What works, how and in which contexts when supporting parents to implement intensive speech and language therapy at home for children with speech sound disorder? A protocol for a realist review.

INTRODUCTION: Speech and language therapists (SLTs) worldwide report challenges with providing recommended, evidence-based intervention intensity for children with speech sound disorder (SSD). Challenges such as service constraints and/or family contexts impact on access to optimal therapy intensity. Existing research indicates that empowering and training parents to deliver intervention at home, alongside SLT support, offers one possible solution to increasing the intensity of intervention children with SSD receive. Digital health could increase accessibility to intensive home practice and help sustain engagement with therapy activities. Further exploration is needed around what makes parent-implemented interventions for children with SSD effective, for who and in which situations. This paper outlines the protocol for a realist review which aims to explore the active ingredients and contextual factors of effective digital parent-led interventions. METHODS AND ANALYSIS: A realist review will explore the research question, following six stages. The scope of the review will be determined, and initial programme theories will be developed about what works in digital parent-implemented interventions for SSD, for whom, how, why and in what circumstances. Relevant secondary data, identified through a formal search strategy, will be selected, appraised, analysed and synthesised using realist principles to test and further refine the initial programme theories. This process will develop refined underpinning explanatory theories which capture the interaction between contexts, mechanisms and outcomes of the intervention. An expert steering group will provide insight to inform explanatory theories, searches, and dissemination. ETHICS AND DISSEMINATION: Ethical approval is not required for this review. The refined programme theories from the review will inform the next stages of a wider study. A subsequent realist evaluation will test and further refine theories with key stakeholders. Following this, the underpinning programme theory will be used to coproduce a digital tool, to support parents to deliver home intervention alongside SLT support.

Applying evidence to practice by increasing intensity of intervention for children with severe speech sound disorder: a quality improvement project.

Speech sound disorder (SSD) affects up to 25% of UK children and may impact on: effective communication; the development of relationships; school progression and overall well-being. The evidence base shows that intervention for children with SSD is more effective and efficient when provided intensively in relation to the number of target sounds elicited in sessions (dose) and number of sessions per week (frequency). Southern Health and Social Care (HSC) Trust's baseline intensity of speech and language therapy (SLT) intervention was similar to that often found in current practice across the UK,where ~30 target sounds were elicited (dose) in once weekly sessions (frequency) over a 6-week block, followed by a break from therapy. This quality improvement (QI) project aimed to increase intensity of intervention for children with severe SSD within Southern HSC Trust's community SLT service to improve outcomes for children and their parents. QI methods supported accurate identification of ten 4-5 year olds with severe SSD and increased the intensity of their intervention over a 12-week period by measuring a range of data and speech outcomes. Findings showed a sustainable increase of dose (number of targets elicited per session) to levels recommended in the research (≥70). However, it was difficult to sustain increased frequency of appointments (to twice weekly) because of contextual factors such as sickness, etc. Accommodating this, measuring days between appointments captured an overall increase in the number of appointments attended across time. Child speech outcomes improved for direct speech measures and parent ratings of intelligibility. The intensive model of intervention has been implemented for children identified with severe SSD across Southern HSC Trust's community service with ongoing audit and development, and findings have been disseminated.

Changes in Children's Speech and Language Difficulties from Age Five to Nine: An Irish National, Longitudinal Study.

In many countries, information on the prevalence of persistent speech and language disorders in early childhood is sparse due to the lack of nationally representative samples and longitudinal studies. Secondary analysis of data collected on over 7500 Irish children at ages 5 and 9 years, found that the prevalence of speech and language difficulties reported by the primary caregivers of Irish children decreased from one in six at age 5 to one in 12 at age 9. However, one in 20 children were reported to have difficulties at both ages. Regression analysis compared children with difficulties at both age 5 and age 9 to those who had been reported to have them at age 5 but no longer had such difficulties at age 9. Children with speech and language difficulties at both age 5 and age 9 were more likely to have two or more developmental impairments as well as current or past hearing impairments. Teachers and parents also reported a greater number of social-emotional difficulties. Family characteristics did not differ significantly across the two groupings. At best, up to one third of the children at ages 5 and 9 with speech and language difficulties had two or more contacts with a speech and language therapists in the preceding 12 month period. Increased support to these children, their parents and teachers would seem to be warranted.

Making the case for the collection of a minimal dataset for children with speech sound disorder.

BACKGROUND: NHS case note data are a potential source of practice-based evidence which could be used to investigate the effectiveness of different interventions for individuals with a range of speech, language and communication needs. Consistency in pre- and post-intervention data as well as the collection of relevant variables would need to be demonstrated as a precursor to adopting this approach in future investigations of speech and language therapy intervention. AIMS: To explore whether routine clinical data collection for children with speech sound disorder (SSD) could be a potential source for examining the effectiveness of intervention(s). METHODS & PROCEDURES: We examined case notes from three UK NHS services, reviewing 174 sets of case notes and 234 blocks of therapy provided for school-age children with SSD. MAIN CONTRIBUTION: We found there was significant variation in pre- and post-intervention data and variables collected by the services. The assessment data available in the case notes across all sites were insufficient to be used to compare the effectiveness of different interventions. Specific issues included lack of consistent reporting of pre- and post-intervention data, and use of a variety of both formal and informal assessment tools. CONCLUSIONS & IMPLICATIONS: The case notes reviewed were from three sites and may not represent wider clinical practice, nevertheless the findings suggest the sample explored indicates the need for more consistent and contemporaneous collection of data for children with SSD to facilitate the investigation of different interventions in practice. Researchers should work with the clinical community to determine a minimal dataset that includes a core outcome set and potential variables. This should be feasible to collect in clinical practice and provide a dataset for future investigations of clinically relevant research questions. This would provide an invaluable resource to the clinical academic and research communities enabling research questions to be addressed that have the potential to lead to improved outcomes and more cost-effective services. WHAT THIS PAPER ADDS: What is already known on the subject While there is some evidence for the efficacy of therapy for children with SSD, studies typically focus on very specific populations who meet strict selection criteria and take place in university clinics or laboratory-style settings which do not reflect typical clinical practice in the UK and elsewhere. An alternative approach to investigating the effectiveness of interventions would be to use NHS case note data. It is not clear from the existing literature whether case note data are sufficiently robust to facilitate such an analysis. What this paper adds to existing knowledge This study found that case note data, in particular assessment data, were highly variable across services and would be insufficient to compare different interventions for this population. Agreement on what should be included in a minimal dataset for children with SSD is required to maximize the potential for NHS clinical case notes to become a resource for future research. What are the actual or potential clinical implications of this work? This study indicates that current clinical practice in SLT for children with SSD is inconsistent with regards to the reporting of pre- and post-intervention assessment data and other important variables in case notes. We make the case for agreeing a minimal dataset with a need for clinicians to work with researchers to determine core outcomes and additional relevant data, which can be feasibly collected in clinical practice.

A classroom intervention targeting working memory, attention and language skills: a cluster randomised feasibility trial.

BACKGROUND: International debate around the best models of speech and language therapy provision for children with language disorders has highlighted the need for research into classroom-based approaches and intervention dosage. Working memory (WM) is a cognitive skill linked to attention and language. 'Recall to Enhance Children's Attention, Language and Learning' (RECALL) is a novel, 6-week, classroom-based intervention delivered by health professionals (HPs) and teachers. It is designed to target WM and enhance attention and language skills in 4-5 year olds. METHODS: A cluster randomised feasibility trial was conducted to investigate aspects of the feasibility of a definitive trial to evaluate RECALL: (i) recruitment and sampling procedures; (ii) compliance and fidelity; (iii) the acceptability of RECALL to HPs and teachers; (iv) the appropriateness of the outcome measures. Six classes of 4-5 year olds participated: two received RECALL, two received an existing intervention targeting attention skills (not underpinned by WM theory), and two received education as usual (no intervention). Ten children in each class (n = 60) were sampled to assess the appropriateness of the outcome measures. Classroom observations were conducted to measure fidelity and semi-structured interviews with HPs, and teachers explored the acceptability of RECALL. RESULTS: The recruitment targets were met, and all six schools completed the trial, but the sampling procedures require modification. Compliance was good (95% of RECALL sessions were delivered), but fidelity to the intervention protocol varied between 76% and 45% across the two schools. This was influenced by large class sizes, child factors, and facilitator factors, e.g., their understanding of the theory underpinning the intervention. The lack of fidelity reduced the dose (number of practice items) accessed by individual children, particularly those most at risk. There were mixed findings regarding the acceptability of RECALL and the appropriateness of the outcome measures. CONCLUSIONS: The trial protocol could be easily scaled-up in a future definitive trial, with an amended sampling procedure. RECALL should be repackaged as a small group intervention to enhance the fidelity of its delivery and its acceptability to HPs and teachers. This study highlights the need for thorough training for professionals who deliver classroom-based interventions for children with language disorders. TRIAL REGISTRATION: ISRCTN13633886 . Registered on 7 September 2018.

How many words make a sample? Determining the minimum number of word tokens needed in connected speech samples for child speech assessment.

Connected speech (CS) is an important component of child speech assessment in both clinical practice and research. There is debate in the literature regarding what size sample of CS is required to facilitate reliable measures of speech output. The aim of this study was to identify the minimum number of word tokens required to obtain a reliable measure of CS across a range of measures. Participants were 776 5-year-olds from a longitudinal community population cohort study (Avon Longitudinal Study of Parents and Children, ALSPAC). Children's narratives from a story retell task were audio-recorded and phonetically transcribed. Automatic analysis of the transcribed speech samples was completed using an automated transcription and analysis system. Measures of speech performance extracted included: a range of profiles of percentage consonant correct; frequency of substitutions, omissions, distortions and additions (SODA); percentage of syllable and stress pattern matches; and a measure of whole word complexity (Phonological Mean Length of Utterance, pMLU). Statistical analyses compared these measures at different CS sample sizes in increments using averages and weighted moving averages, and investigated how measures performed between CS samples grouped into word tokens of at least 50, 75 and 100, and restricted to samples of 50-74, 75-99 and 100-125. Key findings showed that sample sizes of 75 word tokens and above showed minimal differences in most measures of speech output, suggesting that the minimum requirement for samples of CS is a word count of 75. The exception to this is in the case of pMLU and measures of substitutions and distortions when a word count of 100 is recommended.

A qualitative exploration of speech-language pathologists' intervention and intensity provision for children with phonological impairment.

PURPOSE: The aim of this study was to explore the reasons behind speech-language pathologists' (SLPs') current clinical practices (intervention and intensity provision) for children (0-18 years) with phonological impairment. METHOD: Three focus groups each with five SLPs and six 1:1 interviews with SLP managers from one region of the UK (n = 21) were carried out. A thematic analysis was undertaken. RESULT: SLPs often used an eclectic mix of familiar approaches with easily-accessible therapy materials. SLPs only reported deviating from their core approach if the child did not progress in therapy. Mixed responses were gathered on the perceived feasibility of transferring evidence-based intervention intensities into clinical practice. The importance of parents to increase intensity provision at home was noted. Barriers to SLPs' evidence-based decision-making included: time; confidence levels; service-related restrictions and; difficulty replicating research in practice. Having peer support and access to decision-making pathways and manualised intervention protocols were considered ways to overcome these barriers. CONCLUSION: There is a research-practice gap in which SLPs' current practices are driven by organisational factors, their own preferences and child-specific factors. To narrow this gap, SLPs suggested the development of time-saving, evidence-based tools.

Interventions targeting working memory in 4-11 year olds within their everyday contexts: A systematic review.

It has been suggested that diverse interventions applied within children's everyday contexts have the potential to improve working memory (WM) and produce transfer to real-world skills but little is known about the effectiveness of these approaches. This review aims to examine systematically the effectiveness of non-computerised interventions with 4-11 year olds to identify: (i) their effects on WM; (ii) whether benefits extend to near- and far-transfer measures; (iii) if gains are sustained over time; (iv) the active ingredients; and (v) the optimum dosage. Searches were conducted across 12 electronic databases using consistent keywords. Papers were screened by title and abstract (n = 6212) and judged against pre-defined eligibility criteria (n = 63). Eighteen papers were included in the review. They used a range of non-computerised WM intervention approaches that included: (i) adapting the environment to reduce WM loads; (ii) direct WM training with and without strategy instruction; and (iii) training skills which may indirectly impact on WM (physical activity, phonological awareness, fantastical play and inhibition). Both direct training on WM tasks and practicing certain skills that may impact indirectly on WM (physical activity, fantastical play and inhibition) produced improvements on WM tasks, with some benefits for near-transfer activities. The common ingredient across effective interventions was the executive-loaded nature of the trained task i.e., training on a task that taps into attentional and processing resources under executive control and not just the storage of information. Few studies reported dosage effects, measured far-transfer effects (n = 4), or tested the durability of gains over time (n = 4). The lack of a clear theoretical framework in many of the included studies resulted in ambiguous predictions about training and transfer effects, and inadequate use of outcome measures. Methodological issues also constrain the strength of the evidence, including: small samples sizes; an absence of blinding of participant and outcome assessors; and lack of active control groups. Further well-designed and controlled studies with clear theoretical underpinnings are required to expand and enhance the evidence base. The heterogeneity of the interventions and of the study designs (randomised and non-randomised) in the included papers limited the synthesis of evidence across studies. However, this diversity enabled the identification of key ingredients, notably the training of executive-loaded WM tasks, which can help inform novel approaches to WM intervention in everyday contexts.

A classroom-based intervention targeting working memory, attention and language skills in 4-5 year olds (RECALL): study protocol for a cluster randomised feasibility trial.

BACKGROUND: There is international recognition of the need for creative, classroom-based interventions to support children at risk of low academic achievement and well-being, due to poor attention and language skills on school entry. Working memory (WM) is a cognitive skill that is strongly associated with attention and language skills. There has been speculation that WM training, embedded within typical educational activities, may improve children's WM skills and produce transfer effects to real-world skills such as attention and language. However, little is known about the effectiveness of this approach.'Recall to Enhance Children's Attention, Language and Learning' (RECALL) is a novel, 6-week, classroom-based intervention targeting WM, attention and language skills in 4-5 year olds. RECALL was co-produced with health professionals, teachers and parents. This protocol describes the rationale, methods and analysis plan for a proposed cluster randomised feasibility trial of this RECALL programme. METHODS: This is a three-arm, cluster randomised feasibility trial comparing RECALL to an existing programme (active control), and no-intervention (education as usual). We will recruit six schools in socially disadvantaged areas in one region of the UK. Two schools will be randomly allocated to each arm of the trial. In each school, one class of children (ages 4-5 years) of approx. 30 children will be involved in this study. Ten children in each class will be sampled purposefully for outcome measurement including: standardised assessments of WM, language and attention skills; teacher ratings of attention; and parent ratings of functional communication skills. These will be administered at baseline and 1-week post-intervention in order to test the acceptability of the measures. A process evaluation using semi-structured interviews with participants will explore the acceptability of RECALL and the procedures employed in this trial. DISCUSSION: This feasibility study will explore the acceptability of RECALL to the health professionals and teachers who will deliver it and inform the optimal design of the programme. The inclusion of an active control group and the blinding of outcomes assessors enhance rigour in this study. The findings will determine whether this study can be scaled-up into a definitive cluster randomised trial to evaluate the effectiveness of RECALL. TRIAL REGISTRATION: ISRCTN13633886. Registered 7 Sept 2018.

Intervention for children with phonological impairment: Knowledge, practices and intervention intensity in the UK.

BACKGROUND: Across the world, research has shown that intervention for children with phonological impairment can be both effective and efficient. However, it has also raised concerns about the translation of this evidence to practice, highlighting questions around clinician knowledge and the understanding of approaches, and the intensity of intervention provided within real-life clinical contexts. AIMS: To investigate the clinical management of phonological impairment by speech and language therapists (SLTs) in the United Kingdom (UK). METHODS & PROCEDURES: An anonymous, UK-wide, online survey was developed using Qualtrics. The target audience were UK-based SLTs who worked with children with phonological impairment. The following topics were explored: (1) SLTs' understanding of intervention approaches; (2) SLTs' use of intervention approaches to treat phonological impairment; and (3) SLTs' provision of intervention intensity for children with phonological impairment. OUTCOMES & RESULTS: A total of 166 responses were analyzed. To remediate phonological impairment, SLTs most commonly used speech discrimination (79.5%), conventional minimal pairs (77.3%), phonological awareness therapy (75.6%) and traditional articulation therapy (48.4%). Participants least frequently used the complexity approaches targeting the empty set (82.9%) and two- to three-element clusters (75%) as well as the cycles approach (75.6%). Results also showed that some SLTs were uncertain of what the empty set and two- to three-element clusters approaches entailed. In terms of intervention intensity, participants predominantly provided intervention once per week (69%) for a total of 9-12 sessions (ranging from five to 30 sessions, 71.5%) and elicited targets 10-30 times in single words per session (59.4%) in sessions lasting 21-30 min (41.4%). CONCLUSIONS & IMPLICATIONS: The most commonly used intervention approaches identified in the current survey (i.e., speech discrimination, conventional minimal pairs and phonological awareness therapy) may be used eclectically by SLTs, which could impact upon the effectiveness and efficiency of treatment for phonological impairment. The current study also highlighted that almost half the participants always/often used traditional articulation therapy to remediate phonological impairment, even though this approach has been found to be less effective for this difficulty. Additionally, it appears that the currently provided intervention intensity for phonological impairment in the UK is significantly lower than what is indicated in the literature. Therefore, a research-practice gap exists for SLTs in the UK working with children with phonological impairment.

Practice makes perfect? The pedagogic value of online independent phonetic transcription practice for speech and language therapy students.

Accuracy of phonetic transcription is a core skill for speech and language therapists (SLTs) worldwide (Howard & Heselwood, 2002). The current study investigates the value of weekly independent online phonetic transcription tasks to support development of this skill in year one SLT students. Using a mixed methods observational design, students enrolled in a year one phonetics module completed 10 weekly homework activities in phonetic transcription on a stand-alone tutorial site (WebFon (Bates, Matthews & Eagles, 2010)) and 5 weekly online quizzes (the 'Ulster Set' (Titterington, unpublished)). Student engagement with WebFon was measured in terms of the number of responses made to 'sparks' on the University's Virtual Learning Environment Discussion Board. Measures of phonetic transcription accuracy were obtained for the 'Ulster Set' and for a stand-alone piece of coursework at the end of the module. Qualitative feedback about experience with the online learning was gathered via questionnaire. A positive significant association was found between student engagement with WebFon and performance in the 'Ulster Set', and between performance in the 'Ulster Set' and final coursework. Students valued both online independent learning resources as each supported different learning needs. However, student compliance with WebFon was significantly lower than with the 'Ulster Set'. Motivators and inhibitors to engagement with the online resources were investigated identifying what best maximised engagement. These results indicate that while 'independent' online learning can support development of phonetic transcription skills, the activities must be carefully managed and constructively aligned to assessment providing the level of valance necessary to ensure effective engagement.

Use of outcome measurement by paediatric AHPs in Northern Ireland.

BACKGROUND: Professional standards advocate routine use of outcome measurement (OM) in the practice of allied health professionals (AHPs). Historically, OM has focused on impairment and its immediate constraints on activity, while current policy encourages the development and addition of impact-based OM. There appears to be an assumption at this stage of AHP development that the use of OM is well embedded into practice. However, there is no evidence to support this assumption, which leads to the current investigation into the overall readiness of paediatric AHPs-speech and language therapists (SLTs), occupational therapists (OTs) and physiotherapists (PTs)-to use OM. AIMS: To investigate the readiness of paediatric AHPs in the use of OM and to consider what influences this use. METHODS & PROCEDURES: A total of 133 paediatric AHPs working in the National Health Service (NHS) in Northern Ireland completed the Clinician Readiness for Measuring Outcomes Scale (CReMOS). CReMOS's 26 statements are rated on a six-point Likert scale identifying readiness to use OM based on the Transtheoretical Model of Change. OUTCOMES & RESULTS: While about 75% of clinicians were using OM, 25% require support to roll this out in their practice. This pattern was similar across the professions, and while the majority perceived the value of OM, several factors influenced their use. CONCLUSIONS & IMPLICATIONS: Clinicians would benefit from protected time and support from experts/role models to promote and facilitate best practice in the use of OM. Furthermore, funding for AHP services based on measurable outcomes for service users would facilitate their use in practice. Further research teasing out the different types of OM and the supports and barriers to their use would be very valuable.

An investigation of weak syllable processing in deaf children with cochlear implants.

In this study the influence of prosodic foot structure on the processing of weak syllables in children with cochlear implants (CI) was investigated. A battery of tests investigating processing of weak syllables in single and multi-word utterances was carried out on four groups of children: 15 children with CI developing spoken language as expected (Main CI); five children with CI reported to have additional speech and language problems; 15 age matched; and 15 language matched (LM) children with normal hearing (NH). Children in the main CI and, to a lesser extent, the LM groups processed footed weak syllables preferably over unfooted weak syllables (particularly as memory load increased). Thus, these children with CI appear to possess a similar Prosodic Hierarchy (PH) to their LM peers with NH, and possibly due to the impact of delayed and constrained exposure to audition on the development of linguistic processing and short-term memory, are influenced by its foot structure in the processing of weak syllables.