Paediatric Language Therapy: Cheese on toast or chocolate

cake?

Paediatric Language Group

Paediatric Language Group: Recap

Last year we looked at service delivery ie: group vs individual

direct vs indirect

Outcomes: Therapy is good, but no clear difference between service modes (eg some studies group therapy was cheaper, other studies group therapy more expensive)

Differences in outcome of therapy related to: intensity of therapywhat kind of therapy

rather than service delivery.

Question for this year was:

In children 0-6 years, what is the optimum intensity of treatment in treating Specific Language Impairment?

Current Question - Literature Search

Cirrin, Frank M; Gillam, Ronald B. (2008): Language Intervention Practices for School-Age Children With Spoken Language Disorders: A Systematic Review Language, Speech & Hearing Services in Schools 39. 1 110-37.

Mendelsohn, Alan L; Mogilner, Leora N; Dreyer, Bernard P; Forman, Joel A; et al (2001). The impact of a clinic-based literacy  intervention  on language development in inner-city preschool children Pediatrics107. 1: 130-4. 

Gillam, Ronald B; Loeb, Diane Frome; Hoffman, LaVae M; Bohman, Thomas; Champlin, Craig A; et al. (2008): The Efficacy of Fast ForWord Language Intervention in School-Age Children With Language Impairment: A Randomized Controlled TrialJournal of Speech, Language, and Hearing Research51. 1 97-119. 

Current Question - Literature Search

Swanson, Lori A; Fey, Marc E; Mills, Carrie E; Hood, Lynn S. (2005) Use of Narrative-Based Language Intervention With Children Who Have Specific Language Impairment American Journal of Speech - Language Pathology 14. 2 : 131-43. 

Warren, Steven F; Fey, Marc E; Finestack, Lizbeth H; Brady, Nancy C; Bredin-Oja, Shelley L; et al. (Apr 2008) A Randomized Trial of Longitudinal Effects of Low-Intensity Responsivity Education/Prelinguistic Milieu TeachingJournal of Speech, Language, and Hearing Research51. 2 451-70. 

Current Question - Literature Search

Brinton, Bonnie; Fujiki, Martin. (2006)  Social Intervention for Children With Language Impairment: Factors Affecting Efficacy Communication Disorders Quarterly28. 1: 39-41,62. 

 Paul, Diane; Roth, Froma P. (2011) Guiding Principles and Clinical Applications for Speech-Language Pathology Practice in Early InterventionLanguage, Speech & Hearing Services in Schools (Online)42. 3 : 320-330A. 

Problems

Definitions of dosage/ intensity different in different articles.

Not many articles directly looking at intensity/dosage

Generally only mentioned as part of other investigations.

Many different treatment types targeting SLI

Current Question

3 review articles Dosage in language therapy Narrative intervention summary Dosage & distribution in morphosyntax

intervention summary

Article

Warren S, Fey M, & Yoder P. Differential treatment intensity research: a missing link to creating optimally effective communication interventions. Mental Retardation and Developmental Disabilities 2007: 13, 70-77

– research review & discussion paper – noted that in general therapy is effective– general consensus that early intervention is effective– in medical research dosage is clearly defined, in communication research

it is not– different definitions for treatment intensity eg:

quality and quantity of services in a given time number of hours of intervention in specific time period level of participation in a service offered over time ratio of adults: children in intervention context number of specific teaching/therapeutic episodes per unit of time

– no consensus on unit of measurement used across time– argument for standardising terminology (similar to medical fields) – 4 factors proposed to consider when defining “cumulative intervention

intensity”: (multiply these together) dose: the number of properly administered teaching episodes during a single

session of intervention X dose form: ‘active ingredient’ ie typical task or activity within which the teaching

episodes are delivered eg structured drills, prompts for imitation X dose frequency: number of times a dose of intervention is provided per day and

per week X * total intervention duration: time period over which a specified intervention is

presented X *– *usually well defined in research– studies of each intervention type should look to define “cumulative

intervention intensity”

Morphosyntax Intervention

Proctor-Williams, K. (2009) Dosage and distribution in morphosyntax intervention: current evidence and future needs. Topics in Language Disorders, 29, 294-311

– Review article– Outlines & evaluates dose forms and intervention contexts

used to facilitate morphosyntactic acquistion.– Evaluates research outcomes and provides examples of

dosage components– Identifies lack of systematic comparisons of dosage forms

and measurement in research

Dose forms

Techniques:– Time delay/slow rate– Model– Recast– Expansion– Imitation/mand– Imitation/feedback– Question– Direct instruction

Dose forms cont…

Procedures:– May combine 2 or more techniques– Effects may be additive or may negate effectiveness of one

another– Order of presentation of techniques within procedure may

be important to efficacy

Intervention contexts: – Child centred– Hybrid– Clinician directed

Dosage

Distribution within session Dose frequency:

– eg optimal frequency of recasts. – occur 3.5 times more frequently in therapy than available in

child’s typical environment. – children whose parents used higher rates of recasts

showed greater gains.– parents had difficulty sustaining high rate of recasts as

children’s language improved

Hoffman, LM Narrative Language Intervention Intensity and dosage (2009). Topics in Language Disorders 29 (4), 329-343

Responded to Warren, Fey and Yoder’s (2007) article by beginning to define the “active ingredients” in Narrative Intervention

Proposed further investigations into the teaching of – Episodic Structure– Reading & Interest Levels– Genre– Discourse Level Teaching and Performance– Inference/moral/culture

Suggested we need to further clarify the “potent point” or active ingredients before we are able to monitor dosage.

Massed or Distributed Practise?

Riches, NG, Tommasello, M, Conti-Ramsden, G. Verb Learning in Children with SLI: Frequency and Spacing Effects. Journal of Speech Language and Hearing Research 2005: 48, 1397-1411

– Experimental group : 24 children with SLI (mean age 5;6) -1SD on CELF-P & normal intelligence

– Control group: 24 children with typically developing language & intelligence

(mean age 3;4)– All excluded hearing loss, social and emotional difficulties &

Bilingualism– No significant difference in MLU, “Talkativeness”, British Picture

Vocabulary Test. SLI group performed slightly better on the Expressive Vocabulary Test

Riches et al 2005 continued

Modelled three novel verbs for a range of actions in play sessions

“Look, it’s VERBing! See, it VERBs!” 2x2 experimental design combining 2 training regimes (massed

and spaced)– (a) Massed 12, with 12 exposures on a single day, – (b) Massed 18, with 18 exposures on a single day,– (c) Spaced 12, with 12 exposures spread over 4 days (3 per day),

and – (c) Spaced18, with 18 exposures spread over 4 days (4,5,4,5).

Riches et al 2005 continued

•Post Test (immediately after final presentation) & •Retention Test (one week after final presentation)•No significant difference between Control and experimental groups overall•Significantly better post test learning in children in the spaced trials•Retention was significantly lower in the SLI groupBut: •Significantly better retention in Spaced groups•Spaced practices made a bigger difference in learning for the SLI group.

Riches et al 2005 continued

Clinical Bottom Line– Distributed practise leads to better learning and

retention in all children (for verb learning), but it is particularly important for children with SLI

Clinical bottom line

Therapy is good Distributed practice is more effective than

massed practice Active ingredients not clearly enough defined

in the literature

Clinical practice

Surveys of clinicians also indicate therapists are not able to clearly define their active ingredient

Everyone is doing a good job, kids are achieving goals but we are not good at explaining what we are doing when we say ‘we are doing language therapy’

Language therapy isn’t simple like cheese on toast, it’s complicated like chocolate cake. We need to be better at explaining HOW we made our chocolate cake so that other people can also make fantastic chocolate cake too!!