Ensuring treatment fidelity in intervention studies: Developing a checklist and scoring system within a behaviour change paradigm.

BACKGROUND: Treatment fidelity refers to the degree to which an intervention is implemented as intended. Promoting treatment fidelity is important to achieve a valid comparison in intervention research. However, it is often underreported: few studies detail the use and development of fidelity measures. This study aims to promote the treatment fidelity of a modified version of the Derbyshire Language Scheme (M-DLS), a manualised intervention for children with language difficulties, by exploring participants' opinions on training and intervention delivery. Results inform development of a checklist and scoring system to monitor and promote treatment fidelity in a comparison trial. METHOD: Ten student speech and language therapists (SLTs) and two research assistants (RAs) participated in the study. All received training on the M-DLS, and 10 were video-recorded completing role-plays of an M-DLS session in small groups. Feedback was gathered after training and role-plays in focus groups and interviews. Feedback was interpreted using the constructs of the Theoretical Domains Framework (TDF). A treatment fidelity checklist was then developed using the feedback. The first author and two RAs rated role-play videos using the checklist to trial it to inform amendments and to promote interrater reliability. Interrater agreement was calculated using Spearman's test of correlation. RESULTS: Participants discussed the importance of having clear materials and time to practise sessions. They suggested amendments to the materials and training to promote treatment fidelity. The checklist and scoring system accounted for participants' suggestions, with amendments detailed in a log. Spearman's correlation results suggested agreement between the raters was strong. CONCLUSIONS: Results emphasise the importance of training quality, practice and reflective opportunities and clear materials to promote treatment fidelity. The construction of the checklist and scoring system was described in detail, informing the development of future checklists. After further trialling, the checklist can be used to ensure the M-DLS is delivered with high treatment fidelity in the comparison trial. WHAT THIS PAPER ADDS: What is already known on this subject Treatment fidelity is an essential component of intervention effectiveness and efficacy studies, ensuring the intervention is delivered as intended. It is also an essential component of evidence-based clinical practice. However, few research studies report the treatment fidelity process or publish the checklists used, depriving clinicians of useful information for implementation. What this study adds This study describes in detail the iterative process of treatment fidelity checklist development, engaging those implementing the intervention in development. This ensured clarity and interrater reliability of the checklist. Furthermore, a novel scoring system was developed so that accuracy of implementation can be easily compared across users and across practice attempts. What are the clinical implications of this work? The importance of treatment fidelity when implementing effective and efficacious interventions cannot be overstated. The treatment fidelity checklist developed for research can be easily adopted to support accurate implementation in clinical practice through an audit process.

Bidirectional associations between mental health problems and language ability across 8 years of childhood.

Research examining the development of behavior, emotions and language, and their intertwining is limited as only few studies had a longitudinal design, mostly with a short follow-up period. Moreover, most studies did not evaluate whether internalizing symptoms and externalizing symptoms are independently associated with language ability. This study examines bidirectional associations between internalizing symptoms, externalizing symptoms and language ability in childhood in a large, population-based cohort. Longitudinal data from the Millennium Cohort Study, a cohort of children in the United Kingdom followed from birth to 11 years (n = 10,878; 50.7% boys), were analyzed. Internalizing and externalizing symptoms were based on parent reports. Language ability (higher scores reflecting poorer ability) was assessed by trained interviewers at ages 3, 5, 7 and 11 years. Structural Equation Models (SEM) were performed, including random-intercept cross-lagged panel models (RI-CLPM) and cross-lagged panel models (CLPM). Internalizing symptoms, externalizing symptoms and language ability were stable over time and co-occur with each other from early life onwards. Over time, externalizing symptoms in early childhood were associated with less growth in language skills and with increases in internalizing symptoms. In late childhood, language ability was negatively associated with later internalizing and externalizing symptoms. The early start, co-occurrence and persistent nature of internalizing symptoms, externalizing symptoms and (poorer) language ability highlights the importance of comprehensive assessments in young children who present problems in one of these domains. Specifically, among children in the early grades of elementary school, those with language difficulties may benefit from careful monitoring as they are more likely to develop difficulties in behavior and emotions.

Piloting building early sentences therapy for pre-school children with low language abilities: An examination of efficacy and the role of sign as an active ingredient.

BACKGROUND: Early intervention is recommended for pre-school children with low language. However, few robustly evaluated language interventions for young children exist. Furthermore, in many interventions the theoretical underpinnings are underspecified and the 'active ingredients' of the interventions not tested. This paper presents a quasi-experimental study to test the efficacy and examine the active ingredients of Building Early Sentences Therapy (BEST): an intervention based on usage-based theory designed to support young children to understand and produce two-, three- and four-clause element sentences. BEST manipulates the input children hear to support them to harness the cognitive mechanisms hypothesized in usage-based theories to promote the development of abstract linguistic representations. One such input manipulation is the use of signing alongside verbal input signalling both content and morphology of target sentences. AIMS: To examine whether (1) BEST is more efficacious than treatment as usual (TAU); and (2) signing of content and morphology is an active ingredient of the intervention. METHODS & PROCEDURES: A quasi-experimental study recruited children aged 3;5-4;5 years from 13 schools. Schools were assigned to receive either BEST with sign, BEST without sign or TAU. The TAU group received their usual classroom provision. Across arms schools were matched with respect to classroom oral language environment and indices of deprivation. Participants were 48 children (28 boys) with expressive and/or receptive language abilities ≤ 16th centile measured using the New Reynell Developmental Language Scales (NRDLS). Outcomes gathered by researchers blind to treatment arm were NRDLS production and comprehension standard scores and measures of production of targeted sentence structures. OUTCOMES & RESULTS: Primary outcomes indicate that BEST with sign was significantly more efficacious than TAU with respect to NRDLS production standard score, but not comprehension. The advantage for production was maintained at follow-up. BEST without sign was significantly more efficacious than TAU on measures of targeted vocabulary, sentence structure and morphology. The results from this quasi-experimental study provide evidence for the efficacy of a usage-based intervention on expressive language outcomes for preschool children with low language abilities. There is also evidence to support the inclusion of sign as an active ingredient, and so efforts to train interventionists in its use are worthwhile. CONCLUSIONS & IMPLICATIONS: Patterns of findings across outcomes suggest signing of content and morphology may support the development of abstract linguistic representations and accelerate language learning. Given these positive results and the scale of this study, a fully powered randomized controlled trial is warranted. WHAT THIS PAPER ADDS: What is already known on the subject Robust language skills are crucial for positive social, emotional, academic and economic outcomes across the lifespan. There is a paucity of robustly evaluated interventions for preschool children with language difficulties. The development of such interventions is crucial for ameliorating language difficulties and promoting positive educational and psychosocial outcomes. What this study adds to the existing knowledge This paper evaluates BEST, a novel usage-based language intervention targeting children with language difficulties in the early years. Findings indicate that a usage-based intervention is efficacious for treating language difficulties. In particular, BEST benefited expressive language development, bringing benefits to both treated and untreated language structures and improving standard scores. The role of sign as an active ingredient is also supported. Further evaluation is warranted. What are the practical and clinical implications of this work? Findings suggest that BEST may be effective for targeting children who have been identified as having language difficulties. In particular, expressive language may be improved when the intervention is delivered as it was originally manualized, including a signing system to represent content and grammatical morphology. More broadly, these findings also provide preliminary evidence that the use of a signing system does not hinder oral language development in children with language difficulties and may conversely support their expressive language. Future research exploring the role and underpinning mechanisms of sign in language intervention is warranted.

How reliable is assessment of children's sentence comprehension using a self-directed app? A comparison of supported versus independent use.

This study reports on the feasibility of using the Test of Complex Syntax- Electronic (TECS-E), as a self-directed app, to measure sentence comprehension in children aged 4 to 5 ½ years old; how testing apps might be adapted for effective independent use; and agreement levels between face-to-face supported computerized and independent computerized testing with this cohort. A pilot phase was completed with 4 to 4;06-year-old children, to determine the appropriate functional app features required to facilitate independent test completion. Following the integration of identified features, children completed the app independently or with adult support (4-4;05 (n = 22) 4;06-4;11 months (n = 55) and 5 to 5;05 (n = 113)) and test re-test reliability was examined. Independent test completion posed problems for children under 5 years but for those over 5, TECS-E is a reliable method to assess children's understanding of complex sentences, when used independently.

The development and productivity of a measure for identifying low language abilities in children aged 24-36 months.

BACKGROUND: Accurate early identification of children with low language ability is important but existing measures generally have low sensitivity. This remains an area of concern for preventive and public health services. This study aimed to create and evaluate a measure of child language, communication and related risks which can be used by community health nurses to accurately identify children with low language aged 24-30 months. METHODS: The Early Language Identification Measure (ELIM) was developed and comprised five measurement sections, each measuring different aspects of development combined into a single measure. This was tested blind against a reference standard language measure, the Preschool Language Scale-5 (PLS-5), at the universal 24-30-month health visitor review in England. The threshold for likely low language was the tenth centile or below on the PLS-5. The aim was to ascertain the performance of the five individual sections in the scale, and consider the optimum combination of sections, for predicting low language ability. Specificity, sensitivity, and positive and negative predictive values were reported for each of the five sections of the ELIM alone and in conjunction with each other. The performance for children from monolingual English-speaking families and those who spoke languages other than English were also considered separately. RESULTS: Three hundred and seventy-six children were assessed on both the ELIM identification measure and the PLS-5 with 362 providing complete data. While each section of the ELIM predicted low language ability, the optimal combination for predicting language outcome was the parent reported vocabulary checklist coupled with the practitioner observation of the child's communication and related behaviours. This gave a sensitivity of 0·98 with a specificity of 0·63. CONCLUSIONS: A novel measure has been developed which accurately identifies children at risk of low language, allowing clinicians to target resources efficiently and intervene early.

Creating the conditions for robust early language development for all: Part two: Evidence informed public health framework for child language in the early years.

BACKGROUND: One of the most significant developmental accomplishments is the emergence of language in early childhood. Whilst this process is effortless for most children, others can face significant hurdles. Identifying, in the early years, which children will go on to have developmental language disorder is, however, fraught with several well-documented challenges. In the preceding paper we described and linked new research evidence about factors that influence language development in the early years, noting that exposure to some may be time sensitive and that these influences cluster together and can accumulate over time. We demonstrated that risk profiles were associated with and characterised low language trajectories, and we considered how this information could be integrated into a concept that moves beyond screening at single time points in the early years. We argue that this evidence might be used to build an improved early years framework for language thereby creating a more equitable surveillance system that does not leave children living in less advantageous circumstances behind. Underpinning this thinking was a bioecological framework that incorporates the social, environmental and family factors in the child's ecosystem known to influence language development in the early years. AIMS: To develop a proposal for the design and implementation of an early language public health framework based on current best evidence METHODS: We synthesised the findings from the companion paper (Reilly & McKean 2023) regarding early language trajectories, inequalities and clustering of risks with key public health concepts, relevant intervention evidence and implementation theories to develop a new framework for language surveillance and preventative interventions in the early years. MAIN CONTRIBUTION: An evidence informed early language public health framework is presented. Describing in turn (1) essential components; (2) relevant interventions; (3) essential qualities for implementation ((i) probabilistic, (ii) proportionate, (iii) developmental and sustained and (iv) codesigned); (4) system-level structures and (5) processes required to adopt and embed an early language public health framework in an existing Local Government Area's child health surveillance and early prevention-intervention systems. CONCLUSIONS: Children's language development influences their life chances across the life course and language difficulties are unfairly distributed across society. Current evidence points to the need for whole systems approaches to early child language and enables a blueprint for such a framework to be described. WHAT THIS PAPER ADDS: What is already known on the subject Early child language development sets the stage for a child's life chances and language difficulties can have profound long-term consequences. Such difficulties are unfairly distributed across society and the reach of preventative services is not universal or equitable. WHAT THIS STUDY ADDS: Several effective primary and secondary preventative interventions exist but their successful implementation is not straightforward. An early language public health framework of surveillance and intervention is described to provide equitable and effective early interventions to children from 0-4 years. We detail the essential components, interventions and qualities of that framework and describe system-level structures and processes required to adopt and embed an early language public health framework in a given locality. WHAT ARE THE CLINICAL IMPLICATIONS OF THIS WORK?: A whole systems approach to early child language is required and should be co-designed through local collaboration with family, community and children's services stakeholders. A public health speech and language therapist role could catalyse the implementation of such approaches and support continuous improvement.

Creating the conditions for robust early language development for all-Part 1: Evidence-informed child language surveillance in the early years.

BACKGROUND: The emergence of language in the early years is a major developmental accomplishment that underpins learning, enables social interaction and, later, is an indicator of well-being. Learning language is an effortless process for most, but can be challenging for others. There is a need to act early. First, because there are several social, environmental and family factors known to influence how language develops during the critical early years. Second, there is a robust association between a child's socio-economic circumstances and language outcomes. Put simply, children living in less advantaged circumstance have poorer language outcomes, which are apparent very early and persist across the lifespan. Third, children with demonstrated weaknesses in language learning in early childhood have poorer educational, employment, mental health and quality-of-life outcomes across the lifespan. Acting early to counter these impacts is important; however, there are several well-documented challenges in accurately identifying in the early years children who are at later risk of developmental language disorder (DLD) and to deliver prevention and intervention programmes to scale. This is critical because many services do not currently reach those who need them most; as many as 50% of children in need may not be receiving support. AIM: To determine whether an improved surveillance system, based on best evidence, could be developed for the early years. METHODS & PROCEDURES: We summarised findings from longitudinal, population or community studies that: (1) adopted bioecological models, (2) repeatedly measured language (including the early years) and (3) adopted similar methodologies, to identify factors that influence language outcomes. MAIN CONTRIBUTION: The evidence confirmed that language development is not always stable but is characterized by distinct trajectories and each has distinguishing social, environmental features. Children in the change or fluctuating groups tend to live in less advantageous circumstances that may not always support and enable language development. Risk factors tend to cluster and accumulate across the early years and beyond, thereby markedly increasing the likelihood of poorer language outcomes later in life. CONCLUSIONS & IMPLICATIONS: In this the first of two papers, designed to be read together, we integrate research on the social determinants of child language and propose they be embedded into surveillance models. This has the potential to reach more children and those living in disadvantaged circumstances. In the accompanying paper we combine this information with evidence-informed early prevention/intervention approaches and propose the design and implementation of an early language public health framework. WHAT THIS PAPER ADDS: What is already known on the subject There are several well-documented challenges in accurately identifying in the early years children who are at later risk of DLD and reaching those most in need of language support. What this study adds to existing knowledge A combination of child, family and environmental determinants, collectively and cumulatively, play out over time and dramatically increase the risk of later language problems, in particular those children living in disadvantaged circumstances. We propose an improved surveillance system that incorporates these determinants be developed and that this be part of a whole of system approach to child language in the early years. What are the potential or actual clinical implications of this work? Clinicians intuitively act to prioritize children with multiple features or risks; however, they can only do so for those who present or are identified to be at risk. Given many children with language problems are not being reached by many early language services, it is reasonable to ask if this knowledge can be integrated to improve reach. Or is a different surveillance model required?

The development of a digital story-retell elicitation and analysis tool through citizen science data collection, software development and machine learning.

Background: In order to leverage the potential benefits of technology to speech and language therapy language assessment processes, large samples of naturalistic language data must be collected and analysed. These samples enable the development and testing of novel software applications with data relevant to their intended clinical application. However, the collection and analysis of such data can be costly and time-consuming. This paper describes the development of a novel application designed to elicit and analyse young children's story retell narratives to provide metrics regarding the child's use of grammatical structures (micro-structure) and story grammar (macro-structure elements). Key aspects for development were (1) methods to collect story retells, ensure accurate transcription and segmentation of utterances; (2) testing the reliability of the application to analyse micro-structure elements in children's story retells and (3) development of an algorithm to analyse narrative macro-structure elements. Methods: A co-design process was used to design an app which would be used to gather story retell samples from children using mobile technology. A citizen science approach using mainstream marketing via online channels, the media and billboard ads was used to encourage participation from children across the United Kingdom. A stratified sampling framework was used to ensure a representative sample was obtained across age, gender and five bands of socio-economic disadvantage using partial postcodes and the relevant indices of deprivation. Trained Research Associates (RA) completed transcription and micro and macro-structure analysis of the language samples. Methods to improve transcriptions produced by automated speech recognition were developed to enable reliable analysis. RA micro-structure analyses were compared to those generated by the digital application to test its reliability using intra-class correlation (ICC). RA macro-structure analyses were used to train an algorithm to produce macro-structure metrics. Finally, results from the macro-structure algorithm were compared against a subset of RA macro-structure analyses not used in training to test its reliability using ICC. Results: A total of 4,517 profiles were made in the app used in data collection and from these participants a final set of 599 were drawn which fulfilled the stratified sampling criteria. The story retells ranged from 35.66 s to 251.4 s in length and had word counts ranging from 37 to 496, with a mean of 148.29 words. ICC between the RA and application micro-structure analyses ranged from 0.213 to 1.0 with 41 out of a total of 44 comparisons reaching 'good' (0.70-0.90) or 'excellent' (>0.90) levels of reliability. ICC between the RA and application macro-structure features were completed for 85 samples not used in training the algorithm. ICC ranged from 0.5577 to 0.939 with 5 out of 7 metrics being 'good' or better. Conclusion: Work to date has demonstrated the potential of semi-automated transcription and linguistic analyses to provide reliable, detailed and informative narrative language analysis for young children and for the use of citizen science based approaches using mobile technologies to collect representative and informative research data. Clinical evaluation of this new app is ongoing, so we do not yet have data documenting its developmental or clinical sensitivity and specificity.

Associations between responsive parental behaviours in infancy and toddlerhood, and language outcomes at age 7 years in a population-based sample.

BACKGROUND: A wealth of evidence supports the important role high-quality parent-child interactions play in children's early language acquisition. However, the impact on later language outcomes remains unclear. AIMS: To examine the associations between responsive parental behaviours across the early years and child language outcomes at age 7 years with families from an Australian longitudinal cohort study (N = 1148, 50% female). METHODS & PROCEDURES: At child ages 12, 24 and 36 months, parents completed a self-report measure of responsive parental behaviours. Child language was directly assessed at age 7 using the Clinical Evaluation of Language Fundamentals, 4th edition (CELF-4), Australian Standardisation. Linear regression was used to examine associations between responsive parental behaviours from 12 to 36 months (consistently high, inconsistent and consistently low responsive parental behaviours at the three time points) and language scores at age 7 years. Adjusted models were run, including the following potential confounders: child sex; birth weight; birth order; maternal education; socio-economic disadvantage; non-English-speaking background; family history of speech-language problems; mother's vocabulary score; maternal mental health score; and mother's age at birth of child. A final adjusted model was run, including the potential confounder variables as well as adjusting for children's earlier language skills. OUTCOMES & RESULTS: Linear regression results showed children with parents who rated high on responsive parental behaviours at all three time points had higher mean language scores at age 7 than children whose parents reported low responsive parental behaviours across early childhood. This association attenuated after adjusting for earlier child language skills. CONCLUSIONS & IMPLICATIONS: Findings support the consistent use of responsive parental behaviours across the very early years of childhood to support long-term language outcomes. Findings also suggest that models of surveillance and support which monitor and assist families at multiple time-points over the early years are likely to be most effective for preventing ongoing language difficulties. WHAT THIS PAPER ADDS: What is already known on this subject There is extensive evidence consistently demonstrating the important contribution of aspects of parent-child interaction, specifically responsive parental behaviours, to children's language development. What this paper adds to the existing knowledge Understanding the cumulative benefit of responsive parent-child interactions across the very early years may help to inform preventive interventions and service delivery models for supporting young children's language development. This study demonstrates in a large, population-based cohort the contribution of consistency of responsive parental behaviours during infancy and toddlerhood to school-age language outcomes, accounting for other child, family and environmental factors. Capturing regular parent behaviours via self-report during the early years may be a more efficient and less costly method than parent-child interaction observations to monitor the home language-learning environment during routine developmental checks. What are the potential or actual clinical implications of this work? Findings support the need for surveillance of children and families in the early years, ensuring that intervention occurs when families need it most, that is, support is responsive to changing needs and that nuanced advice and support strategies are provided to activate positive developmental cascades. Capturing both parent behaviours and child language may assist clinicians to identify those families who may benefit from parent-child interaction intervention.

Promoting early language development in the Arab world and Sustainable Development Goals 3, 4, 10 and 17.

PURPOSE: This commentary describes a multi-national project which addresses gaps in the design and delivery of health and education services in Arabic-speaking countries in relation to early language development, with a focus on Egypt, Jordan, Lebanon and the Palestinian Territories. This includes: (1) co-production with early years professionals and NGOs of approaches to support early language development; (2) development and standardisation of tools to identify monolingual and multilingual Arabic-speaking children at risk of poor language development; and (3) examination of language development in refugee communities. RESULT: The importance of inter-professional partnership and the inclusion of families in planning support for oral language development is highlighted. Arabic versions of the Communicative Development Inventory (CDI) Toddler were developed, and data collected from 1074 Egyptian, Jordanian and Palestinian monolingual infants aged 8-30 months. Data from 201 age-matched Palestinian infants in Lebanese refugee camps highlight inequalities resulting from limited maternal educational opportunities. Data from 230 multilingual Lebanese 2-year-olds enable the interpretation of CDI scores as a function of language exposure. CONCLUSION: This work contributes to the promotion of robust language development for all Arabic-speaking children. This commentary focusses on sustainable development goal (SDG) 3, SDG 4, SDG 10 and SDG 17.

Editorial Perspective: Maximising the benefits of intervention research for children and young people with developmental language disorder (DLD) - a call for international consensus on standards of reporting in intervention studies for children with and at risk for DLD.

Current methods for reporting interventions do not allow key questions of importance to practitioners, service providers, policy-makers and people with DLD to be answered, and hence limit the implementation of effective interventions in the real world. To extend the existing EQUATOR guidelines to the context of speech language therapy/pathology for children with language disorder and to provide more specific guidance on participants, interventions and outcomes within the CONSORT checklist (used to improve the reporting of randomised controlled trials) and TIDieR (Template for Intervention Description and Replication) to ensure consistency of reporting. We will develop a core team to include representatives from each of the key groups who will either use or be influenced by the final reporting guidance across different countries. To achieve each set of aims, we will conduct reviews of the literature (which present typologies of intervention characteristics in (D)LD and related disorders); carry out focus groups; and use systematic consensus methods such as the Delphi technique, nominal group technique or consensus development conferences. Through the development and adoption of standard intervention reporting criteria, we anticipate that we will overcome the numerous barriers for practitioners, services and policy-makers in applying intervention evidence to practice. We believe that establishing international consensus on reporting guidelines would significantly accelerate progress in DLD research and the ease with which it can be used in clinical practice, by capitalising on the growth in intervention studies to enable international collaboration and new methodologies of data pooling, meta-analyses and cross-study comparisons.

Universal language development screening: comparative performance of two questionnaires.

BACKGROUND AND OBJECTIVE: Low language ability in early childhood is a strong predictor of later psychopathology as well as reduced school readiness, lower educational attainment, employment problems and involvement with the criminal justice system. Assessment of early language development is universally offered in many countries, but there has been little evaluation of assessment tools. We planned to compare the screening performance of two commonly used language assessment instruments. METHODS: A pragmatic diagnostic accuracy study was carried out in five areas of England comparing the performance of two screening tools (Ages and Stages Questionnaire (ASQ) and Sure Start Language Measure (SSLM)) against a reference test (Preschool Language Scale, 5th edition). RESULTS: Results were available for 357 children aged 23-30 months. The ASQ Communication Scale using optimal cut-off values had a sensitivity of 0.55, a specificity of 0.95 and positive and negative predictive values of 0.53 and 0.95, respectively. The SSLM had corresponding values of 0.83, 0.81, 0.33 and 0.98, respectively. Both screening tools performed relatively poorly in families not using English exclusively in the home. CONCLUSION: The very widely used ASQ Communication Scale performs poorly as a language screening tool, missing over one-third of cases of low language ability. The SSLM performed better as a screening tool.

Using Theory to Drive Intervention Efficacy: The Role of Dose Form in Interventions for Children with DLD.

'Dose form' is a construct that has evolved over the last number of years and is central to treating childhood language disorders. In this commentary, we present a framework of dose form that includes techniques, procedures, manner of instruction, and intervention context. We present key findings from a systematic review exploring the impact of intervention dose form on oral language outcomes (specifically morphosyntax and vocabulary learning) in children with DLD. We then discuss the hypothesized theoretical mechanisms of action underpinning these findings.

Editorial Perspective: Speaking up for developmental language disorder - the top 10 priorities for research.

Developmental language disorder (DLD) is one of the most common neurodevelopmental conditions, yet is chronically underserved, with far fewer children receiving clinical services than expected from prevalence estimates, and very little research attention relative to other neurodevelopmental conditions of similar prevalence and severity. This editorial describes a research priority-setting exercise undertaken by the Royal College of Speech and Language Therapists, which aims to redress this imbalance. From consultations with researchers, practitioners and individuals with lived experience, 10 research priorities emerge. Our goal is to share these priorities with the wider research community, to raise awareness and encourage research collaboration to improve outcomes for young people with DLD.

'Making the most of together time': development of a Health Visitor-led intervention to support children's early language and communication development at the 2-2½-year-old review.

BACKGROUND: Early interventions to support young children's language development through responsive parent-child interaction have proven efficacy but are not currently delivered universally. A potential universal delivery platform is the Health Visitor (HV)-led 2-2½-year-old review in England's Healthy Child Programme. It is unclear if it is feasible to offer such interventions through this platform. We report an intervention development process, including extensive stakeholder consultation and co-design which aimed to develop an acceptable, feasible and equitable early language intervention for delivery in this context. METHODS: The study involved five phases including 13 stakeholder co-design workshops with 7 parents and 39 practitioners (HVs, early years practitioners and speech and language therapists): (1) Identification of existing intervention evidence, (2) qualitative review of intervention studies extracting candidate target behaviours for intervention and intervention techniques, (3) co-design workshops with parents and practitioners examining acceptability, barriers and enablers to those behaviours and techniques (particular attention was paid to diverse family circumstances and the range of barriers which might exist), (4) findings were analysed using COM-B and theoretical domains frameworks and a prototype intervention model designed, and (5) co-design workshops iteratively refined the proposed model. RESULTS: Practitioners were committed to offering language intervention at the 2-2½-year-old review but were not sure precisely how to do so. Parents/caregivers wanted to be proactive and to have agency in supporting their own children and to do this as soon as possible. For equitable intervention, it must be proportionate, with higher 'intensity' for higher levels of disadvantage, and tailored, offering differing approaches considering the specific barriers and enablers, assets and challenges in each family. The importance and potential fragility of alliances between parent/caregiver and practitioner were identified as key, and so, strategies to engender successful collaborative partnership are also embedded in intervention design. CONCLUSION: It is possible to develop a universal intervention which parents and practitioners judge would be acceptable, feasible and equitable for use at the 2-2½-year review to promote children's language development. The result is one of the most explicitly developed universal interventions to promote children's language development. Further development and piloting is required to develop materials to support successful widespread implementation.

Developing Preschool Language Surveillance Models - Cumulative and Clustering Patterns of Early Life Factors in the Early Language in Victoria Study Cohort.

BACKGROUND: Screening and surveillance of development are integral to ensuring effective early identification and intervention strategies for children with vulnerabilities. However, not all developmental skills have reliable screening processes, such as early language ability. METHOD: We describe how a set of early life factors used in a large, prospective community cohort from Australia are associated with language abilities across the preschool years, and determine if either an accumulation of risk factors or a clustering of risk factors provide a feasible approach to surveillance of language development in preschool children. RESULTS: There were 1,208 children with a 7-year language outcome. The accumulation of early life factors increased the likelihood of children having low language skills at 7-years. Over a third of children with typical language skills (36.6%) had ≤ two risks and half of the children with low language (50%) had six or more risks. As the number of factors increases the risk of having low language at 7-years increases, for example, children with six or more risks had 17 times greater risk, compared to those with ≤ two risks. Data collected from 1,910 children at 8- to 12-months were used in the latent class modeling. Four profile classes (or groups) were identified. The largest group was developmentally enabled with a supportive home learning environment (56.2%, n = 1,073). The second group was vulnerable, both developmentally and in their home learning environment (31.2%, n = 596); the third group was socially disadvantaged with a vulnerable home learning environment (7.4%, n = 142); the final group featured maternal mental health problems and vulnerable child socio-emotional adjustment (5.2%, n = 99). Compared to developmentally enabled children, the risk of low language at 7-years was greater for children in the three other groups. CONCLUSION: The cumulative and cluster risk analyses demonstrate the potential to use developmental surveillance to identify children within the first years of life who are at risk of language difficulties. Importantly, parent-child interaction and the home learning environment emerged as a consistent cluster. We recommend they be adopted as the common focus for early intervention and universal language promotion programs.

Allocation and funding of Speech and Language Therapy for children with Developmental Language Disorders across Europe and beyond.

BACKGROUND: Children with Developmental Language Disorder (DLD) have a significant deficit in spoken language ability which affects their communication skills, education, mental health, employment and social inclusion. AIM: The present study reports findings from a survey by EU network COST ACTION 1406 and aims to explore differences in service delivery and funding of SLT services for children with DLD across Europe and beyond. METHODS AND PROCEDURES: The survey was completed by 5024 European professionals. COST countries were grouped into Nordic, Anglo-Saxon, Continental, Mediterranean, Central/Eastern and Non-European categories. The use of direct, indirect and mixed interventions, and their relationship to funding available (public, private or mixed) were considered for further analysis. OUTCOMES AND RESULTS: The results revealed that for direct therapy, there were more cases than expected receiving private funding. For indirect therapy, fewer than expected received private and more than expected public funding. For mixed therapy, fewer cases than expected received private funding. CONCLUSIONS AND IMPLICATIONS: The results implies that other factors than evidence-based practices, practitioners experience, and patient preferences, drive choices in therapy. More research is needed to gain a better understanding of factors affecting the choice of therapy.

Validation of a measure of parental responsiveness: Comparison of the brief Parental Responsiveness Rating Scale with a detailed measure of responsive parental behaviours.

Parental responsiveness is vital for child language development. Its accurate measurement in clinical settings could identify families who may benefit from preventative interventions; however, coding of responsiveness is time-consuming and expensive. This study investigates in a clinical context the validity of the Parental Responsiveness Rating Scale (PaRRiS): a time- and cost-effective global rating scale of parental responsiveness. Child health nurse (CHN) PaRRiS ratings are compared to a detailed coding of parental responsiveness. Thirty parent-child dyads completed an 8-min free-play session at their 27-month health review. CHNs rated the interaction live using PaRRiS. Videos of these interactions were then blindly coded using the more detailed coding system. PaRRiS ratings and detailed codings were compared using correlational analysis and the Bland-Altman method. PaRRiS and the detailed coding showed a moderate-strong correlation (rs (28) = 0.57, 95% CI [0.26, 0.77]) and high agreement (Bland-Altman). CHNs using PaRRiS can capture parental responsiveness as effectively as trained clinicians using detailed coding. This may allow (1) increased accuracy and efficiency in identifying toddlers at risk for long-term language difficulties; (2) more accurate allocation to speech and language therapy (SLT) services; (3) decreased burden on SLT resources by empowering CHNs to make more informed referral decisions.

Economic evaluation of the Happy Talk pilot effectiveness trial: A targeted selective speech, language and communication intervention for children from areas of social disadvantage.

Purpose: This study presents a cost-effectiveness analysis of a targeted selective pre-school intervention programme, "Happy Talk", which focuses on language development, by simultaneously enhancing parental interaction and the pre-school environment.Method: Happy Talk (delivered to 77 children) is an add on intervention, and is compared to usual care, adopting a healthcare perspective. Cost-effectiveness analyses were carried out using the Pre-school Language Scale 5- Total (PLS-5) for baseline analysis and the Child Health Utility Instrument (CHU9D) in a secondary analysis.Result: Baseline cost-effectiveness analysis showed Happy Talk was more effective (6.3 point change in total PLS-5 standard score - effect size 0.463SD and more expensive (€82.06) than usual care (cost-effectiveness ratio is €13.02 per unit change). Employing a proxy to estimate monetary net benefit, the benefits outweigh the costs, showing that it is cost-effective. However, results do not persist when health-related quality of life outcome measures are considered.Conclusion: Findings suggest a targeted selective public health approach, could be considered value for money to reduce the societal burden of children with low levels of speech, language and communication. However, measurement of longer term outcomes and a larger trial are required, to definitively inform policy changes.

Early Communication Behaviors in Infants With Cleft Palate With and Without Robin Sequence: A Preliminary Study.

OBJECTIVE: To investigate the early communication behaviors in infants with nonsyndromic isolated cleft palate (iCP) and Robin sequence (RS). DESIGN: Group comparison using parent report. PARTICIPANTS: There were 106 participants included in this study. Two groups were selected from the UK Cleft Collective resource. Parents had completed the Language ENvironment Analysis Developmental Snapshot questionnaire when their child turned 13 months. There were 78 participants in the iCP group and 28 in the RS group. MAIN OUTCOME MEASURE(S): Total number of communication behaviors reported on the questionnaire. Subdomains for expressive and receptive language and social communication behaviors were also analyzed. RESULTS: There were no statistically significant group differences. Parents of infants with RS reported fewer later communication behaviors compared to the iCP group. Infants in both groups had fewer communication behaviors compared to the normative sample. Across the whole sample, post hoc analysis revealed a significant correlation between severity of the cleft and social communication behaviors and expressive but not receptive language. Infants with a cleft of the hard and soft palate were more likely to be in the RS group (odds ratio: 7.04 [95% CI: 1.55-32.04]; P = .01). CONCLUSIONS: Both groups reported similar levels of early communication. Some divergence of more complex language skills was seen, although there were no significant group differences. A relationship with the diagnosis of a cleft of the hard or soft palate with expressive language behaviors was found. Further study into the impact of cleft severity on early speech development and the relationship with later language skills is needed along with longitudinal follow-up of this population.