Application of the ICF to children with speech impairments

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Application of the ICF to children with speech
impairments

• Sharynne McLeod, PhD
• Charles Sturt University, NSW, Australia
• smcleod_at_csu.edu.au

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Who are children with a communication impairment?

• Difficulties with
• Pronunciation (speech)
• Expressive language
• Receptive language
• Stuttering
• Voice production
• Hearing
• (Swallowing)

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Prevalence of children with communication
impairment

• Prevalence in primary and high school students
  (N 14,533) (McKinnon McLeod, 2005)
• Specific learning difficulties 19.1
• Communication disorders 12.4
• Behavioural/emotional difficulty 6.1
• English as a second or other language 5.8
• Early achievers/advanced learners 5.5
• Physical/medical disability 1.4
• Intellectual disability 1.2
• Hearing impairment 0.8
• Visual impairment 0.3
• Total 33.3

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Children with communication impairment

• At risk for lower attainment in
• social/emotional
• educational
• occupational areas
• (Felsenfeld et al., 1992, 1994 Knox
  Conti-Ramsden, 2003 Lewis et al., 2000)

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Application of ICF and ICF-CY

• ICF has been applied to people with communication
  impairment
• USA and Australia
• Predominant focus on adults
• Limited application to children Exceptions
• Simeonsson (2003)
• Hodge (1983) ICIDH
• McLeod Bleile (2004)
• Skeat et al. (2003)
• Drevensek (in process)

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Speech impairment

• Sub-category of communication impairment
• Speech pathologists define speech impairment at
  the Body Function level
• Difficulties with the input, organization and
  production of speech
• segmental level (vowels consonants)
• suprasegmental level (timing, intonation, tones)
• Body structure is typically intact80 are
  classified as having aspeech disorder of no
  known origin

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Speech impairment

• Sub-category of communication impairment
• Speech pathologists define speech impairment at
  the body function level
• Difficulties with the input, organization and
  production of speech
• segmental level (vowels consonants)
• suprasegmental level (timing, intonation, tones)
• Range trouble saying /s/ and /z/ (lisp) to
  completely unintelligible speech
• Umbrella term for speech sound impairment,
  articulation delay, phonological disorder,
  childhood apraxia of speech etc.

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I have to say it again again

• I Do people often ask you to say things again?
• Child Yep
• I And how does it make you feel?
• Child I just dont want to say it.
• I You dont want to ...
• Child And they keep forcing me to.
• I And you,
• Mum You what?
• I Say that one again?
• Child They keep forcing me they keep say..
• I They keep forcing you to.
• Child Mm
• I And hows that make you feel?
• Child I have to say it again and again
• I You have to say it again and again
• I And have you worked out ways so that you can
  help them understand what you are saying?

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• I And have you worked out ways so you can help
  them understand what youre saying?
• Child Mmm
• I What do you do?
• Child You put the thing what you talking about,
  I say, its its um its over there it..it..
• Mum He does a lot of hand actions. He usually
  goes to great lengths to explain everything.
• I Yeah. Cause I can see that in your brain,
  youve got a lot of good stuff to say havent
  you. Nodded Yeah. So you use your hands to show
  them what you mean? Do you do anything else to
  show them?
• Mum Sit up and look
• Child So I say it starts with ch and they still
  cant understand me
• I And you say it starts with ch and they
• Child No, tee
• I With te? And they still cant understand you
  sometimes
• Child yeah,
• I yeah sometimes do you write down what the word
  is?
• Child Yeah sometimes I dont know how to write
  the words
• I Yeah, its a bit hard isnt it?

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Children with speech impairment

• Constitute one of the largest groups of children
  seen in paediatric speech pathology practice
  (Bleile, 2004)

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Children with speech impairment

• Average age of referral 4 years 3 months
  (Shriberg Kwiatkowski, 1994)
• Risk factors
• STRONG Gender Ratio of boys to girls 21
  (Lewis et al., 1989)
• STRONG Positive family history of speech,
  language and/or literacy difficulties (Fox et
  al., 2002, Felsenfeld et al., 1995, Lewis et al.,
  1989)
• MODERATE Low maternal education (Fox et al.,
  2002, Campbell et al., 2003)
• INCONCLUSIVE Low socioeconomic (SES) (Fox et
  al., 2002)

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Children with speech impairment Environmental
and personal factors

• 7.71 times as likely to have a speech impairment
  
• male
• with a positive family history and
• low maternal education level
• (Campbell et al., 2003)

Suggesting the importance of Environmental and
Personal factors
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Consideration of children with speech impairment

• Requires several codes crossing dimensions
• Body Function
• Body Structure
• Activities and Participation
• Environmental Factors
• Personal Factors
• Conventions are being developed but will need
  continuous attention for the foreseeable future
  (Lollar Simeonsson, 2005, p. 329)

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Four sources for discussion of ICF ICF-CY

• Longitudinal Study of Australian Children
• Survey of Australian speech pathologists
• Qualitative study of children
• In-depth case study

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1. Longitudinal Study of Australian Children

• 4-5-year-olds (n 4958) (wave 1)
• Parents were asked do you have concerns about
  your childs speech?
• 13 - Yes
• 11.2 - A little
• 75. - No
• (McLeod Harrison, 2006)

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1. Longitudinal Study of Australian Children

• 4-5-year-olds (n 4958) (wave 1)
• Parents were asked do you have concerns about
  your childs speech?
• 13 - Yes
• 11.2 - A little
• 75. - No
• (McLeod Harrison, 2006)

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1. Longitudinal Study of Australian Children

• Impact of speech impairment on Activities and
  Participation
• Parents and teachers answered questions
• Significant differences (p lt.000) between the 2
  groups for total scale every subscale
• SDQ (Strengths Difficulties Questionnaire)
• Prosociality scale
• Hyperactivity scale
• Emotional symptoms scale
• Peer problems scale
• Conduct problems scale

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1. Longitudinal Study of Australian Children

• Teachers answered questions
• Relationship quality scale
• Warm relationship scale
• Conflict scale
• Open communication scale
• Competencies
• Developmental competencies
• Reading competencies
• Writing competencies
• Numeric competencies
• Again there were significant differences (p
  lt.000) between the 2 groups for every
  scale/subscale

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1. Longitudinal Study of Australian Children

• These data demonstrate the interrelationship
  between
• Body Function
• Activities and Participation
• Environmental Factors
• Personal Factors

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2. Survey of Australian speech pathologists
Major factor to diagnose speech impairment of
unknown origin (McLeod, 2004)
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• improvement in function is often the litmus
  text that society uses to evaluate effectiveness
  of programs and treatments.
• (Lollar Simeonsson, 2005, p. 323)

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2. Survey of Australian speech pathologists

• Write up to three questions you would like to
  ask a person who was coming to see you for a
  speech assessment.
• Think about
• Activity and Participation,
• Environmental Factors, and
• Personal Factors.
• Who you would direct the questions to?

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2. Survey of Australian speech pathologists

• Development of the Speech Participation and
  Activity Assessment of Children (SPAA-C)
• McLeod, S. (2004). Speech pathologists'
  application of the ICF to children with speech
  impairment. Advances in Speech-Language
  Pathology, 6(1), 75-81.

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Speech Participation and Activity Assessment of
Children (SPAA-C)

• Questions for the child
• Questions for friends
• Questions for siblings
• Questions for parents
• Questions for teachers
• Questions for others

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WHY listen to children?

• Children are citizens with rights
• Article 12 Parties shall assure to the child who
  is capable of forming his or her own views the
  right to express those views freely in all
  matters affecting the child, the views of the
  child being given due weight in accordance with
  the age and maturity of the child. emphasis
  added
• United Nations Convention on the Rights of the
  Child (UNCRC) (http//www.unicef.org/crc/crc.htm)

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SPAA-C Questions for the child

• Who you are
• What is your most favourite thing to do? At home?
  At school?
• What games/sports do you play?
• What do you want to be able to do?
• If Mum and Dad said What do you want to do on
  Saturday? What would you do and who would you
  take?
• Your talking
• Sometimes people dont understand me when I use
  big words. Do people sometimes not understand
  what you say?
• What do you think about your talking?
• Do you like your talking?
• Do you like people to talk to you?
• How often do people ask you to repeat things? How
  does this make you feel?
• What do you do when people dont understand you?
  (e.g., keep trying, change your message, give
  up, get cross, etc)

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SPAA-C Questions for the child
etc
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SPAA-C

• Use information to cooperatively plan
• assessment
• goal setting, and
• intervention
• so that changes can directly impact the childs
  whole life

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3. Qualitative study

• Qualitative study of the Activities and
  Participation of children with speech impairment
  (McLeod Daniel, in process)
• We talked with
• Focus children
• Parents
• Siblings
• Friends
• Teacher
• Significant others

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Mosaic approach (Clark Moss, 2001)

• Loris Malaguzzi (translated by Lella Gandini)
• The childis made of one hundred.The child
  hasa hundred languagesa hundred handsa hundred
  thoughtsa hundred ways of thinkingof playing,
  of speakingThe child has a hundred
  languages(and a hundred hundred hundred more)

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Examples of listening to children with a speech
impairment Luke
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Luke his problems are all due to the speech

• One minute I could kill him, and then most of the
  time I just have this overwhelming love for him
  and, and I feel so sorry for him and I know his
  behaviour problems are due to the speech
  frustration, they always have been.
• Um I carry guilt because I get so frustrated with
  him, but hes such a great kid and his problems
  are all due to the speech.

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Examples of listening to children with a speech
impairment James

• Yes, he is different with different people.
  People he knows well hes much more confident,
  happy around. People he doesnt know so well
  hes very shy. Its very hard to introduce him
  to someone, to get him to look someone in the
  eye, say hello, how are you? He sort of says
  hello, then runs off. (Transcript of interview
  with mother)

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Examples of listening to children with a speech
impairment Joshua
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Examples of listening to children with a speech
impairment Joshua

• DAD Theres so many people like, theyre good
  people, theyre intelligent people but you put
  them up against something where they cant
  explain themselves or argue or make a validated
  point and, theyre dominated.
• MUM Yeah
• DAD You need, you need all these skills to
  empower yourself. Its part of your empowerment
  and, if he Joshua doesnt have it (pause) its
  a scary world
• INTERVIEWER Yep. So you see grown up versions of
  Joshua at your work? Is that what your saying?
• DAD Im a union official. I see it everyday.

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3. Qualitative study

• The interrelationship between the components of
  the ICF and ICF-CY
• (Body Structure)
• Body Function
• Activities and Participation
• Environmental Factors
• Personal Factors
• are relevant for these children with speech
  impairment

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4. Case study

• In-depth case study of a child with severe speech
  impairment of unknown origin
• 26 international experts provided assessment,
  analysis and intervention goals for the same
  7-year-old boy
• Review of ICF-CY (Threats McLeod)
• including the most relevant codes for speech
  impairment (McLeod, in process)

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ICF-CY Body Function

• Suggested additions to ICF-CY (Threats McLeod)
• b320 Articulation functions
• b3200 Production of vowels
• b3201 Production of consonants
• b3202 Production of tones
• b3203 Production of syllable shapes
• b3204 Production of intelligible words and
  sentences

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ICF-CY Body Function

• Suggested additions to ICF-CY (Threats McLeod)
• b321 Phonological functions (Sound systems
  functioning)
• note
• Functions of the reception and production of
  meaningful phonological units linked to the
  ambient language.
• inclusions
• phonological recognition, phonological
  representation, phonological processes
• exclusions
• mental functions of language (b167) voice
  functions (b310) articulatory functions (b321)

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ICF-CY Body Function

• Suggested additions to ICF-CY (Threats McLeod)
• b2304 Speech discrimination
• note
• Sensory functions relating to determining spoken
  language and distinguishing it from differing
  sounds and words.
• b23040 Distinguish speech from other sounds
• b23041 Distinguish speech sounds from one another
• b23042 Distinguish words from one another
• b23043 Distinguish nonwords from real words

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ICF-CY Activities and Participation Suggested
additions to ICF-CY (Threats McLeod)

• d133 Acquiring language
• d1330 Acquiring single words or meaningful
  symbols
• d1331 Acquiring grammar
• d1332 Combining words into phrases
• d1333 Acquiring syntax
• d1334 Acquiring discourse types
• d1335 Acquiring conversational speech
• d1338 Acquiring language, other specified
• d1339 Acquiring language, unspecified

• d135 Acquiring speech
• d1351 Acquiring speech sounds
• Learning speech sounds such as consonants,
  vowels, and tones.
• d1352 Acquiring syllables
• Learning to produce different syllables including
  those with final consonants, consonant clusters
  and polysyllabic words.
• d1353 Acquiring prosody, stress and intonation
• d1354 Acquiring intelligible speech
• d1358 Acquiring speech, other specified
• d1359 Acquiring speech, unspecified

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Summary

• The interrelationship between the components of
  the ICF and ICF-CY are relevant for children with
  speech impairment
• Speech pathologists
• traditionally focus on Body Function (and
  Structure)
• additional consideration of Activity and
  Participation, Environmental and Personal Factors
  is important
• ICF-CY is beneficial for holistically considering
  these children and their milieu