking. The HPP was more costly than the clinic-based therapy because it involved two therapists of greater experience than in the traditional clinic based therapy. However, the model of care provided in the HPP could be adjusted to increase the number of


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families included per HPP session. Further research would be required to ascertain whether this would affect the efficacy of the HPP. Gibbard, D (1994) investigated the use of parental-based therapy (PBT) in language delayed preschool children. The PBT intervention consisted of 11 group sessions over a 6 month period, each lasting 1 ¼ hours, with the objective being to increase children’s linguistic complexity by transferring linguistic skills in daily life. At the end of the intervention period, all children had improved but children whose parents were involved in the PBT group had made larger gains in language ability. The same PBT intervention was compared with children who received direct SLT (weekly 30 minute one-to-one sessions with a speech language therapist over a 6 month period). The PBT group had the highest language scores, proving that this type of intervention could be as least as effective as direct SLT whilst being more cost effective. Interestingly, 93.3% of mothers assigned to the PBT group decided to stay in this group, indicating parents are willing to be involved in such an intervention and work and practice on their child’s language development. Gibbard carried out a similar study in 2004 with twenty-two 2-3 year olds, this time investigating the costs to both the health care provider and child’s parents. This time the provision of eleven 90 minute fortnightly group PBT sessions was compared against 3 monthly review and advice visits (labelled as current practice). PBT children made much greater improvements in language skills than current practice. In terms of cost, Gibbard calculated that PBT was more costly per outcome gained than current practice, unsurprisingly since PBT require more of a therapist’s time. The cost from switching from general care to PBT was estimated at £ 3.84 per outcome gained. However, changing a parameter of PBI (for example, increasing the number of children in a group) could significantly decrease the costs of PBI and could make it the more cost effective option (assuming a change in a parameter did not affect outcomes). However, Gibbard also notes that PBI does not just result in costs to the health care provided. Costs to the parents are increased, namely travel monetary and time costs for additional appointments. Computer-based interventions

Two studies investigated the computer-based SLT intervention FastForWord (FFW) (Cohen, 2005, Gillam, 2008). FFW is an interactive computer-based programme for treating specific language impairment using acoustically enhanced speech stimuli. Children play games as part of the programme, the level of which is matched to the changing ability of the child over time. With no exception, the studies did not find any benefit in using FFW in comparison to other SLT computer-based interventions, other computer-based education (i.e. non-speech/language focused) and face-to-face SLT. Cohen, W et al (2005) looked at the effect of adding FFW to children’s regular school SLT and school regime. Seventy-seven 6-10 year olds took part in the study. Group A received FFW, Group B received other educational computer based activities (non-language focused) and Group C received no computer based intervention. Each group showed significant gains in language but no one group performed better than the other, indicating there are no additional benefits for adding a computer-based SLT intervention to standard care. Cohen et al (2005) hypothesised that this could be due, in part, to the fact the population being studied was made up of children with severe mixed-receptive SLI. Gillam (2008) carried out a study with 216 6-9 year olds with less severe language impairments in which FFW was compared with a) another computer-assisted language intervention b) individual language intervention with an SLT c) an educational computer-based programme (non-SLT). However, Gillam (2008) echoed Cohen’s findings- all four interventions made similar language gains.


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This is in contrast to several case reports and single case studies cited by Cohen, 2005 and Gillam, 2008 that document significant benefits of FFW. Type of speech impairment A small number of studies investigated factors relating to the type of speech or language impairment and their impact on treatment. This included the severity of impairment, the type of impairment and the existence of more than one speech or language impairment. Law, J et al (2004) carried out a meta-analysis on 33 studies that investigated different types of SLT interventions. They found that phonological interventions appeared effective, especially if the therapy lasted longer than 8 weeks and was administered by an SLT. Expressive vocabulary and expressive syntax interventions also appeared effective, but more so for severe language impairments. There was no evidence demonstrating receptive language interventions were effective. Law’s (2003) Cochrane systematic review backs up these findings. This review also discussed the effect of using trained parents or clinicians to deliver therapy, however no difference in effectiveness was found. Longer interventions were shown to be more effective and the use of normal language peers in interventions was supported. Group and individual interventions had no difference in terms of outcomes, but this was based on a limited number of studies. There is evidence that interventions for children with phonological disorder and phoneme awareness are effective. (Gillon, 2000 and Hesketh, 2000). Hesketh, A et al (2000) compared a phonological awareness therapy for children with phonological disorder (aged 2-5, n=61) to another type of intervention in common use, articulatory therapy. Whilst little difference was found between the two types of intervention, SLT was clearly beneficial for these children, who improved significantly more than 59 normally speaking comparison children. Tyler (2002, 2003) carried out two studies investigating the effect of SLT interventions on co-existing speech and language impairments. The 2002 study looked at the order in which to carry out therapy in a group of 3-6 year olds with both morphosyntax and phonology impairments. The results showed that carrying out a morphosyntax intervention first appears advisable since this intervention also achieved considerable changes in phonology. In contrast, no cross-domain effect was seen for the phonology first intervention. In 2003, Tyler carried out another study looking at “goal attack strategies” for co-occurring SLT impairments. The strategies were four-fold: 12 weeks of morphosyntax intervention followed by 12 weeks phonology therapy; 12 weeks phonology therapy followed by 12 weeks morphosyntax therapy; weekly alternating of the 2 therapies; simultaneous therapy focusing on the morphosyntax and phonology areas. In terms of morphosyntatic change, the alternating therapy goal attack strategy produced the greatest morphosyntatic change. No single goal attack strategy had better gains in phonological performance. Acceptability of treatment Viewpoints of parents, teachers and nursery staff were examined by the number of studies. Boyle, J (2007) investigated the efficacy of four treatment modalities, SLTs or SLTAs delivery of therapy and group vs. individual therapy. Boyle et al (2007) looked at parental and teacher perceptions of treatment as well as treatment efficacy. Parents expressed benefits of all treatment modalities and no


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type of therapy was preferred. However, parents consistently said it was important to cater for a child’s individual needs by providing the most appropriate type of therapy. Several parents expressed concern that therapy had been ‘cut off’ i.e. not phased out, at the end of the study. This was particularly pertinent in group therapy where parents felt children may have forged friendships. There was also an expression of need for long term care and parents raised the idea of teachers carrying on the SLTs/SLTAs work. Glogowska (2002) carried out a questionnaire and in depth qualitative interviews with parents involved in an RCT to determine if early SLT was more favourable than a “watchful waiting” approach. At the end of the study, the majority of parents expressed a desire for further therapy and that their child needed further therapy. Some parents whose children received SLT later (i.e. “watchful waiting” first) expressed anxiety and worry and believe that this may have stunted their child’s progress. Half of these parents indicated receiving SLT initially would have made them worry less about their child’s difficulties; whereas a third said it would have made no difference. In contrast, the majority of parents whose child had received SLT first were happy and satisfied with SLT. Further investigation in when and how treatment should be delivered must take parents into account. Whilst Barrett’s (1992) investigation into the benefits of intense therapy for speech delay demonstrated clinical benefits, some issues of acceptability of the intense mode of treatment were raised by nursery staff. Out of the six nurseries that took part, 3 nurseries considered the intensive therapy an improvement, 2 did not and 1 nursery was unsure. Nursery staff commented that the intensive therapy ensured a relationship was built up quickly and maintained between the therapist and child. However, the intensive nature made the therapy difficult to fit in with other care programmes. Clearly, despite the benefits of intensive treatment, some consideration needs to be given to practical factors. Non-SLT benefits Several studies discussed the benefits of SLT interventions on non language outcomes. It seems SLT interventions have implications beyond improving language gains. Robertson, S B et al (1999) found that late talking toddlers who received an early SLT intervention showed improvements on a range of language measures and the children improved in their interpersonal relationships, play and leisure and coping skills. Parental stress also dramatically reduced and their perception of their child’s behaviour and skills was also changed. Thus indicating, early intervention for speech delay not only improves language but increases social skills and decreases disruption to the parent-child relationship. Boyle, J et al (2007) also sought views from parents and teachers on children’s progress following one of four intense programmes of SLT (varied in who delivered therapy and whether group or individual sessions). Parents consistently expressed that their child’s self-confidence and enthusiasm for learning had improved. Behaviour was reportedly better and children showed less frustration. Parents also reported tangible benefits were seen in literacy and other curriculum. Teachers backed up these views especially with regard to improvement in children’s self-confidence. Gillon, G (2000) investigated the effects of a phonological awareness (PA) programme on children’s speech production and reading. The intervention was designed to improve children’s awareness of the sound structure of spoken language and to develop knowledge of the connection between speech and print. The programme consisted of two 1 hour sessions per week with a total of 20 hours of intervention


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being delivered. This was compared with a traditional phonological and language skills intervention, a minimal once monthly intervention with a speech language therapist and a group of normally developing children. Children receiving the PA intervention improved in both phonological awareness, speech production and reading development. Phonemic awareness skills for the PA group were comparable to ‘normal development’. Gillon followed the progress of twenty children from the PA group in 2002. One year on following the intervention, children who had received the PA intervention were reading at, or above the level expected for their age. In contrast, those who did not receive the PA intervention remained poor readers. Gillam (2008) investigated the use of computer-based SLT interventions. However, children who received non-language focused computer educational packages made very similar gains to those receiving the language-focused computer package, FastForWord. This was in part due to the nature of the therapy. As well as receiving computer-based therapy of some kind (language or non-language focused) children were given the opportunity to socialise with same-ability peers and a positive attentive environment. Several parents commented their children made friendships more easily in this setting. Socialisation appears to improve language outcome and a variety of educational activities could be important for language gains. Summary The benefits of SLT interventions extend beyond language gains. Improvements in social skills, peer relationships, self-confidence and literacy may be seen as a result of SLT interventions. Consideration needs to be given as to when and how SLT interventions are delivered. There is some evidence that early intervention and more intense interventions may be produce greater speech and language gains. There appears to be little evidence at present for the use of computer-based SLT interventions. Successful delivery of SLT interventions can be achieved through training parents, via speech language therapists and speech language therapist assistants. However, there are cost and time implications according to who delivers treatment and the intensity of treatment. Further research is required to identify which types of children and/or parents may benefit from different types and delivery of therapy. References 1. Almost, D. & Rosenbaum, P. 1998, "Effectiveness of speech intervention for phonological

disorders: a randomized controlled trial", Developmental Medicine and Child Neurology, 40, 5, 319-325.

2. Barratt, J., Littlejohns, P., & Thompson, J. 1992, "Trial of intensive compared with weekly speech therapy in preschool children", Archives of Disease in Childhood, 67, 1, 106-108.

3. Baxendale, J. & Hesketh, A. 2003, "Comparison of the effectiveness of the Hanen Parent Programme and traditional clinic therapy", International Journal of Language & Communication Disorders, 38, 4, 397-415.

4. Boyle, J., McCartney, E., Forbes, J., & O'Hare, A. 2007, "A randomised controlled trial and economic evaluation of direct versus indirect and individual versus group modes of speech and language therapy for children with primary language impairment", Health Technology Assessment (Winchester, England), 11, 25, pp. iii-iv, xi.


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5. Cirrin, F. M. & Cirrin, F. M. 2008, "Language intervention practices for school-age children with spoken language disorders: A systematic review. [References]", Language, Speech, and Hearing Services in Schools, 39, 1, p. Jan-S137.

6. Cohen, W., Hodson, A., O'Hare, A., Boyle, J., Durrani, T., McCartney, E., Mattey, M., Naftalin, L., & Watson, J. 2005, "Effects of computer-based intervention through acoustically modified speech (Fast ForWord) in severe mixed receptive-expressive language impairment: outcomes from a randomized controlled trial", Journal of Speech Language & Hearing Research, 48, 3, 715-729.

7. Cole, K. N. & Dale, P. S. 1986, "Direct language instruction and interactive language instruction with language delayed preschool children: a comparison study", Journal of Speech Language & Hearing Research, 29, 2, 206-217.

8. Gibbard, D. 1994, "Parental-based intervention with pre-school language-delayed children", European Journal of Disorders of Communication : Journal of the College of Speech and Language Therapists, London, 29, 2, 131-150.

9. Gibbard, D., Coglan, L., & MacDonald, J. 2004, "Cost-Effectiveness Analysis of Current Practice and Parent Intervention for Children under 3 Years Presenting with Expressive Language Delay", International Journal of Language & Communication Disorders, 39, 2, 229-244.

10. Gillam, R. B. & Gillam, R. B. 2008, "The efficacy of FastForWord Language intervention in school-age children with language impairment: A randomized controlled trial. [References]", Journal of Speech, Language & Hearing Research, 51, 1, Feb-119.

11. Gillon, G. T. 2000, "The efficacy of phonological awareness intervention for children with spoken language impairment", Language, Speech, and Hearing Services in Schools, 31, 2, 126-141.

12. Gillon, G. T. 2002, "Follow-up study investigating the benefits of phonological awareness intervention for children with spoken language impairment", International Journal of Language & Communication Disorders, 37, 4, 381-400.

13. Glogowska, M., Roulstone, S., Enderby, P., & Peters, T. J. 2000, "Randomised controlled trial of community based speech and language therapy in preschool children", British Medical Journal (Clinical research ed.), 321, 7266, 923-926.

14. Glogowska, M., Campbell, R., Peters, T. J., Roulstone, S., Campbell, R., & Enderby, P. 2002, "A multimethod approach to the evaluation of community preschool speech and language therapy provision", Child: Care, Health & Development, 28, 6, 513-521.

15. Hesketh, A., Adams, C., Nightingale, C., & Hall, R. 2000, "Phonological awareness therapy and articulatory training approaches for children with phonological disorders: a comparative outcome study", International Journal of Language & Communication Disorders / Royal College of Speech & Language Therapists., 35, 3, 337-354.

16. Law, J., Garrett, Z., & Nye, C. 2003. "Speech and language therapy interventions for children with primary speech and language delay or disorder. Cochrane Database of Systematic Reviews:


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Reviews," in Cochrane Database of Systematic Reviews 2003 Issue 3, John Wiley & Sons, Ltd, Chichester (UK).

17. Law, J., Garrett, Z., & Nye, C. 2004. "The efficacy of treatment for children with developmental speech and language delay/disorder: a meta-analysis (DARE provisional record)", Journal of Speech, Language, & Hearing Research, 47, 924-943.

18. Robertson, S. & Weismer, S. 1999, "Effects of treatment on linguistic and social skills in toddlers with delayed language development", Journal of Speech, Language, & Hearing Research, 42, 5, 1234-1248.

19. Tyler, A., Lewis, K., Haskill, A., & Tolbert, L. 2002. "Efficacy and Cross-Domain Effects of a Morphosyntax and a Phonology Intervention", Language, Speech, and Hearing Services in Schools, 33, 1, 52-66.

20. Tyler, A. A., Lewis, K. E., Haskill, A., & Tolbert, L. C. 2003. "Outcomes of Different Speech and Language Goal Attack Strategies", Journal of Speech, Language & Hearing Research, 46, 5, 1077-1094.

Table 13: Literature

Study Country Study design Study quality

Subjects Intervention

Almost, D (1998)

Canada RCT Good N=30 <6 yrs old Severe phonological disorders

Early treatment vs. late treatment

Barrett (1992)

UK RCT Good N=37 4-6 year olds with expressive or expressive/receptive language impairment

Parent-based vs. SLT administered intervention

Baxendale (2003)

UK Clinical trial Good/ average

N=42 2- 5 year olds with language delay

Intensive individual SLT vs. traditional 1x weekly sessions

Boyle (2007)

UK

RCT (HTA) Good N=152 6-11 year olds with persistent primary receptive and/or expressive language impairment

Direct (SLT) vs. indirect (SLTA) Group vs. individual therapy

Cohen (2005)

UK RCT Excellent N= 77 6- 10 year olds with severe mixed receptive-

expressive language

impairment

FastForWord computer-based intervention vs. standard SLT vs. non-SLT computer-based activities

Cole (1986) USA RCT Good N=44 3-6 year olds with language delay

Direct SLT teacher led vs. interactive


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language instruction Gibbard (1994)

UK RCT Good N=36 2-3 year olds with little or no expressive language (<30 words)

Parental based SLT vs. no treatment or direct SLT (one-to-one basis between therapist and child)

Gibbard (2004)

UK Cost effectiveness study

Good N= 22 2- 3 year olds with little or no expressive language (<30 words)

Parental based SLT vs. 3 monthly review/advice appointments with an SLT

Gillam (2008)

USA RCT Excellent N=216 6-9 year olds with language impairment

FastForWord vs. another language computer-based intervention vs. an educational non-SLT computer-based intervention vs. traditional SLT

Gillon (2000)

New Zealand

Clinical trial Good N= 91 5-7.5 year olds with spoken language impairment and early reading delay

Phonological awareness intervention vs. traditional intervention vs. minimal intervention (Additional comparison with ‘normally’ developing children)

Gillon (2002)

New Zealand

Clinical trial (longitudinal)

Good 20 children from Gillon (2000) study reassessed

Longevity of effect of phonological awareness intervention

Glogowska (2000)

UK RCT Excellent N= 159 children < 3.5 years with speech delay

Community speech and language therapy provision vs. “watchful waiting”

Glogowska (2002)

UK Qualitative study

Good N= 159 children < 3.5 years with speech delay

Community speech and language therapy provision vs. “watchful waiting”

Hesketh (2000)

UK RCT Good/ average

N= 61 3-5 year olds with phonological disorder

Phonological awareness therapy

Law (2004) Worldwide Systematic review/ Meta-

Excellent 33 studies included in meta-analysis

Range of SLT interventions


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analysis Law (2003) Worldwide Systematic

review Excellent 25 studies Range of SLT

interventions Robertson (1999)

USA RCT Good/ average

21 late-talking toddlers

Early intervention with SLT

Tyler (2002) USA RCT Good/ average

27 3-6 year olds with impairments in both morphosyntax and phonology

Order of treatment

Tyler (2003) USA RCT Good/ average

47 3-6 year olds with impairments in both morphosyntax and phonology

Goal attack strategies i.e. how to approach multiple goals

17. References Cited

1. Archibald, L. & Gathercole, S. 2006. Short-term and working memory in specific language impairment. Journal International Journal of Language & Communication Disorders, 41, 6, 675 – 693.

2. Bercow, J. 2008. Better Communication: An Action Plan to Improve Services for Children and

Young People with Speech, Language and Communication Needs Department of Health.

3. Bishop, D. 1992. The underlying nature of specific language impairment, Journal of Child Psychology and Psychiatry, 33, 3-66.

4. Bishop, D. & Clarkson, B. 2003. Written language as a window into residual language deficits: a

study of children with persistent and residual speech and language impairments. Cortex, 39, 215-237.

5. Bryan, K. 2008. Speech, Language and Communication difficulties in Juvenile Offenders. In C.

Hudson (ed) The Sound and the Silence: Key Perspectives on Speaking and Listening and Skills for Life. Coventry: Quality Improvement Agency.

6. Bryan, K. 2004. Preliminary study of the prevalence of speech and language difficulties in

young offenders, International Journal of Language and Communication Disorders, 39, 3, 391-400.

7. Conti-Ramsden, G., Botting, N., Simkin, Z. & Knox, E. 2001. Follow-up of children attending

infant language units: Outcomes at 11 years of age. International Journal of Language and Communication Disorders, 36, 207-219.




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8. Crosbie, S., Holm, A, & Dodd, B. 2005. Intervention for children with severe speech disorder: A comparison of two approaches. International Journal of Language and Communication Disorders, 40, 4, 467-491.

9. Department of Health 2009. Healthy lives, brighter futures - The strategy for children and young

people's health. www.dh.gov.uk

10. Department of Health 2009. Securing better health for children and young people through world class commissioning: A guide to support delivery of Healthy lives, brighter futures: The strategy for children and young people's health. www.dh.gov.uk

11. Enderby, P. & Emerson, J. 1995. Does speech & language therapy work? London: Whurr.

12. Hamilton, J. 1999. Speech Language and Communication Therapy: a perspective from HMYOI

Polmont. Internal Report (Forth Valley Primary Care NHS Trust).

13. Hart, B. & Risley, T. 1995. Meaningful Differences in the Everyday Experience of Young American Children. Paul H Brookes Publishing Company.

14. ICAN 2006. Cost to the Nation of Children’s Poor Communication www.ican.org.uk.

15. Jerome, A., Fujiki, M., Brinton, B., James, S. 2002. Self-esteem in children with specific language impairment. Journal of Speech Language & Hearing Research, 45, 700-714.

16. Johnson, C., Beitchman, J., Young, A., Escobar, M., Atkinson, L., Wilson, B., et al., 1999.

Fourteen-year follow-up of children with and without speech/language impairments: Speech/language stability and outcomes. Journal of Speech Language and Hearing Research, 42, 744-760.

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