SINGING FROM THE SAME HYMN SHEET The im importance of adopting a - - PowerPoint PPT Presentation

SINGING FROM THE SAME HYMN SHEET –

The im importance of adopting a population approach to in intervention for child ild wit ith la language le learning dif iffic icult ltie ies

James Law Professor 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

• f services for 0-14 year olds.

and in the US..

• Two nationally representative surveys that include measures
• f 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

• verall increase. “

Is the burden distributed unfairly?

• Social gradient

Social gradie ient in in oral l la language skil kills amongst 5-6 6 year old ld child ildren on the Australian Early Development Census (AEDC) in in 2015 and the UK’s Mille illenium Cohort Study in in 2005

2 4 6 8 10 12 14 16

Most disadvantaged Quintile 2 Quintile 3 Quintile 4 Least disadvantaged % Developmenetally vulnerable language skills

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

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Subtitle

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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
• f 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

• utcome –

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 BCT de defin finit itio ion Ex Exam ample le

Prompt sel elf- evalu luation of

• f

per perfor

• rmance

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?’ Ens Ensurin ing com

• mprehension
• n

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. Rec ecastin ing 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 so

socia ial l cap apital

• 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 (eg individual 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 delivery

Helena 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
• f 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., McCartneyE., 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
• f 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