the current evidence base for school-aged children …...evidence base for interventions for...

Evidence base for interventions for school-

aged children with DLD

November 2017

Susan Ebbels 1

The current evidence base for

school-aged children with

Developmental Language

Disorder (DLD)

Svensk Intresseförening för Tal & Språk

24th November, 2017

Dr Susan Ebbels

Moor House Research and Training Institute;

Division of Psychology and Language, UCL.

Plan

Consider the quality and quantity of evidence regarding

intervention for:

• Different methods of service delivery

– training of others

– education-led language groups

– “indirect” SLT-led therapy through another person

– “direct” therapy with an SLT

– collaborative teaching (SLT and teacher together)

• Different areas of language (all direct SLT)

– sentence structure and complexity

– Narrative structure

– Vocabulary and word finding



November 2017

Susan Ebbels 2

Appraising the evidence

Need to distinguish clearly between

1. Evidence an intervention is effective

(for improving

– A aspect of language using B measure

– in children with C diagnosis of D age

– when delivered by E with F amount of training and G amount

of experience

– in H setting

– with I number of peers with J diagnosis

– for K number of hours, distributed in L type of way)

2. No evidence regarding (in)effectiveness(for .......)

3. Evidence an intervention is NOT effective (for .....)

Evidence of effectiveness

• Studies might find effects which are due to factors other

than the intervention investigated

– Maturation or practice effects (need control group / items / period)

– Assessor bias (need ‘blind’ assessment)

– (Un)predictable differences between groups (need random

assignment, with large enough numbers)

• Studies vary in the robustness of their design with RCTs

being the gold standard.

• SpeechBite website http://www.speechbite.com/

• What Works on Communication Trust website

http://www.thecommunicationtrust.org.uk/schools/what-

works-database.aspx



November 2017

Susan Ebbels 3

Colour-coding system for evidence

• Dark green – strong evidence is effective (RCT)

• Light green – weaker evidence is effective (some

experimental control, not RCT)

• Orange – no reliable evidence re (in)effectiveness

– Insufficient control to draw conclusions

– Results not published

• Red – strong evidence is NOT effective

EFFICACY: Evidence

supporting the treatment

Po

siti

ve

resu

lts

1. Anecdotes /clinical experience

2. Change in raw score

3. Change in standard score

5. Within-participant design (control items/area)

6. Within-participant design (single baseline & control items/area)

8. Between-participant comparisons (non-random assignment)

10. Between-participant design (randomised control trial)

4. Within participant design (single baseline)

7. Within-participant multiple baseline design

9. Combined between and within participant designs

Details in Ebbels (2017),

IJSLP, 19, 218-213



November 2017

Susan Ebbels 4

G. Course / resources available

F. Course / resources popular

E. Practitioners say know how to use intervention

C. Practitioners show evidence of ability to carry out intervention accurately

D. Practitioners show evidence of being able to use aspects of intervention

B. Practitioners’ clients improve as result of intervention (using designs 1-10)

EFFICACY: Evidence


EFFECTIVENESS:

The Treatment in

Practice A. Treatment in common use as designed

Po

siti

ve

resu

lts

















EFFICACY: Evidence


EFFECTIVENESS:

The Treatment in


10

8

6

4

2

9

7

5

3

1



November 2017

Susan Ebbels 5







EFFICACY: Evidence


EFFECTIVENESS:

The Treatment in












Po

siti

ve r

esu

lts

Ne

gati

ve r

esu

lts

Service delivery



November 2017

Susan Ebbels 6

Child

ren w

ith identified

Language D

isord

er

CO

MP

LE

XIT

Y &

SE

VE

RIT

Y

Childre

n just

belo

w a

ge

expecta

tions

Po

or

resp

on

se t

o i

nte

rven

tio

n

Intervention A

ll c

hildre

n

Children

Direct

SLT-led

intervention

Indirect SLT-led

intervention

Education–led groups

following language

programmes

High quality teaching for all

Education tiers

Tier 2

Tier 3A

Tier 3B

Tier 3

Tier 1

Intervention

All

child

ren

Children


Tier 1

Education tier



November 2017

Susan Ebbels 7

EFFECTIVENESS:

The Treatment in

Practice

Justice et al., 2010







A. Treatment in common use as designed

Whole class teaching using

programmes for “at risk”

pre-school children

(all children) Neuman et al., 2011

Vadasy et al., 2015 Grammar,

morphology &

vocab

Receptive vocab

(all children)

EFFECTIVENESS:

The Treatment in

Practice

Starling et al., 2012

Snow et al., 2014

Girolametto et al., 2003

Landry et al., 2011

Piasta et al., 2012

Starling et al., 2012








Listening & writing

Starling et al., 2012 Speaking & reading

Impact of training for

education staff

Snow et al., 2014 Language & literacy

2° aged

with DLD

1°aged

(all children)

Pre-school

(all children)

Girolametto et al., 2003

Landry et al., 2011

Piasta et al., 2012

More talkative

vocab

vocab

Markussen-Brown et al., 2017



November 2017

Susan Ebbels 8

Education staff CPD – Meta-analysis

(Markussen-Brown et al., 2017)

• Effects of teacher CPD

– Small (non-sig) effect on children’s vocab

– Small-medium effects on children’s PA and

alphabet knowledge

– Medium effect on adult-child interaction

• BUT, improvements in child outcomes not

mediated by improvements in adult-child

interaction

– Large effects on physical classroom space,

Education staff CPD – Meta-analysis

(Markussen-Brown et al., 2017)

• Features of CPD associated with improved

educator outcomes

– Better outcomes for CPD which was longer and more

intense

• Average amount in studies was 50-60 hours

– courses alone had no sig effects,

– courses + coaching and significantly larger effects

– Most important factor was whether training included

more than one component



November 2017

Susan Ebbels 9

LD low

average

high

average

above

average

Functional

impact

low

average

high

average

above

average

Functional

impact

LD



November 2017

Susan Ebbels 10

Evidence for SLT specific roles at

Tier 1 approaches

Only one of above studies involved training specifically by

SLTs (Starling et al., 2012)

Possible roles for SLTs:

1. Health promotion via training/coaching for education staff

and parents re

a) Identification of Language Disorder

b) Changing practice and interactions with children to improve

children’s language and/or access to curriculum and social

participation

2. Work collaboratively with others (discussed later)

Talk of the Town (Thurston et al., 2016)

• RCT

• SLT support at Tiers 1 and 2

– Observation of staff (Tier 1)

– targets for developing practical strategies (Tier 1)

– training sessions on identification of children with

SLCN (Tier 1)

– delivery of education-led language programmes (Tier

2),

– and support as required while education staff

delivered the language programmes (Tier 2).

• No effect on language or reading

comprehension, but education staff valued input



November 2017

Susan Ebbels 11

EFFECTIVENESS:

The Treatment in

Practice

Impact of health

promotion by SLTs?



E. Parents say know how to use intervention

C. Parents show evidence of ability to carry out intervention accurately

D. Parents show evidence of being able to use aspects of intervention

B. Children improve as result of intervention (using designs 1-10)


Thurston et al., 2016, Talk of the Town

Thurston et al., 2016, Talk of the Town

Summary of evidence for Tier 1

• Education-led approaches – Teachers using published programmes (with training) can improve

oral language (esp vocab) of (at risk) pre-school children in their classes

– At least 15 hours (but more usually 50-60 hours) training for education staff plus 1:1 follow-up support and/or coaching improves average abilities of populations of (at risk) pre-school and primary aged children

– Very little evidence that these approaches improve language, communication, participation or well-being of children with SLCN

• SLT roles – >8hrs training by SLTs + lesson observations & feedback improves

some aspects of language in secondary aged children

– No good evidence with other age groups of effectiveness of SLT roles within Tier 1



November 2017

Susan Ebbels 12

Priority questions for future research for

SLTs supporting Tier 1 approaches

Does training of school staff by SLTs

1. improve outcomes for children with identified

Language Disorder?

– which children?

– which outcomes?

2. reduce referrals to SLT?

3. close (or widen) the gap for low-achieving children?

What is the minimum amount of

training/coaching/feedback required for progress?

Thoughts • SLTs are well-qualified to provide training / coaching /

feedback for teachers in strategies to encourage

language development in all children

• However, we have to recognise that this is a huge

time commitment

– Minimum 8 hours in groups + 3 hours 1:1 per teacher

(ideally 50-60 hours)

– Would need to be specially commissioned

– Do we have enough SLTs to do this for all teachers?

– Is this best use of our time?

– Benefits for children with Language Disorders are uncertain

– What are we not doing while doing this?

• ? Our focus should be on influencing teacher CPD and

ITT rather than delivering training ourselves



November 2017

Susan Ebbels 13

Intervention A

ll child

ren

Children


SLT roles

Influence public

awareness and

policies and

recommend

evidence-based

programmes

Tier 1

Education tier

© Ebbels, McCartney, Slonims, Dockrell &Norbury (2017)

yes

Led by education

Continuing mild-

moderate impact?

Small group &/or 1:1 work – provider must be well-trained

and very closely monitored

School monitor treatment fidelity

& progress

High risk?

SLT Assessment

yes

no

yes

yes

Good progress? no

no

Comprehension difficulties or

complex needs?

yes

yes

direct SLT

Indirect intervention – provider must be well-trained and very

closely monitored

no SLT monitor treatment

fidelity & progress

Continuing moderate-

severe impact?

yes

no

no

SLT concerns

? no

Good progress? no

SLT monitor progress

Good progress?

Continuing severe

impact?

no

no

yes

Increase frequency

of SLT, change

methods

no

Direct SLT

Quality first teaching

School monitor progress

Good progress?

Led by education

yes

yes

Indirect intervention led by SLT

“Red flags” and risk factors: • Severity/pervasiveness • Family history • Age • Neurodevelopmental disorder

Teacher / Parent concern

Collaborative work between

SLT, families and education



November 2017

Susan Ebbels 14

“Red flags” and “risk factors”

• Red flags = if child has these they should be assessed by an SLT and may need intervention

• Risk factors = indicate increased risk of long-term difficulties, but – risk factors do not predict difficulties at an

individual level

– a child with language difficulties (but no “red flags”) may not (yet) need SLT assessment, but education support and “watchful waiting”

– more risk factors indicate more likelihood of long-term needs, therefore closer monitoring needed

“Red flags” in school-aged children

From Visser-Bochane et al. (2017) & Bishop et al. (2016)

• Over 5 years:

– difficulty in (re-)telling a coherent story,

– difficulty understanding what is read or listened to or following spoken instructions,

– poor reciprocal conversation,

– over-literal interpretation



November 2017

Susan Ebbels 15

Risk factors for persisting language difficulties

• School-age (Conti-Ramsden et al., 2009, Stothard et al., 1998, Tomblin et al., 2003)

• Family history of language or literacy difficulties (Zambrana et al., 2014)

• Severity / pervasiveness, especially comprehension difficulties (Beitchman et al., 1996, Bishop and Edmundson, 1987, Eadie et al., 2014, Tomblin et al., 2003, Zambrana et al., 2014, Fisher, 2017)

• Lower non-verbal IQ (Bishop and Edmundson, 1987, Eadie et al., 2014, Tomblin et al., 2003; Oliver et al., 2004)

• Neurodevelopmental disorder, e.g., Down syndrome, ASD (Pickles et al., 2014)

• Male (Zambrana et al., 2014; Rudolph, 2017)

• Multiple risk factors (Zambrana et al., 2014)

• Socioeconomic status (Fisher, 2017) & maternal education (Rudolph, 2017)

Social disadvantage • Association between social disadvantage and language skills

(e.g., Reilly et al., 2014; Letts et al., 2013)

• Parents and children share genetic risk factors for DLD (Bishop 2006)

• Teenagers with DLD achieve fewer educational qualifications at 16 years (Snowling et al., 2001; Dockrell et al., 2011; Conti-Ramsden et al., 2009)

• 25% of teenagers with DLD were not entered for any examinations (Conti-Ramsden et al., 2009)

• Adults with DLD have lower employment outcomes (Johnson et al., 2010; Whitehouse et al., 2009)

• Therefore adults with DLD likely to have lower SES and their children are at genetic risk of DLD

• So, we should expect a higher proportion of children with DLD to come from low SES



November 2017

Susan Ebbels 16

Intervention Children SLT services


following language

programmes

Education tiers

Child

ren just

belo

w a

ge

expecta

tions

Tier 2

EFFECTIVENESS:

The Treatment in

Practice

Bowyer-Crane et al. (2008;

2011)

Hutchinson & Clegg (2011)

St John & Vance (2015)

Fricke et al. (2013; 2017)

Sibieta et al. (2016)

Clarke et al. (2010)

Lee & Pring (2016)

Hagen et al. (2017)

Language

programmes delivered

by education staff

Primary-

aged

children








Fricke et al. (2013)

Haley et al. (2017)

Pre-school

children

Haley et al. (2017) Taught

vocab only

Vocab enrichment intervention

programme

Narrative intervention

programme

Secondary

-aged

children

Murphy et al (2017), VEIP

(EAL children) Dockrell et al., 2010



November 2017

Susan Ebbels 17

Summary of effectiveness of education-

led language programmes • These interventions can be effective

– for primary school-aged children with weak language regardless of NVIQ

– Only for taught vocab in pre-school (taught in groups)

– ?not secondary-aged children (?vocab)

– delivered at least 3x30 mins per week in small groups (often plus

2x30mins 1:1 sessions)

– by very well-trained (4+ days) and very regularly supported (at least

fortnightly) teachers or TAs

– for improving expressive language, narrative and vocabulary (& PA)

– improved language and vocabulary can lead directly to improved reading

comprehension

• But these do not appear to improve

– listening comprehension

• Roll out of these programmes can be tricky – they take time and assistant resource

SLT roles in Tier 2 intervention?

• Only a minority of the studies above involved SLTs

training education staff to deliver programmes

• Others developed by psychologists

• Not clear who should provide training for education

staff delivering Tier 2 interventions considering time

commitment is large

– 4 days plus fortnightly support

– Should SLTs provide this?

– Other possibilities: Charities? Companies?

Psychologists? Specialist teachers?



November 2017

Susan Ebbels 18

Intervention Children SLT roles?


following language

programmes

Education tiers

Advise & problem-solve re

evidence-based

programmes Tier 2

At risk c

hild

ren

Child

ren just

belo

w a

ge

expecta

tions

Priority questions for future research into

education-led language programmes

1. Which children are most / least likely to benefit from

education-led language programmes?

2. Which areas of language are most / least likely to benefit?

3. What is the minimum level of support required by education

staff to be able to successfully deliver these interventions?

4. Who is best placed to provide this training?

5. What should the SLT role be (if any)?

6. Do these groups reduce referrals to SLT?



November 2017

Susan Ebbels 19

SLT-led

Individualised Provision

• Individualised approach, led by specialist

• Specialist has duty of care

• Research considers

• Direct vs. Indirect

• Group vs. 1:1

• collaborative vs. pull-out

SLT-led individualised interventions

• Usually for children with ‘additional or complex

needs’

– a need for interventions involving technical SLT

knowledge and skill,

– and/or persisting conditions with poor prognostic

factors.

• Where long-term intervention is also anticipated.

• Training/coaching of others and collaborative

work would be child specific



November 2017

Susan Ebbels 20

Intervention Children

Direct

SLT-led

intervention

Indirect SLT-led

intervention

Tier 3

Education

tiers

Tier 3B

Tier 3A C

OM

PL

EX

ITY

& S

EV

ER

ITY

Po

or

resp

on

se t

o i

nte

rven

tio

n

Child

ren w

ith identified

language d

isord

er


Direct

SLT-led

intervention

Indirect SLT-led

intervention

Tier 3B

Tier 3A

SLT roles in intervention

Assessment, planning, direct

intervention, monitoring of

progress

Assessment, planning, training &

monitoring others’ delivery of

indirect intervention, monitoring

of progress

CO

MP

LE

XIT

Y &

SE

VE

RIT

Y

Po

or

resp

on

se t

o i

nte

rven

tio

n

Child

ren w

ith identified

language d

isord

er



November 2017

Susan Ebbels 21

Boyle et al. (2007, 2009) Comparison of 1:1 vs. group and SLT vs. SLTA

• Large RCT comparing:

– SLT 1:1

– SLT ‘group’ (2-5 per group)

– SLTA 1:1 (SLTAs had degrees in psychology)

– SLTA ‘group’ (2-5 per group)

– “normal therapy” (mostly “consultancy”, half had little or no

contact with SLT)

• Project intervention 3x 30-40 mins per week for 15

weeks (mean 38 sessions = 19-25 hours)

• Results

– All project methods of delivery equally effective for

improving expressive language

– Direct intervention > control

– Individual intervention > control

– Progress maintained a year later

– no change in receptive language in any group

– children with E-LI > RE-LI in both receptive and

expressive language

• Dickson et al (2009) found

– SLTA group intervention was cheapest, but

– SLT group intervention provided most gain per £



November 2017

Susan Ebbels 22

EFFICACY: Evidence


“direct” and “indirect”

interventions targeted at

child’s specific

difficulties

Boyle et al. (2009)

Expressive difficulties only

Boyle et al. (2009)

Receptive difficulties

Regardless

of whether

intervention

provided by

SLT or

“SLTA”












Indirect SLT-led

intervention Tier 3A





of progress

CO

MP

LE

XIT

Y &

SE

VE

RIT

Y

Po

or

resp

on

se t

o i

nte

rven

tio

n

Child

ren w

ith identified

language d

isord

er



November 2017

Susan Ebbels 23

“Indirect” SLT-led intervention:

key factors

• Who employs provider – McCartney et al. (2011): intervention provided by school staff

under “consultative model” was not effective

– If assistant is provided to the school by a research project (Boyle et al. 2009), or SLT services (Mecrow et al., 2010) intervention can be effective, but not for those with receptive language difficulties (Boyle et al. 2009).

• Training and support – McCartney et al. (2011)

• little training / support (although targets, manual and materials provided)

• limited monitoring from SLTs (one mid-intervention meeting)

• Amount of intervention provided (need for monitoring) – McCartney et al. (2011): 10 hours (aimed for 20)

– Boyle et al (2009): 20 hours

– Mecrow et al. (2010): 29 hours

Mecrow et al.

(2010)

“indirect” interventions

targeted at child’s

specific difficulties

McCartney et al.

(2011)

Assistant

provided to

the school

+ve -ve

School staff

with limited

training,

support &

monitoring

Boyle et al.

(2009)

Expressive

difficulties

only

Boyle et al.

(2009)

Receptive

difficulties

Assistant

(psychology

graduate)

provided to

the school



November 2017

Susan Ebbels 24

Summary of studies investigating indirect SLT

• Indirect SLT intervention can be effective

– for primary school-aged children

– with expressive difficulties only

– delivered at least 3x30 mins per week

– by well-trained assistants under direct control of SLTs or researchers

– for improving expressive language and vocabulary

• But they do not improve

– listening comprehension

– receptive or expressive language in children with receptive language

difficulties

• Giving a programme to a school to carry out will probably NOT be

effective!!

• ? secondary-aged children

Priority questions for future research on indirect

SLT intervention

Only a few studies already done, thus more needed particularly

aiming to identify

1. For which targets this approach can be effective?

2. For which children?

3. What is the minimum level of SLT support/training/monitoring

required for assistants to be able to successfully deliver

these interventions (for which targets and which children)?

4. Are indirect SLT interventions more cost-effective than direct

SLT interventions (for which children/targets)?



November 2017

Susan Ebbels 25

What constitutes good progress?

• Education-led input: – increasing rate of progress – attainment gap with peers closing

• Indirect SLT – if making progress against specific targets continue

indirect SLT (introducing new targets) – if not making progress against targets, move to direct

SLT

• Direct SLT – if making progress against specific targets continue

(introducing new targets) – if not making progress against targets, increase

frequency, change targets, try a different approach


Direct

SLT-led

intervention

Tier 3B




progress

CO

MP

LE

XIT

Y &

SE

VE

RIT

Y

Po

or

resp

on

se t

o i

nte

rven

tio

n

Child

ren w

ith identified

language d

isord

er



November 2017

Susan Ebbels 26

Direct SLT intervention

• Likely to be long-term

• May involve referral to a different service

• Most evidence is for direct SLT, BUT

• For those who might actually benefit from indirect

SLT

• expressive language targets

• for children without receptive language impairments

• SEE LATER

• Some limited evidence for those who don’t appear to

benefit from indirect SLT and thus need direct SLT

• receptive language targets

• for children with receptive language difficulties

Aims of direct SLT intervention

• Cure is probably not the goal

• At this stage we are aiming to

A. Teach new skills

B. Teach new strategies

C. Help people in the environment to maximise learning

and functional communication, participation and

well-being



November 2017

Susan Ebbels 27

• Studies focusing on specific methods

– Discussed later

• Studies focusing mainly on method of delivery,

with wide range of targets

– Discussed next

Ebbels et al. (2017) Effectiveness of 1:1 direct SLT

• evaluated the effectiveness of all 1:1 intervention

delivered in a special school for children with Language

Disorders during one school term,

• All 72 students in school involved – Aged 7-16 years (mean 13;4)

– 63 (88%) with receptive language disorders

• All SLTs involved

• For every target for every student, a control area was also measured on which they did not receive intervention



November 2017

Susan Ebbels 28

Overall results

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

target control

pre-therapy

post-therapy

• Targets and controls did not differ pre-intervention

• Significant progress on both targets (d=1.3) and controls (d=0.4), but

• Targets improved significantly more than controls (d=1.1)

• Mean of 4.2 hours intervention per target

Progress, split by language area

• No effect of target area or interaction of target area and progress

• Targets improved more than controls for all language areas

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

% c

han

ge

Target area

Target

Control



November 2017

Susan Ebbels 29

Participant characteristics

• No effect on response to intervention of

– Gender: girls vs boys

– Receptive language status: <85 vs. >85

– ASD status

– Educational Key Stage

-ve

Ebbels et al. (2017)


“direct” interventions

targeted at child’s

specific difficulties +ve

Boyle et al. (2009)

Expressive

difficulties only

Boyle et al. (2009)


Plus many more

focusing on specific

areas – discussed later,

including some for

children with receptive

language difficulties



November 2017

Susan Ebbels 30


Direct

SLT-led

intervention

Indirect SLT-led

intervention

Tier 3B

Tier 3A




progress




of progress

Po

or

resp

on

se t

o i

nte

rven

tio

n

CO

MP

LE

XIT

Y &

SE

VE

RIT

Y

• o

f im

pact of

impairm

ent on

functionin

g in c

urr

ent

conte

xts

•of

receptive language d

ifficultie

s

Child

ren w

ith identified

language d

isord

er

Summary of studies of direct SLT intervention

• Direct SLT intervention can be effective

– for primary and secondary school-aged children with DLD

– delivered at least 30 mins per week by SLT

– for improving expressive language and vocabulary

– Children with receptive language difficulties did not make

general language progress in Boyle et al. (2009)

– But do in studies where outcome measures are more

specific (e.g., Ebbels et al., 2017 and others)



November 2017

Susan Ebbels 31

Priority questions for future research on direct

SLT intervention

Only a few rigorous studies with children with receptive language

difficulties. Thus more needed, particularly aiming to identify:

1. What is the most cost-effective approach (for different targets

/ children)?

2. What is the ideal amount and frequency of intervention (for

different targets /children)?

All

child

ren

Children

Intervention

Direct

SLT-led

intervention

Indirect SLT-led

intervention

Education-led groups

following language

programmes

Quality first teaching for all

CO

MP

LE

XIT

Y &

SE

VE

RIT

Y

•of

impact of

impairm

ent on f

unctionin

g in

curr

ent

conte

xts

•of


ifficultie

s

Po

or

resp

on

se t

o i

nte

rven

tio

n

Child

ren just

belo

w a

ge

expecta

tions

At risk c

hild

ren

Child

ren w

ith identified

language d

isord

er



November 2017

Susan Ebbels 32

All

child

ren

Children

Intervention

Throneburg et al. (2000) -

vocabulary

Gillam (2014) – narrative & vocabulary

Low risk

High risk

Other children

DLD

Smith-Lock et al., (2013 a, b)

DLD

Hadley et al. (2000)

Kindergarten classes

Child

ren just

belo

w a

ge

expecta

tions

At risk c

hild

ren

Child

ren w

ith identified

language d

isord

er

Gallagher & Ebbels (2017)

DLD








EFFECTIVENESS:

The Treatment in

Practice Collaborative intervention

Throneburg et al.

(2000)

Collaborative > pull-out /

class-based for vocab, for

DLD +?others, primary-aged

Smith-Lock et al.

(2013a; 2013b)

Grammar

DLD, primary-aged

Gillam et al. (2014) Narrative & vocabulary,

all children primary-aged

Hadley et al. (2000) Vocab & some P.A,

All children, pre-school

Gallagher & Ebbels

(2017)

Language, literacy, numeracy,

DLD secondary-aged



November 2017

Susan Ebbels 33

Summary of studies of collaborative delivery of

SLT in the classroom

Collaborative teaching effective for

• Primary age – grammatical structures taught in small groups rotating

between education and SLT staff effective (DLD)

– Vocabulary (DLD + others)

– Narrative (all children)

• Pre-school age

– Vocabulary (all children)

• Secondary-age

– Language, literacy and numeracy (DLD)

For children with persistent language

disorders

• SLTs may be key to improving the language and

communication outcomes for these children

– although the actual intervention may be delivered

indirectly by others

• Children with receptive language problems seem

to need direct intervention with an SLT to make

progress with expressive or receptive language



November 2017

Susan Ebbels 34

low

average

high

average

above

average

Functional

impact

LD

For children with persistent language

disorders

• SLTs may be key to improving the language and

communication outcomes for these children

– although the actual intervention may be delivered

indirectly by others

• Children with receptive language problems seem

to need direct intervention with an SLT to make

progress with expressive or receptive language

• Collaborative work is key to reducing the

functional impact of difficulties



November 2017

Susan Ebbels 35

low

average

high

average

above

average

Functional

impact

LD

All

child

ren

Children

Intervention

Direct

SLT-led

intervention

Indirect SLT-led

intervention


following language

programmes



Assessment, planning, direct intervention,

monitoring of progress

Assessment, planning,

training & monitoring others’

delivery of indirect


progress

Influence

public

awareness

and

policies

Advise &

problem-solve re

evidence-based

programmes

CO

MP

LE

XIT

Y &

SE

VE

RIT

Y

•of

impact of

impairm

ent on f

unctionin

g in

curr

ent

conte

xts

•of


ifficultie

s

Child

ren just

belo

w a

ge

expecta

tions

At risk c

hild

ren

Child

ren w

ith identified

language d

isord

er

Po

or

resp

on

se t

o i

nte

rven

tio

n



November 2017

Susan Ebbels 36

© Ebbels, McCartney, Slonims, Dockrell &Norbury (2017)

yes

Led by education

Continuing mild-

moderate impact?

Small group &/or 1:1 work – provider must be well-trained

and very closely monitored

School monitor treatment fidelity

& progress

High risk?

SLT Assessment

yes

no

yes

yes

Good progress? no

no

Comprehension difficulties or

complex needs?

yes

yes

direct SLT

Indirect intervention – provider must be well-trained and very

closely monitored

no SLT monitor treatment

fidelity & progress

Continuing moderate-

severe impact?

yes

no

no

SLT concerns

? no

Good progress? no

SLT monitor progress

Good progress?

Continuing severe

impact?

no

no

yes

Increase frequency

of SLT, change

methods

no

Direct SLT

Quality first teaching

School monitor progress

Good progress?

Led by education

yes

yes

Indirect intervention led by SLT

“Red flags” and risk factors: • Severity/pervasiveness • Family history • Age • Neurodevelopmental disorder

Teacher / Parent concern

Collaborative work between

SLT, families and education

Plan









• Implicit grammar facilitation approaches

• Explicit meta-linguistic approaches





November 2017

Susan Ebbels 37

• Much of the content of this part of the day (sentence

level) is discussed in

– Ebbels, S. H. (2014). Effectiveness of intervention for

grammar in school-aged children with primary language

impairments: a review of the evidence. Child Language

Teaching and Therapy, 30: 7-40.

– Available from: http://clt.sagepub.com/content/30/1/7?etoc

– FREE FOR ANYONE TO ACCESS

Implicit vs. explicit approaches

Implicit approaches

• Child does not have to understand or learn anything about the structure of language

• Adult manipulates environment and style and content of own communication to facilitate spontaneous language acquisition

• Often used with younger children

Explicit approaches

• Tell the child the underlying rule they are trying to learn

• May use visual support to highlight target structures

• Often used with older children

http://clt.sagepub.com/content/30/1/7?etoc

http://clt.sagepub.com/content/30/1/7?etoc



November 2017

Susan Ebbels 38

Grammar facilitation approaches

• Assume that the child has normal language learning

mechanisms and can learn from repeated exposure

to examples of particular forms

• They have language difficulties because they have

slow processing or limited processing capacity.

• Therefore, intervention should increase the

frequency, saliency, meaningfulness and opportunity

to make use of target constructions.

Different grammar facilitation

approaches

• Imitation

• Modelling

• Focused stimulation

• Expansion

• Recasting



November 2017

Susan Ebbels 39

EFFICACY: Evidence

supporting the treatment Implicit approaches

Mulac & Tomlinson (1979)

Matheny & Panagos (1978)

Nelson et al. (1996)

Leonard (1975)

Wilcox & Leonard (1978)

Courtwright & Courtwright

(1976)

Tyler et al (2002; 2003)

Gillam et al (2012)

Gillam et al. (2008)

Imitation

Imitation

Re-casting

Contextualised

language facilitation

(lots of targets)

Modelling +

Evoked Prod

Mod + EP +

re-casting

Implicit learning

from computerised

trials (Cn)

Cleave et al. (2015) Recasting

Hsu & Bishop (2014) - specific

Nelson et al (1996) Mod + EP +

re-casting

Bishop et al. (2006) Hsu

& Bishop (2014) - TROG











Meyers-Denman & Plante, 2016 Re-casting

EFFICACY: Evidence


EFFECTIVENESS: The

Treatment in Practice

+ve -ve

Fey et al. (1993; 1997)

Implicit approaches

Mulac & Tomlinson (1979)

Matheny & Panagos (1978)

Gillam et al. (2008)

Bishop et al. (2006)

Hsu & Bishop (2014) - TROG

Cleave et al. (2015)

Leonard (1975)

Wilcox & Leonard (1978)

Courtwright & Courtwright

(1976)

Tyler et al (2002; 2003)

Gillam et al (2012)

Hsu & Bishop (2014) - specific

Nelson et al (1996)

Meyers-Denman & Plante, 2016



November 2017

Susan Ebbels 40

Gillam et al. (2008) RCT

• 216 children with language impairments

• 6-9 years

• 1:1 with SLT / computer

• 4 x 20mins per day for 6 weeks (=40hrs)

• Four groups

1. FFW

2. CALI (computer assisted language intervention), e.g., Earobics,

Laureate Learning software

3. AE (academic enrichment): educational computer games (Maths,

Science, Geography)

4. ILI (individualised language intervention with SLT): contextualised

language facilitation approaches. Targeted semantics, grammatical

morphology, clause structure, narration and phonological

awareness (all in one session).

• Results

– ALL groups (including AE) made significant progress on

standardised language tests,

– no effect of group on language progress

– Further progress made at 3m and 6m follow-up

– Only effect of group was on blending words subtest of CTOPP

where language groups > AE

• Conclusions

– All intervention improves language (including playing Maths,

Science, Geography computer games)

– No difference between the different intervention programmes

(including academic enrichment)

– Effects found were probably practice effects



November 2017

Susan Ebbels 41

Summary of evidence for

Grammar Facilitation approaches

• These methods are effective

– for pre-school and early school-aged children

– with expressive language delays and difficulties

– delivered 1:1 or in groups

– by SLT or parents

– For improving a range of expressive morphology and syntax targets

– Contextualised intervention may be better

– Alternating this with phonological therapy may be best

– May improve comprehension on specific items

• No evidence for effectiveness with

– Children > 9 years old,

– By anyone other than SLT or parents trained by SLT

• Academic enrichment may be just as good

• Comprehension progress may not generalise

Priority questions for future grammar

facilitation research

1. Are these methods better than academic enrichment?

2. Can grammar facilitation methods be successfully delivered

by school staff?

3. Are GF methods successful with children

– > 9years

– With receptive language difficulties – can they generalise beyond

specific items targeted?



November 2017

Susan Ebbels 42

Plan













Explicit metalinguistic approaches

and how they are used

• provide explicit teaching of language often in the context of specific visual cues to aid the child’s learning

• Different sentence constituents are highlighted (often

with colours and/or shapes). – Evidence for “Shape Coding by Susan Ebbels®”, “Colourful

Semantics” and “Meta-Taal” (like Shape Coding)

• Children need to be

1. taught the basics of the system first,

2. then the system can be used

• as a tool to teach the rules and/or structure of language

• as an aid to comprehending or producing sentences

• to correct written work and/or oral language



November 2017

Susan Ebbels 43

Shape Coding

1. Codes parts of speech with colours

2. Codes phrases with shapes (drawn in black).

3. Codes verb morphology with arrows (for tenses)

and lines (for plurals)

Shape Coding - colours

Colour Pattern Scheme colours

(with a few alterations)

Noun / Pronouns (boy, table, I)

Det / Possessive pronouns (the, a, my)

Verb (push, melt)

Adjective (hard, sad)

Preposition (in, through)

Adverb (quickly, carefully)

Coordinating conjunction (and, but, or)

Subordinating conjunction (because, if)



November 2017

Susan Ebbels 44

• Phrases grouped with shapes and linked with colour, a question and a symbol

Shape Coding - shapes

Aux, modal,

or copula

Verb Phrase

Prepositional

Phrase

Adjective

Phrase

• Extra shapes

• ‘Subjects’ and ‘objects’ have different shapes

NP: Subject NP: Object

Basic sentence Templates



November 2017

Susan Ebbels 45

John should eat

John is happy

Basic sentence Templates

John laughed

John is at school

The hungry boy should eat

A tall boy is happy

Increasing complexity add “pink and

green words” to ovals and rectangles

Two naughty boys laughed

My big brother is at his amazing school



November 2017

Susan Ebbels 46

This hungry boy should eat

A tall boy is happy

in their classroom

in the kitchen

Increasing complexity add “where”

Some naughty boys laughed

My big brother is at his amazing school

at his school

Increasing complexity add “and”

Some boys laughed and pointed

A boy, his brother and his dad eat and drink

The boy and the girl are happy and healthy



November 2017

Susan Ebbels 47

Increasing complexity (4) add “and”

The boy and the girl are happy and healthy

Some boys laughed and pointed

A boy, his brother and his dad eat and drink

he ate

Verb tenses

• Vertical arrow = finite verb (in the middle=present, left=past tense)

• horizontal arrow pointing left = past participle

he eats

he has eaten he had eaten



November 2017

Susan Ebbels 48

Plurals (in English)

• Double red line used for plural nouns and pronouns

• Double blue lines used for plural verb

The boy is short

The boys are short

He is short

They are short

The boy and his dog are short

De är korta

Plurals in Swedish?

• Double red line for plural nouns and pronouns

• Double green lines for plural adjective

• Double pink lines for plural determiner

Pojken är kort

Pojkarna är korta

Han är kort

Pojken och hans hund är korta



November 2017

Susan Ebbels 49

EFFICACY: Evidence


Explicit approaches

to teaching

grammar Ebbels et al (2007) SC

Ebbels (2007) SC

Spooner, (2002) like CS

Guendouzi (2002) like CS

Bryan (1997) CS

Ebbels & van der Lely (2001)

SC

Zwitzerlood et al. (2015) like SC


Prod

Comp

& Prod

Prod

Comp

Prod

Prod

Prod

Prod 1. Anecdotes /clinical experience










EFFICACY: Evidence


Explicit approaches

Ebbels et al (2007) SC

Ebbels (2007) SC

Spooner, (2002) like CS

Guendouzi (2002) like CS

Bryan (1997) CS

Ebbels & van der Lely (2001)

SC



Ebbels et al. (2014) SC Comp

Bolderson et al. (2011) CS Prod

Kulkarni et al. (2014) SC Prod

Calder et al. (in press) SC Prod

& Comp

EFFECTIVENESS: The

Treatment in Practice



November 2017

Susan Ebbels 50

Evidence for metalinguistic approaches

• Can be effective for

– Pre-school, primary and secondary school-aged children

– with profound receptive and expressive difficulties

– delivered 1:1, in class in language school or pair

– by SLT for improving

• expressive sentence structure (esp. verb argument structure)

• comprehension of coordinating conjunctions

• comprehension and expression of sentences involving

“movement” (passives, ‘wh’ questions)

• use of regular past tense in speech

• production (but not comprehension) of relative clauses

• use of past tense in writing

• No evidence of effectiveness by anyone other than

SLT

Priority questions for future research on

explicit meta-linguistic methods

1. Can anyone other than SLTs successfully deliver

metalinguistic intervention?

2. Which components are necessary?

– Explicit teaching of rules?

– Explicit feedback regarding the nature of errors?

– Visual templates?

3. Are explicit or implicit therapy methods more effective (for

which ages and profiles)?

4. Is a combination of explicit and implicit approaches more

effective (for which ages and profiles) and how should they

be combined?



November 2017

Susan Ebbels 51

Combined explicit and implicit

• Effective for teaching expressive grammar to 5 year olds

with SLI, although articulation difficulties reduced

effectiveness (Smith-Lock et al., 2013a)

• Only if weekly, not daily (Smith-Lock et al., 2013b)

• Effective for teaching regular past tense to children with

SLI (Kulkarni et al., 2014)







EFFECTIVENESS:

The Treatment in

Practice A. Treatment in common use as

designed

Smith-Lock et al.

(2013a; 2013b)

Combined explicit

and implicit approach

weekly

Smith-Lock et al.

(2013b) daily

Kulkarni et al. (2014)

Calder et al. (in press)



November 2017

Susan Ebbels 52

Plan













Narrative therapy

Explicitly teach narrative structure =

macrostructure (Klecan-Aker et al., 1997)

• Some use question words, or cue cards to help children

(Hayward & Schneider, 2000 ; Davies et al., 2004)

• Microstructure = Sentence level grammar (often

targeted implicitly at same time)



November 2017

Susan Ebbels 53

+ve -ve

EFFICACY: Evidence


Explicit teaching of

narrative structure with

implicit teaching of

grammar Klecan-Aker (1997)

Fey et al. (2010)

Swanson et al. (2005)

Davies et al. (2004)

Hayward & Schneider

(2000)

Petersen et al (2008)

Swanson et al. (2005)

Davies et al. (2004)

Fey et al (2010)


Narrative

structure

Grammar

Narrative

structure

Grammar

Grammar

Narrative

structure



Narrative

structure

Grammar











Evidence for narrative based approaches

• Explicit teaching of story grammar is effective for

– Primary school-aged children (aged 5-9)

– with receptive and/or expressive difficulties (including with co-occurring

neuromuscular impairments or low NV IQ) or “learning (i.e., reading)

disabilities”

– delivered 1:1, in pairs or groups

– by researcher or SLT

– for improving

• story grammar and length of stories

• Don’t know about

– children >9 years

– Whether anyone other than researcher/SLT can teach narrative

• Implicit teaching of grammar in the context of explicit teaching

of narrative structure is not effective for improving

– grammar or sentence complexity



November 2017

Susan Ebbels 54

Priorities for future narrative

research

1. Does explicit narrative therapy improve story

grammar in children aged over 9 years?

2. Can anyone other than researcher / SLT deliver

narrative therapy effectively?

3. Is it possible to work effectively on both narrative

structure and sentence level work in parallel?

Plan















November 2017

Susan Ebbels 55

‘Robust’ / ‘Rich’ vocabulary

therapy/instruction Beck & McKeown (2007), Beck et al. (2002), Justice et al. (2014)

• Based on many studies on teaching vocabulary to

typically developing children (although some low vocab,

or in disadvantaged areas)

• Therapy should focus on Tier 2 / academically relevant

words

– Too low frequency to be acquired readily by children with vocab

weaknesses as too infrequent in conversation

– Highly important for reading academic materials across the

curriculum (where occur frequently)

– E.g., ordinary, analyse, summarise, necessity, predict

– Range of parts of speech

Intervention should use a range of techniques

1. Identify target word

2. Define word explicitly

3. Link word to other related words

4. Discuss how word used in other contexts

5. Demonstrate / act out meaning

6. Ask child to repeat word

7. Discuss phonology / orthography

8. Discuss how word used in sentences

– Including variations in grammatical form

– Ask child to produce their own sentence using the

word

9. Discuss morphologically related words

‘Robust’ / ‘Rich’ vocabulary instruction Beck & McKeown (2007), Beck et al. (2002), Justice et al. (2014)

Semantics

Phonology/

orthography

Grammar: • Part of speech

• Syntax

• Morphology



November 2017

Susan Ebbels 56

Standard SLT practice Justice et al. (2014)

• 23 SLPs working with 48 * 5-7 year olds

• Coded 2 therapy sessions each

• Words targeted:

Word class %

Taught

Nouns 77%

Adjectives 9%

Prepositions 8%

Verbs 5%

Other (interrogatives,

adverbs, articles)

2%

Tier %

Taught

Tier 1 87%

Tier 2 12%

Tier 3 <1%

Standard SLT practice Justice et al. (2014)

Area Technique % Used

Semantics

Link word to other related words 82%

Define word explicitly 57%

Discuss how word used in other contexts 15%

Demonstrate / act out meaning 11%

Phonology/

orthography

Repeat word 80%

Discuss phonology / orthography

11%

Grammar Discuss how word used in sentences 3%

Discuss morphologically related words 0.2%



November 2017

Susan Ebbels 57











EFFICACY: Evidence

supporting the treatment Vocabulary

teaching

Munro et al. (2008)

Parsons et al. (2005)

Throneburg et al. (2000)

Zens et al. (2009)

Good et al. (2015)

Semantic &

phonological

Semantic &

phonological

Semantic &

phonological

Morphological

awareness

Katz & Carlisle (2009) Morphological

awareness

Spencer et al. (2017) Semantic &

phonological

+ve -ve

+ve -ve

Munro et al. (2008)

Parsons et al. (2005)

Throneburg et al. (2000)

Zens et al. (2009)

Good et al. (2015)

Semantic & phonological, delivered

by teachers after 90 mins training

Katz & Carlisle (2009)

Murphy et al (2017)

Vocab enrichment programme

(delivered by teachers after 5 hours

training)

Wright et al. (in press)

St John & Vance (2014)

Spencer et al. (2017)

Semantic & phonological, plus use in

sentences (delivered by usual SLTs in school)



November 2017

Susan Ebbels 58

Summary of evidence for vocabulary

intervention

– Intervention (semantic + phonological) can improve

comprehension of targeted words

• By primary and secondary school-aged children

• Delivered by SLT, teacher or collaboratively (in groups or 1:1)

– This might generalise to control words

– Intervention focused on explicit teaching of morphological

awareness can improve

• Targeted words (including both meaning and spelling)

• Generalisation to control words (more for spelling than meaning)

• In primary school-aged children

– Grammatical components rarely used in standard intervention

Priority questions for future vocabulary

intervention research

1. Can we improve effectiveness of intervention by including a

grammatical component?

– A few studies with morphology, now need to look at role of syntax

and argument structure (particularly if teaching verbs)



November 2017

Susan Ebbels 59

Intervention for Word Finding

Difficulties

• Research focuses on semantics versus

phonology

• Intervention

– discusses links between words in terms of semantics

and/or phonology

– Discusses details of the phonology and semantics of

targeted words











EFFICACY: Evidence


Intervention for

word finding

difficulties

Best (2005)

McGregor (1994)

German (2002)

Wilson et al. (2015)

Marks & Stokes (2010)

Bragard et al. (2012)

+ve -ve

German et al. (2012)

Wing (1990)

Ebbels et al. (2012)

Best et al. (2017)

Semantic

P or S

Wright (1993)

Wright et al. (1993)

Wright et al. (1993)

Semantic

Phonological

Phonological

Semantic

Phonological/

perceptual

Wing (1990) Semantic

P&S

S < P&S

P&S



November 2017

Susan Ebbels 60

Evidence of effectiveness of therapy for

WFD difficulties • Phonological therapy is effective for

– Children aged 5-11 years

– Delivered 1:1

– By SLT

– For targeted words

– little generalisation to other words

• Semantic therapy is effective for

– Children over 6 years,

– Delivered 1:1

– By SLT

– Effects generalise to other words, especially within category

– But not to discourse

• Relative effectiveness of phonological vs. semantic therapy may vary

by child ?semantic better if also DLD?, ?phonological better if purer WFDs?

Priority questions for future WFD therapy

research

1. How should generalisation to discourse be

achieved?

2. Is semantic therapy effective for children under the

age of 7 years?

3. Which is more effective (for which children)?

• Semantic therapy

• Phonological therapy

• A combination

4. Can WFD therapy be successfully delivered in

other ways than 1:1 with SLT?



November 2017

Susan Ebbels 61

OVERALL SUMMARY (1)

WFD:

• semantic intervention effective and generalises

(?Xdiscourse) for those with WFDs and DLD delivered 1:1

• 1:1 phonological intervention seems effective

(?generalisation) for those without co-occurring DLD

• ?anyone other than SLT

Vocab:

• combined semantic and phonological intervention seems

effective (?generalisation) by SLT or TAs (collaborative

SLT/teacher ?best)

• Morphological awareness training improves vocab and

spelling (some generalisation)

• standard practice doesn’t include grammatical components

OVERALL SUMMARY (2)

Narrative

• explicit teaching improves narrative structure (and vocab)

• implicitly targeting grammar at same time, not effective

Grammar

• Explicit teaching by SLT (?anyone else) improves production

and comprehension (usually)

• Combined explicit and implicit effective when delivered

weekly (not daily)

• Implicit approaches effective for improving specific targets in

young children with expressive language delays and

difficulties (?Xreceptive language difficulties and older

children)

• Fast ForWord not effective



November 2017

Susan Ebbels 62

OVERALL SUMMARY (3 Service delivery) • Collaborative teaching some evidence of effectiveness

• Direct individualised intervention usually effective (see above),

collaborative ?best

• Indirect individualised intervention effective for children with

expressive difficulties (?Xreceptive) if assistant provided to the

school and >20 hours intervention. Not effective via usual

consultancy model

• Education-led small group interventions delivered by very well-

trained and supported school staff can be effective if delivered at

least 3x30 mins per week (?SLT role?)

• (intensive) training (and coaching) of education staff may

improve their classroom practice. Can co-occur with progress in

older children with DLD and younger TD children (?younger

children with DLD)

• Health promotion: no robust evidence

All

child

ren

Children

Intervention

Direct

SLT-led

intervention

Indirect SLT-led

intervention


following language

programmes



Assessment, planning, direct intervention,

monitoring of progress

Assessment, planning,

training & monitoring others’

delivery of indirect


progress

Influence

public

awareness

and

policies

Advise &

problem-solve re

evidence-based

programmes

CO

MP

LE

XIT

Y &

SE

VE

RIT

Y

•of

impact of

impairm

ent on f

unctionin

g in

curr

ent

conte

xts

•of


ifficultie

s

Child

ren just

belo

w a

ge

expecta

tions

At risk c

hild

ren

Child

ren w

ith identified

language d

isord

er

Po

or

resp

on

se t

o i

nte

rven

tio

n

the current evidence base for school-aged children …...evidence base for interventions for...

Documents