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Effectiveness of intervention for children with primary pragmatic

communication needs

Elaine Lockton and Catherine Adams

School of Psychological SciencesUniversity of Manchester, UK

Outline

• Pragmatic language impairment (PLI)

• The Social Communication Intervention Programme (SCIP) trial

• Interventions

• Outcomes

• Conclusions and way forward for complex intervention studies

Pragmatic Language Impairment

• Many children with a variety of communication disorders have disrupted use of language or pragmatics

• PLI - Where pragmatics is disproportionately disrupted compared to other aspects of language (such as syntax) development– Bishop 2000

Communication characteristics

• May be talkative• Turn-taking and topic maintenance problems• Information management problems• Inappropriate questioning• Comprehension difficulties• Disorganised narratives• Poor at making inferences• Persistent subtle language impairment into middle

childhood and beyond– Rapin & Allen 1987, Bishop & Adams 1989, Adams 2001

PLI interventions

• Pragmatic communication needs are increasingly part of caseload as more children with ASD are identified

• Recognition of negative consequences of on mental health and social relationships (Whitehouse et al 2009)

• Importance of communication skills in quality of life and well-being

PLI interventions

• Amount and nature of typical provision not known

• Weak evidence base • Currently no guidelines to suggest which

method is preferred for a specific individual’s needs

• Choice of communication intervention may be similar across HFA/PLI groups

• No randomised controlled trials

Evidence for PLI interventions

• Rich clinical expertise literature on broader issues of social communication and conversational disability (Brinton & Fujiki 1995, 2005; Timler, Olswang et al 2005)

• Positive outcomes in case studies of social communication (Adams, 2001; Olswang, Coggins & Timler, 2001; Timler, Olswang & Coggins, 2005)

• Positive effects on conversational skills and some language test scores after intensive therapy in a case-series study (Adams et al, 2006)

Outline



• Interventions

• Outcomes


The Social Communication Intervention Programme (SCIP)

A randomised control trial of intervention for children with pragmatic language impairment

Catherine Adams and Elaine Lockton

Funded by the Nuffield Foundation

Aim

• Ascertain the effectiveness of an intensive social communication therapy (SCIP), compared to treatment-as-usual, for children who have PLI

– On standardised language assessment functioning

– On functional pragmatic ability and broader social communication as rated by parents and teachers

Participants

Referred from SLT caseloads

• 6 – 11 years old

• Pragmatic communication impairment observed by the child’s SLT

• Attending mainstream primary education provision and identified as having Special Educational Needs/Additional Support Needs

• Receiving regular, ongoing attention from SLT services

• No diagnosis of frank autism• No severe difficulties in emotional

development, behaviour needs, unintelligibility, or hearing loss

• Score ≤ 58 on the General Communication Composite of the Children’s Communication Checklist

• Score ≥ 5th centile on the Ravens Coloured Progressive Matrices

Outline



• Interventions

• Outcomes


SCIP intervention

• Complex intervention– Multiple observations– Variable outcomes– Individualisation in treatment delivery

• Manual of intervention– Assessment findings mapped to aspects and goals of

intervention in the SCIP manual– Systematic procedure to allow for prioritisation of

therapy goals identified by the mapping process

SCIP intervention framework

Social communication

social understanding

pragmatics language

processing

Social Understanding and Social Interaction

• Aimed at enhancing understanding of social communication conventions and behaviours, mediated through language – Understanding social context

– Understanding emotions

– Developing and understanding flexibility

– Understanding thoughts and intentions

– Understanding friendships

Language Processing

• Focused on enhancing complex language skills (such as narrative) in order to support social communication– Word-finding and semantics

– Narrative construction

– Understanding idiomatic language

– Understanding of text and complex sentences

– Comprehension monitoring

Pragmatics

• Focused on building understanding and application of pragmatic behaviours and rules in a metacognitive context– Conversation skills

– Understanding information requirements

– Turn taking conventions

– Topic management

– Discourse style

Sabotaging turn-taking

• Consolidate rules/cues• Child can identify, demonstrate and repair• In games, stories, conversation

• Developing heightened self-awareness and self-monitoring skills

• Awareness of the mismatch between habitual social interaction behaviours and conventionally expected behaviours

• Intensive individualised practice

Sabotaging listening skills

The child takes a turn to show that they know what fidgeting is and that you can't listen and fidget at the same time

Is this puppet a good listener?The SLT uses the puppet to show the child that it is harder to listen to the story when the puppet is fidgeting

Individualisation

• Teacher main concerns

– “finds difficulty in staying on task - LSA consistently by side”

– “in whole group teaching - lots of visual prompts needed for good sitting/listening/looking”

Individualisation

• Parents main concerns

– “Friendships and learning social rules”

– “Fixed routines - set aisles at the supermarket”

– “Found it very difficult to cope if he couldn’t stop by the fish counter”

SCIP intervention

• Intensive, reflective and highly individualised• Provides explicit explanations of social

conventions, social behaviours and the vocabulary of interaction

• Support for language comprehension (language scaffolding)

• Close consultation with parents, teachers and support staff for generalisation and suitability of targets as new skills and awareness emerge

SCIP intervention

• Up to three, one-hour therapy sessions per week (up to a maximum of 20 sessions)

• Delivered in school by specialist therapist or trained assistant

• One-to-one sessions, provision of whole class and home based activities

• Parent/teacher/LSA attendance and input solicited throughout

Skills, training and supervision

• Specialist therapists– Extensive specialist knowledge

– Responsible for case management and intervention planning

• Assistants– Intensive and specialised training in pragmatic

communication needs• Principles of intervention - reinforcing targeted vocabulary,

differentiation, using visual supports for learning, managing pace, personalising the intervention to the child

• Therapy methods - modelling, role play, sabotage

• Observation and video recordings used to inform training needs

Treatment-as-usual

• As provided by their local SLT services

• Continued to receive LSA support– Limited direct intervention addressing communication

skills• Delivered by speech-language practitioners or support workers

– Indirect interventions• Typically advice and training on communication for

education/support staff/parents

• Strategies for language support in the classroom and for modifications to the environment (such as use of visual cues)

Outline



• Interventions

• Outcomes


Standardised language assessments

• Receptive and expressive language

CELF- 4 Core Language Standard Score (CLSS)

• Measure of ability to interpret, remember and tell a pictured narrative

• Initial telling of the story (ERRNI-I)

• Story recall (ERRNI-R)

• Comprehension (ERRNI-C)

Expression, Reception and Recall of Narrative Instrument (ERRNI)

Targeted Observation of Pragmatics in Children’s Conversation (TOPICC)

• Derived, a priori, from the CCC-2

• Autism-type communication problems scale (CCC-2 AUT) identified as a control for bias

Pragmatics rating scale (CCC-2 PRAG)

• Language Skills (PRO-LS)

• Social Communication (PRO-SC)

• Social Situations (PRO-SS)

• Peer Relationships (PRO-PR)

Parent reported outcome (PRO)

• Child’s behaviour in typical classroom situations - starting or completing a task, problem-solving skills, asking for help, working in a group etc

Teacher reported classroom learning skills (TRO-CLS)

Parent/teacher reported measures

Parent reported outcomes T2

• Language skills– “He is asking lots of questions and is putting things in the

correct context. He is more confident and willing to participate where he used to be silent”

• Social communication– “He is finding it easier to wait his turn to speak and will at least

say “excuse me” before butting in! He is definitely following conversations and will chip in if something catches his interest”

– “He still switches off instantly if the topic is of no interest”


• Social situations– “He seems more able to communicate as an equal. There isn’t

as much silence around the table or on car journeys! He is expressing his needs more appropriately”

– “He still disengages himself if he is out of his depth or disinterested”

• Peer relationships– “His relationships have been strengthened. Other children

want him around rather than just wanting to mother him. He can take them or leave them depending on his mood”


• Main concerns now

– “Our concerns are the same but we are thrilled with the progress made in a short space of time”

– “There has certainly been a step change in our child although many communication difficulties remain”


• Language skills– “He will now sometimes initiate conversation with others. He will

enquire more e.g. has asked if his friend has had a nice Christmas” – “He is asking what new words mean all the time and will then try to

use the word”

• Social communication– “He still struggles to take turns. He will say “excuse me” when he

wants to interrupt but still doesn’t see why he then has to wait his turn”

– “The majority of his communication is on a needs only basis about his particular interest”

– “He will not share what he has done at school that day etc”


• Social situations– “He wants to involve himself socially but doesn’t know how

e.g. if the others are playing tig, he doesn’t know how to get himself included. He is equally happy sometimes to disengage himself and let it all just happen around him”

• Peer relationships– “He shows more kindness especially to other children in

distress”– “He has expressed missing another child who has gone to

another school”


• Main concerns now– “Meaningful friendships- this will become more of an

issue as high school looms when he will need to initiate conversations to fit in”

– “Asking for help/expressing displeasure. He is displaying some aggressive behaviour if he is not getting his own way. This is easier for him than wading through tricky language to get his message across”

– “Social rules. Knowing what will help him fit in. Instinctively recognising appropriateness”

Teacher reported outcomes

• “Improved incredibly!- asking questions, more responsive in whole class situations, becoming more independent”

• “Able to listen better even if not being targeted personally”

Outline



• Interventions

• Outcomes


Conclusions

• Increased emphasis on importance of patient reported outcomes

• Changes meaningful to those living and working with the children daily

• Central to current aspirations of delivering services which are designed around the family

How and why is SCIP having an effect?

• Difficult to attribute intervention effects to the specific content of SCIP rather than increased specialist attention

• Fair comparison with the care that would have been received were the trial not to have taken place

• Potential for future exploration of mediators• Also moderators – for which individuals is

SCIP preferred choice?

Implications for future complex intervention studies

• Unlikely to be uniform outcome effects across participants

• Outcomes at the levels of activity and participation

• Specific to an individual’s unique context• Novel measures such as differentiated,

individualised criteria for change may need to be adopted

Acknowledgements

Researchers & assistants:

Jenny Freed

Jacqueline Gaile

Gillian Earl

Kirsty McBean

Jenny Gibson

Anna Collins

Ruth Wadman

Rachel Stevens

Catherine Bird

Vivienne McKenzie

Sibyl Havers

Collaborators:

Dr Catherine Aldred

Dr Janet Baxendale

Professor Jonathan Green

Dr Marysia Nash

Professor James Law

Dr Andrew Vail

Advisory committee:

Bonnie Brinton

Martin Fujiki

Geoff Lindsay

Sue Roulstone

Thanks also to:

Nuffield Foundation

Greater Manchester and

Edinburgh NHS SLT Services

Parents and children in Edinburgh

and NW England

University of Manchester

undergraduate and postgraduate

SLTs

Further information

http://www.psych-sci.manchester.ac.uk/scip/

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Effectiveness of intervention for children with primary ...research.bmh.manchester.ac.uk/scip/projectoverview/conference... · Effectiveness of intervention for children with primary