Evidence based pathways to intervention for children with language disorders

Background: Paediatric SLT roles often involve planning individualised intervention for specific children (provided directly by SLTs or indirectly through non-SLTs), working collaboratively with families and education staff and providing advice and training. A tiered approach to service delivery is currently recommended, whereby services become increasingly specialised and individualised for children with greater needs.  Aims: To examine 1) evidence of intervention effectiveness for children with language disorders at different tiers and 2) evidence regarding SLT roles; and to propose an evidence-based model of SLT service delivery.  Methods: Controlled, peer-reviewed studies, meta-analyses and systematic reviews of interventions for children with language disorders are reviewed and their outcomes discussed, alongside the differing roles SLTs play in these interventions. We indicate where gaps in the evidence base exist and present a possible model of service delivery consistent with current evidence, and a flowchart to aid clinical decision making.  Main Contribution: The service delivery model presented resembles the tiered model commonly used in education services, but divides individualised (Tier 3) services into Tier3A: indirect intervention delivered by non-SLTs, and Tier 3B: direct intervention by an SLT. We report the evidence for intervention effectiveness and which children might best be served by each tier, the role SLTs could take within each, and the evidence of effectiveness of these roles. Regarding universal interventions provided to all children (Tier 1) and those targeted at children with language weaknesses (Tier 2), there is growing evidence that approaches led by education services can be effective when staff are highly trained and well-supported. There is currently limited evidence regarding additional benefit of SLT-specific roles at Tiers 1 and 2. With regard to individualised intervention (Tier 3): children with complex or pervasive language disorders progress significantly following direct individualised intervention (Tier 3B), whereas children with milder or less pervasive difficulties can make progress when intervention is managed by an SLT, but delivered indirectly by others (Tier 3A), provided they are well-trained, -supported and -monitored.  Conclusions: SLTs have a contribution to make at all tiers, but where prioritisation for clinical services is a necessity, we need to establish the benefits and cost-effectiveness of each contribution. Good evidence exists for SLTs delivering direct individualised intervention, and we should ensure that this is available to those children with pervasive and/or complex language impairments. In cases where service models are being provided which lack evidence, we strongly recommend that SLTs investigate the effectiveness of their approaches

Evidence-based pathways to intervention for children with language disorders

Background  Paediatric speech and language therapist (SLT) roles often involve planning individualized intervention for specific children, working collaboratively with families and education staff, providing advice, training and coaching and raising awareness. A tiered approach to service delivery is currently recommended whereby services become increasingly specialized and individualized for children with greater needs.  Aims  To stimulate discussion regarding delivery of SLT services by examining evidence regarding the effectiveness of (1) intervention for children with language disorders at different tiers and (2) SLT roles within these tiers; and to propose an evidence‐based model of SLT service delivery and a flowchart to aid clinical decision‐making.  Methods & Procedures  Meta‐analyses and systematic reviews, together with controlled, peer‐reviewed group studies where recent systematic reviews were not available, of interventions for children with language disorders are discussed, alongside the differing roles SLTs play in these interventions. Gaps in the evidence base are highlighted.  Main Contribution  The service‐delivery model presented resembles the tiered model commonly used in education services, but divides individualized (Tier 3) services into Tier 3A: indirect intervention delivered by non‐SLTs, and Tier 3B: direct intervention by an SLT. We report evidence for intervention effectiveness, which children might best be served by each tier, the role SLTs could take within each tier and the effectiveness of these roles. Regarding universal interventions provided to all children (Tier 1) and those targeted at children with language weaknesses or vulnerabilities (Tier 2), there is growing evidence that approaches led by education services can be effective when staff are highly trained and well supported. There is currently limited evidence regarding additional benefit of SLT‐specific roles at Tiers 1 and 2. With regard to individualized intervention (Tier 3), children with complex or pervasive language disorders can progress following direct individualized intervention (Tier 3B), whereas children with milder or less pervasive difficulties can make progress when intervention is managed by an SLT, but delivered indirectly by others (Tier 3A), provided they are well trained and supported, and closely monitored.  Conclusions & Implications  SLTs have a contribution to make at all tiers, but where prioritization for clinical services is a necessity, we need to establish the relative benefits and cost‐effectiveness at each tier. Good evidence exists for SLTs delivering direct individualized intervention and we should ensure that this is available to children with pervasive and/or complex language disorders. In cases where service models are being provided which lack evidence, we strongly recommend that SLTs investigate the effectiveness of their approaches

Public health approaches still have room for individualized services: response to commentaries on 'Evidence-based pathways to intervention for children with language disorders'

First paragraph: We welcome these commentaries and an open discussion about SLT roles in improving the lives of children with language disorder. Our motivation comes in part from our lived experiences of situations like those above, where there is a perception from schools and indeed families (cf. Bercow 10 Years On) that the needs of children with language disorder are not being met. We focus our response on three key issues that arise from these thought-provoking comments

CATALISE: A multinational and multidisciplinary Delphi consensus study. Identifying language impairments in children

Delayed or impaired language development is a common developmental concern, yet thereis little agreement about the criteria used to identify and classify language impairments inchildren. Children's language difficulties are at the interface between education, medicineand the allied professions, who may all adopt different approaches to conceptualising them.Our goal in this study was to use an online Delphi technique to see whether it was possibleto achieve consensus among professionals on appropriate criteria for identifying childrenwho might benefit from specialist services. We recruited a panel of 59 experts representingten disciplines (including education, psychology, speech-language therapy/pathology, paediatricsand child psychiatry) from English-speaking countries (Australia, Canada, Ireland,New Zealand, United Kingdom and USA). The starting point for round 1 was a set of 46statements based on articles and commentaries in a special issue of a journal focusing onthis topic. Panel members rated each statement for both relevance and validity on a sevenpointscale, and added free text comments. These responses were synthesised by the firsttwo authors, who then removed, combined or modified items with a view to improving consensus.The resulting set of statements was returned to the panel for a second evaluation(round 2). Consensus (percentage reporting 'agree' or 'strongly agree') was at least 80 percentfor 24 of 27 round 2 statements, though many respondents qualified their responsewith written comments. These were again synthesised by the first two authors. The resultingconsensus statement is reported here, with additional summary of relevant evidence, and aconcluding commentary on residual disagreements and gaps in the evidence base.</p

Phase 2 of CATALISE: a multinational and multidisciplinary Delphi consensus study of problems with language development: Terminology.

Background: Lack of agreement about criteria and terminology for children’s language problems affects access to services as well as hindering research and practice. We report the second phase of a study using an online Delphi method to address these issues. In the first phase, we focused on criteria for language disorder. Here we consider terminology.Methods: The Delphi method is an iterative process in which an initial set of statements is rated by a panel of experts, who then have the opportunity to view anonymised ratings from other panel members. On this basis they can either revise their views or make a case for their position. The statements are then revised based on panel feedback, and again rated by and commented on by the panel. In this study, feedback from a second round was used to prepare a final set of statements in narrative form. The panel included 57 individuals representing a range of professions and nationalities. Results: We achieved at least 78% agreement for 19 of 21 statements within two rounds of ratings. These were collapsed into 12 statements for the final consensus reported here. The term ‘Language Disorder’ is recommended to refer to a profile of difficulties that causes functional impairment in everyday life and is associated with poor prognosis. The term, ‘Developmental Language Disorder’ (DLD) was endorsed for use when the language disorder was not associated with a known biomedical aetiology. It was also agreed that (a) presence of risk factors (neurobiological or environmental) does not preclude a diagnosis of DLD, (b) DLD can co-occur with other neurodevelopmental disorders (e.g. ADHD) and (c) DLD does not require a mismatch between verbal and nonverbal ability. Conclusions: This Delphi exercise highlights reasons for disagreements about terminology for language disorders and proposes standard definitions and nomenclature. </p

The effectiveness of semantic intervention for word-finding difficulties in college-aged students (16–19 years) with persistent Language Disorder

Background and aims Little evidence exists for the effectiveness of intervention for older adolescents and young adults with language disorders, particularly for those over 16 years. This study involves college-aged students aged 16–19 years with Language Disorder and Word-Finding Difficulties and investigates whether progress in word finding following 1:1 semantic intervention is greater than progress during a baseline period as measured by a standardised test. Methods Twenty-five college-aged students (20 males and 5 females) with Language Disorder and Word-Finding Difficulties (aged 16;4–18;4 years) participated in a single baseline design study comparing progress on the Test of Adolescent and Adult Word Finding during an intervention period with progress during a baseline period of equal length. Intervention was focused on semantics of different words from those in the Test of Adolescent and Adult Word Finding and was delivered 1:1 by the participants’ usual Speech and Language Therapist, 30 minutes per week, for eight weeks. Results The participants made significant progress in raw score on the Test of Adolescent and Adult Word Finding during both the baseline ( d  = 1.4) and intervention ( d  = 2.5) periods, but progress during the intervention period was significantly greater than during the baseline period ( d  = 1.16). Individual data showed reliable change for five participants during the baseline period and for 20 participants during the intervention period. At the start of the study, all participants had standard scores below 85, but after intervention, 10/25 participants scored above 85. Conclusions Four hours of semantic intervention led to significantly greater gains on a standardised test of word finding than during a baseline period of equal length in 16–19 year olds with Language Disorder and Word-Finding Difficulties. The words in the standardised test had not been included in the intervention, indicating generalised gains. Implications This study shows that intervention (at least for Word-Finding Difficulties) can be effective for this older age group of college-aged students with Language Disorder and therefore the effectiveness of Speech and Language Therapy services for this age group in a wider range of areas of language should also be investigated

Production of change-of-state, change-of-location and alternating verbs: A comparison of children with specific language impairment and typically developing children

Correct use of verb argument structure relies on accurate verb semantic representations whose formation depends partly on use of reverse linking. We predicted that children with Specific Language Impairment (SLI), who have difficulties with reverse linking, would have inaccurate semantic representations for verbs and hence difficulties with verb argument structure. Fifteen participants with SLI (mean age: 13;1), grammar-matched (GM) (8;3), vocabulary-matched (VM) (8;8), and chronological age-matched (CAM) controls (13;1) described 24 video scenes involving four change-of-state, four change-of-location, and four alternating verbs. All groups performed worse on change-of-state than change-of-location verbs. The participants with SLI performed significantly worse than VM and CAM but not GM controls on change-of-state verbs. However, they did not differ from any group on alternating or change-of-location verbs. We concluded young people with persistent SLI have difficulties with aspects of verb argument structure into their teenage years. © 2012 Copyright Psychology Press Ltd