SLI in Preschoolers: Which service delivery model?

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SLI in Preschoolers Which service delivery model?

• Paediatric Language Group

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Paediatric Language Group- a quick update

• Change of leadership - thank you to Brooke Butt
  for all your hard work
• New group leaders
• Katie Carmody (Sydney Childrens Hospital)
• Mary Falco (Sydney Childrens Hospital)
• Sara Beckett (Bankstown Community Health)
• Current members - mainly of community health
  paediatric speech pathologists and a few private
  therapists from both metropolitan and rural areas
• Cover a broad range of topics

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The challenges in coming up with a clinical
question ..

• Difficulties
• Broad topic, language has many theoretical
  constructs and many clinical elements
• Language impairment is a heterogeneous group
• There are a huge range of intervention techniques
  in use, with varying levels of evidence.

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The challenges in coming up with a clinical
question .. (cont)

• Useful to keep in mind
• Start with a broad clinical question that can be
  answered
• Decide on type of question Diagnostic?
  Predictive? Comparing types of intervention or
  service delivery models?
• Ensure topic is relevant motivating to group
  members and will have implications for clinical
  practice

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Current Question

• In children 0-6 years, which service delivery
  models are effective in treating Specific
  Language Impairment?

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Current Question (cont)

• Reasoning for question significant variation in
  how children with language impairment are treated
• -group therapy -direct therapy (SP)
• -individual therapy -indirect therapy (non SP)
• -parent training
• Type of service delivery model has implications
  on the efficacy of services.

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Searching the evidence

• Search terms
• specific language impairment
• language therapy/intervention/outcomes,
• individual therapy,
• group therapy,
• direct therapy,
• indirect therapy
• and a mix of all terms

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Searching the evidence (cont)

• Results, 11 articles matched search terms and fit
  the clinical question.
• Boyle J, McCartney E, Forbes J, OHare A. A
  randomised control trial and economic evaluation
  of direct vs indirect and individual vs group
  modes of speech and language therapy for children
  with primary language impairment. Health
  Technology Assessment 2007 11 (25)
• Boyle et al. (2009). Direct versus Indirect and
  individual versus group modes of language therapy
  for children with primary language impairment
  principal outcomes from a randomized controlled
  trial and economic evaluation. International of
  Journal of Communication Disorders, 44 (6)
  826-846
• Dickson et al (2009). Cost analysis of direct
  versus indirect and individual versus group modes
  of manual based speech-and-language therapy for
  primary school-age children with primary language
  impairment. International of Journal of
  Communication Disorders, 44 (3) 369 - 381

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• Gallagher Chiat (2009). Evaluation of speech
  and language therapy interventions for pre-school
  children with specific language impairment a
  comparison of outcomes following specialist
  intensive, nursery-based and no intervention.
  International of Journal of Communication
  Disorders, 44 (5)
• Gibbard (1994). Parental based intervention with
  preschool delayed children, European Journal of
  Disorders in Communication, 29, 131-150
• Ward (1999). An investigation into the
  effectiveness of an early intervention method for
  delayed language development International of
  Journal of Communication Disorders, 34 (3)
• Baxendale et al (2003). Comparison of the
  effectiveness of the Hanen Parent Programme and
  traditional clinic therapy, International Journal
  Communication Disorders, 38 (4), 397415

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• Gibbard (2004). Cost-effectiveness analysis of
  current practice and parent intervention for
  children under 3 years presenting with expressive
  language delay, International Journal Language
  Communication (39)2, 229244
• Moller et al (2008). Implementation and
  evaluation of a parent training for language
  delayed children
• Buschman et al (2009). Parent based language
  intervention for 2 yr old children with specific
  expressive language delay- a randomised
  controlled trial Arch Dis Child 2009 94 110-116
• Law (1997). Evaluation intervention for language
  impaired children a review of the literature.
  European Journal of Communication Disorders (32)
  1-14

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Articles

• Boyle J, McCartney E, Forbes J, OHare A. A
  randomised control trial and economic evaluation
  of direct vs indirect and individual vs group
  modes of speech and language therapy for children
  with primary language impairment. Health
  Technology Assessment 2007 11 (25)

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Articles Boyle et al. (Cont)

• Participants 163 school children aged 6-11yrs in
  Scotland below 10th percentile on CELF, normal
  IQ, no comorbidity
• Experimental groups split into
• direct individual
• direct group
• indirect individual
• indirect group
• Controls received normal community health services

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Articles Boyle et al. (Cont)

• Treatment group received 20hrs therapy across 15
  weeks. Consistent program delivered to all
  groups (comprehension monitoring, vocabulary
  development, grammar, narrative therapy).
• Results
• no significant difference at 12 months review
  between any of the groups
• indirect group therapy was most cost-effective,
  but authors warn caution as this was reliant on
  high level of training and support for therapy
  aides in program

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Articles Boyle et al. (Cont)

• Strengths large RCT
• Limitations noted by authors
• when designing the therapy protocol used there
  was an overall lack of evidence on therapy
  effectiveness for this population
• study was unable to reach the intended number of
  participants for the initial power calculation
• language delay was heterogenous- mixed
  receptive/expressive and levels of delay.

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Articles Gallagher Chiat (2009)

• Gallagher, A. Chiat, S. 2009, Evaluation of
  speech and language therapy interventions for
  preschool children with specific language
  impairment a comparison of outcomes following
  specialist intensive, nursery-based and no
  intervention. International Journal of Language
  and Communication Disorders, 44 (5), 616- 638.

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Articles Gallagher Chiat (2009) (cont)

• Participants 24 preschoolers (36? 41yrs) in
  London. Delay of 18 months or more (at least 2
  standard deviations from the mean) on receptive
  and/or expressive language scores. No co
  morbidity.
• Controls (n8) from waiting list of local
  community health.

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Articles Gallagher Chiat (2009) (cont)

• Experimental group
• 1) Intensive direct group therapy (n 8) with
  2 speech pathologists, weekly appointments, 4
  hours a week for 24 weeks. Total 96hrs contact
  with SP.
• 2) Indirect in class therapy (n 8) weekly
  sessions for 2 blocks of 6 weeks (joint sessions
  SP/preschool staff), classroom staff trained to
  continue therapy during break between blocks.
  Total 12 hrs direct.
• Targeted linguistic concepts, grammatical
  markers, increasing utterance length, vocabulary
  and attention to adult lead tasks.

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Articles Gallagher Chiat (2009) (cont)

• Results
• Intensive treatment group vs. preschool
  consultation intensive group showed
  statistically significant improvement in
  comprehension of grammar vocabulary and
  expressive vocabulary expressive information
  compared to psk gp.
• Intensive treatment group vs. control showed
  significantly more improvement on all language
  measures.
• Preschool vs. control significant improvements
  in comprehension of grammar, but not in other
  areas.

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Articles Gallagher Chiat (2009) (cont)

• Strengths
• Control group used (no intervention). Therapy
  targets activities matched for both
  intervention groups. Therapy activities clearly
  described.
• Limitations
• Teasing apart different outcomes related to
  dosage, not intervention model? Limited
  motivation on classroom based staff, training was
  offered to teachers and carers, but was declined.
  Classroom staff were inconsistent week to week,
  which may have affected outcomes.

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Articles Gibbard

• Gibbard, D. (1994). Parental Based intervention
  with preschool language delayed children.
  European Journal of Disorders in Communication,
  29, 131 -150.
• Participants 35 children were recruited from a
  clinical population at Comm. Health Centre. Aged
  2 3 ? 33 and had 30 or less single words. No
  comorbidity.

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Articles Gibbard (continued)

• First Experiment-
• 18 parents attended parent training sessions at
  Community Health once per fortnight for 6 months
  (11 sessions, approx 14 hours of therapy).
  Traditional language stimulation strategies. (2
  groups)
• Significant improvements in language skills found
  on Reynell, RAPT and mothers word lists
• Showed consistent results from each group.

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Articles Gibbard (continued)

• Experiment 2
• 17 children split into three groups
• Direct individual Speech therapy
• Indirect parental training (speech and language)
• Indirect parental group (general cognition/non
  specific therapy)
• No significant difference between direct and
  indirect language therapy.
• Indirect language therapy (group) made
  significantly more gains than those who were in
  the non specific group.

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Articles Gibbard (continued)

• Strengths
• Repeat testing of group model first to see if
  consistent gains were made from group to group
• Community Health Setting
• Limitations
• Small sample size

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Articles Baxendale Hesketh (2003)

• Baxendale, J. Hesketh, A., 2003 Comparison of
  the effectiveness of the Hanen Parent Program and
  traditional clinic therapy. International Journal
  of Language and Communication Disorders, 38 (4),
  397 415.

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Articles Baxendale Hesketh (2003) (cont)

• Participants 37 children aged 26 ? 36 with
  diagnosed expressive language impairment (scores
  less than 81 on PLS-3). With or without receptive
  language impairment. No co-morbidity. English
  speaking Caucasian background.

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Articles Baxendale Hesketh (2003) (cont)

• Experimental group
• 19 children assigned to the Hanen Parent Program,
  11 week program (8x 2.25 weekly group sessions
  and 3x home visits) by two trained SPs.
• Control Group 18 children assigned to
  traditional individual clinic based therapy with
  SP (number of sessions matched with Hanen).
• Assessed pre-treatment, 6mths, 12mths. No
  therapy for 6mths following treatment.

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Articles Baxendale Hesketh (2003) (cont)

• Results
• At 6 mths 42 of Hanen participants and 61 of
  individual therapy participants showed
  improvement in standard scores on PLS-3.
• At 12 mths 79 Hanen participants and 67
  individual therapy participants showed
  improvement on standard scores.
• No significant differences were found between
  each treatment group for parent interaction
  measures at 6 or 12 mth post-tx.

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Articles Baxendale Hesketh (2003) (cont)

• Results
• Trend fewer children with expressive-only delay
  made improvement with Hanen group than children
  with rec/exp delay (but small numbers).
• Different families benefit from different types
  of therapy and should be selected accordingly
• Hanen more time/cost intensive (Hanen 19-28hrs
  per child Clinic 4hrs-9hrs, av 8hrs).

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Articles Baxendale Hesketh (2003) (cont)

• Strengths of paper Number therapy sessions
  matched for individual and group therapy.
• Limitations No control group, wide ranges of
  experience level in SPs delivering individual
  therapy. Heterogenous language delays.

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Clinical bottom line

• The research reviewed showed gains in language
  abilities.
• No significant difference identified between
  group and individual therapy.
• Some differences identified between direct
  indirect therapy, however these were usually
  related to training and motivation of the SP
  aides administering therapy (negative and
  positive effects).

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Clinical bottom line (cont)

• Cost effectiveness of group differed from study
  to study. Consideration if settings and
  demographics is required to ensure groups run
  effectively in the local clinical setting.

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Current Clinical Practice

• Sydney South West Area Health Service Hanen It
  Takes Two to Talk Quality Improvement Project.
• SSWAHS is a very diverse community
• High SP referral rates
• High levels of global developmental delay and
  ASD.
• High numbers of families with multiple children
  accessing SP Services
• Evaluating the use of Hanen ITTT as a way to
  create a sustained change in the community.

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Current Clinical Practice (cont)

• Training of all SSWAHS SPs in Hanen ITTT during
  2010 and 2011.
• Minimum of three Hanen ITTT groups will be run at
  each centre during 2010 2011.
• Data collection on children referred to the
  service aged 0 30
• Three clinical pathways
• 1) Hanen ITTT
• 2) Traditional language groups
• 3) Individual therapy

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Current Clinical Practice (cont)

• Data is collected on
• Parents attitudes to groups (why do they chose to
  participate or not participate)
• Time per client spent on therapy and preparation
• Outcomes will be measured at the completion of
  the group (or equivalent period of time for
  individual) and eight months post initial
  assessment

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Current Clinical Practice (cont)

• Pre and post
• standardised assessment measure of language
• Macarthur Bates Communication Development
  Inventory.
• Hanen Questionnaires
• Parent Child Interaction Check
• Parent Carer Self Rating Scales
• Parent Satisfaction
• Clinician Satisfaction

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Current Clinical Practice

• Northern Beaches Community Health Early
  Language Playgroups, for preschoolers with
  language delays.
• Focus on language development through parent
  training, group activities and individual
  activities.
• Playgroup 1 services children aged 110 ? 29
  with less than 30 single words

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Current Clinical Practice

• Playgroup 2 services children 20 ? 36 with 50
  words, but limited two word combinations.
• Group involve one parents only training sessions
  followed by 6 weekly group sessions with parents
  and children present.

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Current Clinical Practice (cont)

• Collecting pre and post data during 2010
• using first words and verbs checklists
• parents use of language stimulation strategies
• Preverbal development.
• (measures developed based on research during
  group development)

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Current Clinical Practice (cont)

• Data Analysis to date
• Preliminary qualitative analysis in July 2010
• Play group 1 increased preverbal ability and
  increase in vocabulary noted
• Playgroup 2 increased preverbal skills,
  increased vocabulary and increased lengths of
  utterance to more than two words.

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Development of a new question

• In reviewing the literature on service delivery
  models group vs. individual direct vs. indirect
  was not typically the defining factor of success.
  
• Significant effects may be present based on
• Dosage (amount and frequency of therapy)
• Motivation and training of therapist and
  therapists and therapy aides/assistants

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Development of a new question

• Articles reviewed also raised questions regarding
  the timing of intervention and the longitudinal
  maintenance of therapy gains (i.e. more than 12
  months post therapy)

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Where to from now.

• Next year, our meetings will be at
• Bankstown Community Health Centre
• Sydney Childrens Hospital Randwick
• Please contact Sara Beckett sara.beckett_at_sswahs.n
  sw.gov.au
• Ph 9780 2772 if you are interested in
  joining us in our literature reviews.