SINGING FROM THE SAME HYMN SHEET –

The importance of adopting a population approach to intervention for child with language learning difficulties

James LawProfessor of Speech and Language Science

University of Limerick – Practitioner Conference May 2017

Is child language a public health problem?

What is a public health problem?

For a health problem to be considered a public health issue, three criteria must be met:-

• It must place a large burden on society, a burden that appears to be getting larger;

• The burden must be distributed unfairly (i.e., certain segments of the population are unequally affected);

• There must be evidence that upstream preventive strategies could substantially reduce the burden of the condition

The burden - Is it getting larger?

• Prevalence estimates suggest DLD is as prevalent as childhood obesity, reported to be 7% in Australia. Approximately 5% to 8% of children may have DLD.

• In population-based samples, which use broader criteria and include less severe DLD, estimates are higher. Population-based studies report 14% to 20% of 4-5 year old children may be affected by DLD, with similar levels also reported at age 7 years.

• In Australia, there has been a major increase in the number of speech pathology service claims made to Medicare, Australia’s publicly funded universal health care system. The speech pathology Medicare service items reported went from 3,051 in 2004-05, to 115,167 in 2012-13, with majority of services for 0-14 year olds.

and in the US..

• Two nationally representative surveys that include measures of speech and language disorders in children at multiple points in time are the National Survey of Children’s Health and the National Survey of Children with Special Health Care Needs.

• The National Survey of Children’s Health showed an increase in prevalence of speech and language disorders from 3.8 percent (n = 2,697) in 2007 to 4.8 percent (n = 3,916) in 2011, a 26 percent increase.

• The National Survey of Children with Special Health Care Needs showed an increase in prevalence from 3.2 percent (n = 8,435) in 2005-2006 to 5.0 percent (n = 11,936) in 2009-2010, an increase of 56 percent

• “The best available evidence shows an increase in the prevalence of speech and language disorders over the past decade in the U.S. child population. Trends in annual Supplemental Security Income initial allowances parallel this overall increase. “

Is the burden distributed unfairly?

• Social gradient

Social gradient in oral language skills amongst 5-6 year old children on the Australian Early Development Census(AEDC) in 2015 and the UK’s Millenium Cohort Study in 2005

0

2

4

6

8

10

12

14

16

Mostdisadvantaged

Quintile 2 Quintile 3 Quintile 4 Leastdisadvantaged

% D

evel

op

men

etal

ly v

uln

erab

le la

ngu

age

skill

s

Access

• Access to services is not equitably distributed –i.e., it is not easy for all children to access relevant services.

• It is often those families who are most in need of services, who access them the least.

• Barriers to accessing health services reported by vulnerable families include cost, as well as availability and accessibility of health services.

• Not only are there financial barriers to access, but more socially advantaged parents are more likely to have the skills and knowledge based on their education and experience to be resourceful and access the services they need.

What can you do about it?

The three pillars of evidence based practice..+1

Best research evidence

needs to be:-

Accessible – is it easy to find?

Readily interpretable – what does it mean?

Meaningful in a practice context – can I use it?

Divisible into its components - what are the key elements that make an intervention work?

Realistic – what sort of effects should we be expecting?

Translatable - across cultures and languages

Meaningful to policy makers and those mediating whether an intervention is introduced and supported

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And the “What works” (WW) for children

with speech and language needs

and the Communication Trust WW interactive website:-

www.thecommunicationtrust.org.uk/schools/what-works

Section Header slideSubtitle

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“Foundations for Life”

Review of the evidence for early developmental interventions –in many cases not even including language development

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http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004110/pdf

Source

Intervention evidence

• Lots of intervention evidence available from What Works for SLCN, SpeechBite etc plus 15 or so systematic reviews

• Need to separate out into:-

• Universal

• Targeted selective

• Targeted indicated

• Specialist

• Not always an easy task (partly because people are not clear about their sampling)

How robust is the evidence?

Findings from the EEF report..

• 44 intervention studies (quasi-experimental and randomised)

• Specific outcomes• Phonological awareness ( n= 8 ): an understanding of the sound structure of the spoken language.

• Vocabulary: expressive and receptive (n=20) – the ability to use or understand words.

• Expressive language (n=7) : children’s ability to use language in an accurate and coherent manner.

• Receptive language (n=9): children’s ability to understand complex language forms including grammar, inferential use of language etc.

• Sample sizes varied considerably from 12 (Tsybina and Eriks-Brophy, 2010) to 2250 (Apthorp et al.2012) and the studies varied considerably in terms of whether they were clear Universal (7), or targeted – selective (20) or targeted –indicated/specialist (17)

• Equally balanced between programmes and practices

What did we recommend?

1. There is a need to explore the potential role of parent child interaction interventions with young children as a means of promoting children’s language abilities and ensuring that children are ready for learning when they get to nursery at 2-3 years.

• Care needs to be taken to identify parent/child dyads where there is some concern about the interaction AND there is an identified language difficulty.

• The outcomes for such a study would be improved interaction, vocabulary and potential early word combinations.

• The comparison intervention here would most likely be with routine care – from health visitors and other community services.

2. There is a need for an efficacy trial of training teachers (professional development) to deliver interventions within the classroom drawing on the work of Piasta, Dockrell and The Hanen Centre’s Learning Language and Loving It.

• The outcome for such a study should be vocabulary (receptive and expressive), narrative skills and pre-reading skills.

• The comparison here should be with routine care in comparable early years settings AND with targeted (indicated) interventions provided by specialist staff such as speech and language therapists.

Some thoughts on the randomisation question

• Randomisation reduces bias by washing out the contextual factors – but are those factors of interest

• Randomisation per se tells you nothing about how an intervention works – just whether

• Internal and external validity – especially the latter means the results are generalizable –you can take what you are doping in one place and apply it to another

• Serious concerns that this may not be feasible in highly contexualised, complex interventions such as intervention for children with language learning difficulties. Cf the example of classroom size (Cartwright and Hardie 2012)

• Comes back to both your population and to the way that the intervention is administered. First and second generation interventions commonly vary widely in their impact Remember the best external evidence is only one of the pillars of EBP

• We also need well informed patients and the practitioners perspective plus, of course, a better understanding of the active ingredients of interventions

But what about active ingredients – the application of behaviour change techniques

• The Medical Research Council (Craig et al. 2008) - only by understanding how an intervention works can we design, apply and replicate effective interventions;

• Based on behaviour change theory drawing from smoking cessation and increasing healthy eating and physical exercise (Michie et al. 2011);

• BCT replicable and aims to alter the causal processes

Active ingredients - Logic models – a public health example

Logic models and theories of change..

Identify children with SLCN

Deliver intervention –

meeting predetermined

criteria

Parent and child respond to

intervention

Monitor primary outcome –

speech/language

Monitor impact – wellbeing,

QOL, independence

What are the ingredients of speech and language therapy interventions?

• The Behaviour Change Technique Taxonomy (BCTT) comprises 93 Behaviour Change Techniques (BCTs) agreed by a panel of international experts (Michie et al, 2013);

• SLT interventions are complex due to many interacting elements within them, difficulties with replication and to identify the causal mechanisms, or active ingredients (Michie et al., 2011a;

• Developed by team at Newcastle precisely for children with speech and language disorders focussing on phonological awareness (Stringer and Toft 2016 plus student input from Atkinson and Spalding).

Some illustrations..(from Stringer et al.)BCT definition Example

Prompt self-

evaluation of

performance

Prompt the client to evaluate their own

performance of the behaviour through

questioning and/or modelling the client’s

current behaviour.

NOTE: in SLT this may be considered

‘encouraging self-monitoring’

The therapist repeats an incorrectly

performed behaviour and asks the client to

judge their production e.g. if the client states

that the first sound of ‘zebra’ is /s/, the

therapist asks ‘is it sssebra? Is that right?’

Ensuring

comprehension

After having given information, ask

questions about the information.

The therapist gives the client 3 instructions

and asks the client to explain what number 1

was.

Explaining to the client how/when to use the

‘ing’ rule and then asking them to explain it

back in their own words.

Recasting The therapist repeats a behaviour that

corrects an error the client has made or

expands the behaviour used (usually a

language form). It occurs immediately after

the initial behaviour and does not explicitly

correct the client.

The child responds to the question ‘what’s

happening?’ by saying ‘pouring juice into the

box’. The therapist recasts this response by

saying ‘the baby is pouring juice into the

box’.

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Collaborative working and the development of social capital..• External evidence often gives the impression that if you get an “effect” in a trial that is

sufficient

• Context is critical and ownership essential – especially between health and educational practitioners

• At the heart of this relationship is trust but also the development of social capital

• Social capital theory has been widely used elsewhere but not in this area• McKean, C. Law, J., Laing, K.,Cockerill, M., Allon-Smith, J., McCartney, E., & Forbes, J. (2016) A qualitative case study

in the social capital of co-practice for children with speech, language and communication needs International Journal of Language & Communication Disorders DOI: 10.1111/1460-6984.12296

• McCartney, E., Forbes, J., McKean,C. Karen Laing, K. Cockerill, M & Law, J. Variation in headteachers' approaches to meeting the needs of primary school children with speech, language and communication needs (SLCN) in one English Local Authority: a systems approach.

• Forbes, J., McCartney E., McKean,C. Karen Laing, K. Cockerill, M & Law, J Productive interprofessional social capital affect relations in the ‘Language for All’ study on cross-professional working for primary school age children with speech, language and communication needs

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The European perspective

COST ACTION IS1406

Enhancing children's oral language skills across Europe and beyond:

a collaboration focusing on interventions for children with difficulties learning their first language

#COSTIS1406

http://research.ncl.ac.uk/costis1406/

COST Domain: Individuals, Societies, Cultures and Health

Aim and objectives of the Action

Aim

to increase the effectiveness of interventions for children with Language Impairment and provide a better understanding of the context in which those interventions are delivered.

Objectives

1. Create a coherent understanding of the population “in need” of intervention and develop standardised terminology

2. Identify the best evidence based practice related to LI, drawing on literature and practice expertise

3. Place the intervention evidence within the health, education and social care policy landscape of the country concerned

4. Facilitate and organise the training of Early Stage Researchers.

Which countries are involved in Action 1406?

Who is in our “Core” group?

Chair James Law UK

Vice chair Elin Thordardottir Iceland

Working group 1 Chair David Saldana Spain

Vice chair Carol-Anne Murphy Ireland

Working group 2 Chair Ellen Gerrits Netherlands

Vice chair Cristina McKean UK

Working group 3 Chair Seyhun Topbas Turkey

Vice chair Elin Thordardottir Iceland

EDITORIAL BOARD Chair: Maria Kambanaros Cyprus

Vice chair Kakia Petinou Cyprus

TRAINING COMMITTEE Chair Mila Vulchanova Norway

Vice chair Kristine Jensen De Lopez Denmark

OTHER ROLES Short Term Scientific Mission Co-ordinator Jan de Jong Netherlands

The Working Groups

1. The linguistic and psychological underpinnings of interventions for LI

What are the key skills that we need to be targeting in interventions – eg. language knowledge and skills, working-memory and other relevant cognitive (for example meta-cognition) and wider processing skills (attention and executive functioning)?

2. The delivery of interventions for LI

How have we developed evidence based service delivery models for children with LI (egindividual vs group therapy, direct vs indirect therapy, mainstream vs special schools, the use of ICT in service delivery)?

3. The social and cultural context of intervention for children with LI

What institutional (physical, managerial) and socio-cultural factors (demographics, ethnicity, migration, changing family structures) impact on the interventions provided to children with LI?

Training Schools

• Systematic Reviews and their Potential Role in the COST Action (January 2016, Newcastle)

• Mixed Methods for Healthcare Research: Applied Survey and Qualitative Methods (December 2016, Aalborg)

• Best Practice for Intervention Research (March 2017, Seville)

Short Term Scientific Missions• Developing and Framing Systematic Reviews on the Linguistic and Psychological Underpinnings of

Intervention

Carol-Anne Murphy and David Saldana (Limerick to Seville, March 2016).

• Outlining the Key Constructs on Services Related Issues

Naomi Buchmann and James Law (Munich to Newcastle, March 2016)

• Speech and Language Services in Croatia and UK

Ana Matić and James Law (Zagreb to Newcastle, April 2016).

• Collate data of survey on service deliveryHelena Oosthuizen and Ellen Gerrits (Cape Town to Utrecht, July 2016)

• Dosage Intervention for Children with LI

Anna-Kaisa Tolonen and Cristina McKean (Oulu to Newcastle, October 2016)

• Knowledge Elicitation Methods

Maja Kelić and Sue Roulstone (Zagreb to Bristol, November 2016)

• Modelling Grammatical Learning in Language Impaired Children

Maria Garraffa and Maria Kambanaros (Edinburgh to Limassol, October 2016)

Dissemination

To find out more:http://research.ncl.ac.uk/costis1406

http://www.cost.eu/

To wrap up..

• Understanding populations is the key to effective and equitable service delivery;

• The social gradient is a consistent feature of most aspects of development across populations;

• Emerging evidence that some populations are not especially well served (but if you don’t ask the question you cannot find this out);

• In the UK the public health model has been embraced. The evidence supporting it is better in some areas than others and does not necessarily relate to language;

• Early does not necessarily mean young (although it does here);

• Indicated and selective targeted interventions have been developed in a number of areas with some pretty sizeable effects although replications are much needed. Genuinely universal interventions are much less common and less well evaluated;

• Need to have a more nuanced view of evidence based practice;

• Commonality of terminology across populations and languages helps the applicability of evidence based practice although contexts are likely to vary considerably.

Some useful references on the public health/child language question

• Cartwright, N. & Hardie, J. (2012) Evidence based policy: A practical guide to doing it better. Oxford: Oxford University Press.

• De Cesaro, B.C., Gurgel, L.G., Pisoni, G., Nunes, C., Reppol,C.T. 2013Child language interventions in public health: a systematic literature review CoDAS;25(6):588-94

• Forbes, J., McCartney E., McKean,C. Karen Laing, K. Cockerill, M & Law, J Productive interprofessional social capital affect relations in the ‘Language for All’ study on cross-professional working for primary school age children with speech, language and communication needs

• Gascoigne M. & Gros, J. (2017) Talking About a Generation: Current policy, evidence and practice for speech, language and communication London: The Communication Trust.

• Law, J., Reilly, S. & Snow, P. (2013) Child speech, language and communication need in the context of public health: A new direction for the speech and language therapy profession. International Journal of Language and Communication Disorders DOI: 10.1111/1460-6984.12027

• Law, J., Levickis, P., McKean, C., Goldfeld, S., Snow, P., Reilly, S. (2017) Child Language in a Public Health Context. Melbourne: Murdoch Children’s Research Institute.

• Law, J. & Pagnamenta, E. (2017) Public Health Interventions: Promoting the development of young children’s language Bulletin of the Royal College of Speech and Language Therapists 777 January12-15.

• Law, J. Charlton, J., Dockrell, J., Gascoigne, M., Mckean, C. and Theakston, A. (2017) Early Language Development: Needs, provision and intervention for preschool children from socio-economically disadvantage backgrounds. London: Education Endowment Foundation

• Law, J. Charlton, J. & Asmussen, K. (2017) Child language as a wellbeing indicator. London: Early Intervention Foundation

• Law, J. Charlton, J., Boyle,J. McKean, C., Dockrell, J. Patterns of Competence and signals of risk. London: Early Intervention Foundation

• McCartney, E., Forbes, J., McKean,C. Karen Laing, K. Cockerill, M & Law, J. Variation in headteachers' approaches to meeting the needs of primary school children with speech, language and communication needs (SLCN) in one English Local Authority: a systems approach.

• McKean, C. Law, J., Laing, K.,Cockerill, M., Allon-Smith, J., McCartney, E., & Forbes, J. (2016) A qualitative case study in the social capital of co-practice for children with speech, language and communication needs International Journal of Language & Communication Disorders DOI: 10.1111/1460-6984.12296

• Olusanya, B., Ruben, R., & Parving, A. (2006). Reducing the Burden of Communication Disorders in the Developing World: An Opportunity for the Millennium Development Project. Journal of the American Medical Association, 296; 441-444.

• Schoolwerth, A. C., Engelgau, M. M., Hostetter, T. H., Rufo, K. H., Chianchiano, D., McClellan, W. M., ... & Vinicor, F. (2006). Chronic kidney disease: a public health problem that needs a public health action plan. Prev Chronic Dis, 3(2), 1057-1061.

• Wylie, K., McAllister,L., Davidson, B. Marshall, J. & Law, J. (2014) Shifting towards Public Health?: Considerations for SLP Educational Programs New Horizons in Speech Language Pathology’ ‘Folia Phoniatrica et Logopaedica’;66:164-175 DOI:10.1159/000365752