D. Enfoque sistémico
III. Cambio climático y migración: Centro-Mesoamérica un caso delicado
This study aimed to identify which intervention components are used by SLTs in England with preschool children with PSLI and which factors might lead SLTs to modify what they do. The identification of interventions and modifying factors was based on several data sets collected from SLTs in England: focus groups, two national electronic surveys, and further exploratory investigations and consensus and
validation activities at regional SIG events and national events. The data revealed many‘activities’ and
‘strategies’ commonly used by SLTs with these children, some of which could be mapped directly onto the typology themes (identified in Study 2.1: identifying the themes of speech and language therapy practice). The data also highlighted the fine-tuning that goes on with respect to how interventions are actually delivered and identify some of the factors that might influence this.
Research questions
1. Which intervention components do SLTs use and consider relevant to preschool children with PSLI? 2. Which factors lead SLTs to adapt or modify their use of intervention components?
3. How do intervention components relate to the developing typology?
Methodology summary
A summary of the methods is shown in Figure 14; the methods are described in detail in Chapter 1 (see Methodology overview).
Findings
Data collection was preceded by a review of the findings from a number of previous studies carried out by this group to identify activities and strategies that had already been mentioned by SLTs in connection with
children with SLCN.37,89,96,115In addition, a selection of published programmes was reviewed to identify
activities and strategies that were explicitly mentioned: the Nuffield Centre Dyspraxia Programme (NDP),116
the Derbyshire Language Scheme (DLS),117the Makaton programme,118core vocabulary,119the Hanen
programme,120cued articulation121and the Metaphon programme.122The data were used for later
comparison with the interventions presented in the survey to check for comprehensiveness.
A first step in meeting the aim to identify interventions that SLTs use with preschool children with PSLI was conducting focus groups with SLTs.
Content analysis of focus groups
A coding framework was developed by a member of the research team in NVivo 9 software. The framework sought to classify interventions into different categories. The categories were designed to incorporate the different types of disorder within PSLI (e.g. expressive or receptive language, speech, social communication) as well as the different types of intervention (i.e. activities, strategies, programmes or resources). Categories in the framework were not mutually exclusive, so, for example, an intervention might be coded as both an expressive and a receptive language activity. The results of the content analysis are shown in Table 19.
As shown in Table 19, a large range of interventions was coded. It can be seen that, although participants were encouraged to give detail rather than list programmes or resources, a large number of programmes and materials were coded. Another noteworthy finding is that a large number of strategies for language were coded (n= 150) relative to receptive (n = 43) and expressive (n = 33) language activities. By contrast, speech
activities (n= 90) were more commonly coded than speech strategies (n = 51). There were also a large number
of strategies (n= 123) that were classified as general speech, language and communication strategies.
Identifying interventions used by SLTs
Data were collected from SLTs via focus groups (n = 40) at six case study sites and two national electronic surveys (n = 191, n = 190). The focus groups and surveys identified:
• the interventions SLTs use with preschool children with PSLI and their components
• the ways in which SLTs modify their interventions in relation to child, context and family factors
• the rationale and purposes that SLTs state for using those interventions The focus group data were analysed using content analysis. The survey data were analysed using descriptive statistics
See Chapter 1, Focus groups and Assessment tool survey
Mapping the interventions onto themes of practice (typology) Data were collected from SLTs at SIG events (n = 34)
and national consensus events (n = 86)
The SIG events used the intervention list derived from the focus groups and surveys to determine:
• whether or not the interventions could be mapped onto the typology themes • whether or not the SLTs felt the interventions were essential, advisory or they did not use them in relation to a particular typology theme
At the national consensus events SLTs were asked to:
• provide a description (vignette) of a preschool child with PSLI they had recently worked with and map the interventions they had used with this child onto the typology themes
See Chapter 1, Specific interest groups and National consensus events
Therapy rationale
One of the aims of the focus groups was to explore SLTs’ rationales for therapy. There were 178 references
to rationales coded in NVivo 9. These are not going to be reported in full here; however, some noteworthy points are considered. SLTs reported a wide range of rationales for their intervention use, depending on the
intervention being delivered. For example, a rationale provided for‘adult–child interaction’ was ‘to adapt
their communication style to then give the child a chance to learn words more effectively’ (SLT_107). In
relation to information-carrying word (ICW) activities, by contrast, an example of a rationale provided was ‘you can do verbs and you can do vocabulary development at the same time, as you’ve got a structure you
can embed other things in to’ (SLT_025). Thus, rationales showed great variation depending on which
particular activity or strategy was being referred to.
Rationales were also provided at a broader level, for example relating to later outcomes [‘importance of
language as the foundation of learning and literacy’ (SLT_107)] and evidence of effectiveness [‘I think
there’s been some recent evidence that actually it’s pretty strong and robust in terms of being effective
intervention’ (SLT_108)].
It was noted that SLTs appeared to find it difficult to provide explicit rationales for their interventions, with many rationales provided in terms of the intervention activity aiming to improve the area that it was targeting, without a clear description of the mechanism of change. Making rationales explicit often involved detailed probing from the facilitator.
TABLE 19 Numbers of interventions coded using a framework developed in NVivo 9
Categories of interventionsa Number of interventions coded
Generic speech, language and communication activities 27
Social communication and participation activities 19
Expressive language activities 33
Receptive language activities 43
Speech activities 90
Materials 152
Programmes 121
General speech, language and communication strategies 123
Language strategies 150
Speech strategies 51
Strategies– non-speech, language and communication 15
Strategies– unsure 22
Therapy modifications
The focus groups also took a preliminary look at factors that might lead to the individualisation or
modification of therapy. Many SLTs talked about the importance of adapting therapy and appeared to find it difficult to describe work in relation to a generic child. Therapists often prefaced their descriptions about
the use of an intervention with‘well it depends’ or ‘depending on . . .’, with ‘depends/depending’ being
said 62 times across the focus groups. The following quote from a SLT who attended the focus groups indicates how important the role of adaptations is in planning therapy:
. . . but it’s not one size fits all and you can’t be, that’s not what we‘re about as therapists, now I’m
aware that as we’re talking, we’re talking so much about adapting and changing and in professional
judgement and those split second judgements that you make and then adapt your own interaction or your own information.
SLT_095 Modifying factors were coded in NVivo 9. Table 20 shows the numbers of factors coded that relate to the child, the family and the context. Examples of commonly raised factors that lead to modifications in relation to these areas are described in more detail in the following three sections.
Child factors
Factors that were commonly described as important in modifying interventions included the age of the
child, the severity and complexity of a child’s difficulties and whether the child had been making progress.
Immediate in-session adaptations were also described in terms of the child’s attention and behaviour.
Family factors
A diverse range of factors was raised in relation to adapting therapy for families, including providing
therapy that fits around the family lifestyle (e.g. to fit in with a hectic home), managing parents’ needs and
preferences, cultural differences and dealing with low levels of engagement or attendance:‘There’s so
many variables about the family, the needs of the family, the place of the family’ (SLT_108).
Context factors
A number of the context factors raised at the focus groups were centred around the influence of the setting and the mode of intervention delivery, for example whether SLTs were working in a clinic or a nursery, in groups, with parents, through assistants or directly with the child. Service constraints was also identified as a theme that ran through the focus groups, with therapists frequently describing time and staffing pressures and issues of access to published programmes that restricted their choice and planning of interventions and thus led to adaptations. It should be noted, however, that service constraint issues were not followed up in subsequent aspects of the research as they are not factors that therapists chose to make adaptations in relation to. They therefore are important to note but are less relevant for making recommendations regarding how and why therapy should be individualised.
TABLE 20 Number of factors coded which lead SLTs to modify their interventions
Factors leading to modification Number of factors coded
Child factors 156
Family factors 141
The frequency of use of interventions
Interventions and modifying factors identified from the focus group content analysis were used to populate
two surveys. Alongside interventions identified from other sources, such as the BCRP,37,89the two surveys
aimed to explore which intervention components SLTs use with preschool children with PSLI, as well as to examine what factors lead SLTs to adapt or modify their use of intervention components. Both surveys utilised predetermined response options. The focus was on components of interventions, that is, activities and strategies, rather than on specific programmes or resources, which are more generalised and may include a range of components within them.
In the first survey SLTs were asked to report the frequency of use of intervention activities and select
whether they use them with all preschool children (aged between 2 years and 5 years 11 months) with PSLI, those with primarily language difficulties or those with primarily speech difficulties. They were also asked to select factors that led them to adapt their interventions. In the second survey respondents were asked to base their responses on a specific preschool child with PSLI. In the second survey SLTs were not asked directly about factors that were reported to lead to adaptations; instead, the survey was designed to gather more detailed child, family and contextual information, the purpose being to explore whether or not particular profiles of child/family/context could be linked to particular patterns or individualisation of interventions.
The lists of interventions utilised in survey 1 was refined for survey 2 following the results of that survey and more detailed analysis of the SLT focus groups. Further, to reduce the length of the lists of interventions that SLTs were presented with in survey 2, relevant lists of intervention activities or strategies were presented in relation to the case that they had selected (i.e. speech, language or social communication). These differences mean that, although the surveys are reported together here, there are not matching intervention data for all of the presented interventions. It is also noteworthy that a higher proportion of SLTs would be expected to select interventions in survey 1 than in survey 2, as survey 1 refers to general intervention use whereas in survey 2 responses are based on a specific child.
Participating speech and language therapists
Survey 1 received 191 responses. As participants were not screened for inclusion all participant responses were included in the analysis. Survey 2 received 217 responses; of these, 27 respondents did not meet the inclusion criteria, 17 because they had not worked with a child with PSLI in the last 12 months and 10 because they did not select a preschool child with PSLI. Participants in survey 2 were invited to complete the survey more than once. Ten respondents did so and therefore 180 different SLTs completed the survey.
The number of years since qualifying as a SLT is provided for survey participants in Table 21; the majority
had been qualified for> 11 years. For survey 2, more detailed information on the background of the
participating SLTs, their work location and the delivery of interventions can be found in Appendix 26.
TABLE 21 Years since survey participants qualified as a SLT
Years since qualified Survey 1 (n= 217), % Survey 2 (n= 180), %
0–2 15 12
3–5 20 21
6–10 23 16
Child information from survey 2
In survey 1, therapists reported on their general use of interventions. However, in survey 2, therapists reported on interventions that had been used with a particular child from their caseload. The children that they selected were aged between 22 and 72 months, with a mean [standard deviation (SD)] age of 47
(11.0) months. The majority of the children were male (n= 146, 77%).
Approximately half of the SLTs selected a child with primarily speech difficulties (n= 93, 49%) and
approximately half selected a child with primarily language difficulties (n= 89, 47%). Those with
language difficulties were reported to have either expressive language difficulties (n= 45, 24%) or mixed
expressive/receptive language difficulties (n= 44, 23%). Only one respondent selected a child with
primarily receptive difficulties. In total, 4% (n= 8) of respondents selected a child with primarily social communication difficulties. Because of the low number of children with primarily social communication difficulties, findings for this group are not reported here.
Other detailed information on the children and their context, including the languages spoken and exposed to, ethnic heritage, preschool childcare provision, medical history, the severity of the PSLI, the effect of PSLI on activity and participation and their behaviour, attention and listening, confidence, awareness, frustration and engagement with therapy, is reported in Appendix 27. Broader contextual and family information was also gathered and is also presented in Appendix 27. These data were extracted to explore whether or not child/family/context factors are related to particular patterns or individualisation of interventions and will be analysed at a later date.
Patterns of intervention use for children with primary speech and language impairment Descriptive data from both surveys are presented in Table 22. These show the wide variety of interventions
in use. From examining the data four key findings emerged in relation to SLTs’ reported use of
interventions with preschool children with PSLI:
l there are differences between intervention activities that SLTs report using for children who have
primarily speech delay and intervention activities that SLTs report using for children who have primarily language delay (surveys 1 and 2)
l strategies are more likely than activities to be reported to be used for all children with PSLI (survey 1)
l for children with primarily speech difficulties, intervention activities are reported to be more commonly
used than strategies, whereas for children with primarily language difficulties the opposite is true, with strategies reported to be more commonly used than activities (survey 2)
l there is diversity in the responses for some interventions, with about half the sample reporting that
they do use particular interventions and half reporting that they do not (survey 1).
These key findings from the survey data are addressed individually in the following section, with supporting data provided in relation to each finding.
Interventions for those with primarily speech difficulties and primarily language difficulties Data
in Table 22 indicate that SLTs differentiate quite clearly between the intervention activities that are used for children who have primarily speech delay and the intervention activities that are used for those who have primarily language delay. It can be seen that there are a number of intervention activities with relatively high usage for those with primarily speech difficulties but relatively low usage for those
with primarily language difficulties. For example, minimal pairs was reported to be used by a large number of participants for those with primarily speech difficulties (survey 1: 85%; survey 2: 57%) but by a relatively low number of participants for those with primarily language difficulties (survey 1: 5%). Similar findings can be found for auditory discrimination activities, with a large number reporting using these activities for those with primarily speech difficulties (survey 1: 83%; survey 2: 87%) and a low number reporting using these activities for those with primarily language difficulties (survey 1: 6%). There are also a number of interventions for which the opposite is true, with relatively high usage reported for those with primarily
TABLE 22 Proportions of SLTs reporting the use of interventions for children with primarily speech difficulties and the use of interventions for children with primarily language difficulties
Activities
Speech Language Percentage using
intervention always/sometimes with any child with speech impairment (survey 1) (n= 189)
Percentage using intervention with a specified child with speech impairment (survey 2) (n= 93)
Percentage using intervention always/sometimes with any child with language impairment (survey 1) (n= 189)
Percentage using intervention with a specified child with language impairment (survey 2) (n= 93) ICWs 1 NA 81 41 Concepts training 0 NA 73 NA Basic/key vocabulary 0 NA 69 52 Visual timetables 2 NA 48 33 Auditory memory activities 4 7 48 14 Barrier games 7 13 47 12 What’s in the bag/box 2 30 40 54 Turn taking 2 NA 35 61 Singing hello/ goodbye songs 3 NA 35 NA Core vocabulary 33 24 24 NA Play NA 18 NA 72 Sharing/reading books NA 12 NA 69 Attention and listening NA 31 NA 62 Singing NA 8 NA 48 Anticipation activities NA NA NA 33 Sound awareness activities NA 70 NA 28 Practising key phrases NA NA NA 19 Working on specific aspects of expressive syntax and/or morphology NA NA NA 18 Working on semantics and word finding skills
NA NA NA 17 Matching words and objects NA NA NA 15 Picture sequencing NA NA NA 11 Work on narrative skills NA NA NA 6 Phonological awareness 73 48 6 NA continued
(survey 1): primarily language 81%, primarily speech 1%; basic/key vocabulary (survey 1): primarily language 69%, primarily speech 0%].
Differences between the use of strategies and the use of activities
Table 23 displays intervention activities and Table 24 displays intervention strategies that SLTs reported in
survey 1 that they used always/sometimes with‘all children’. It can be seen that a much higher proportion
of SLTs reported using strategies than activities.
Table 25 displays activities and Table 26 displays strategies that were reported to be used for children with primarily language difficulties. Comparison between the two indicates that higher percentages of SLTs reported using strategies than activities for children with language impairments.
TABLE 22 Proportions of SLTs reporting the use of interventions for children with primarily speech difficulties and
the use of interventions for children with primarily language difficulties (continued )
Activities
Speech Language Percentage using
intervention always/sometimes with any child with speech impairment (survey 1) (n= 189)
Percentage using intervention with a specified child with speech impairment (survey 2) (n= 93)
Percentage using intervention always/sometimes with any child with language impairment (survey 1) (n= 189)
Percentage using intervention with a specified child with language impairment (survey 2) (n= 93) Auditory discrimination 83 87 6 NA Minimal pairs 85 57 5 NA Rhyme awareness 61 25 4 NA Focused auditory stimulation 30 n/a 3 NA Segmentation and blending 73 45 3 NA Auditory bombardment 47 27 3 NA Sequencing sounds 80 NA 3 NA Maximal oppositions 45 12 3 NA Cued articulation 47 26 2 NA Syllable counting NA 65 NA NA Drilling speech sounds NA 40 NA NA Signing NA 26 NA NA Oromotor work NA 28 NA NA Cycles approach NA 3 NA NA
Pitch and volume work
NA 1 NA NA
Tongue twister NA 0 NA NA
TABLE 23 Reported use of intervention activities by SLTs in survey 1
Intervention activities n Used always/sometimes with‘all children’, %
Turn taking 185 61
What’s in the bag/box 189 52
Visual timetables 189 41
Core vocabulary 190 24
Phonological awareness 190 15
Rhyme awareness 188 13
Auditory discrimination 190 9
Segmentation and blending 189 8
Auditory bombardment 187 8
Minimal pairs 190 4
Sequencing sounds 190 4
Maximal oppositions 181 4
Cued articulation 188 3
TABLE 24 Reported use of intervention strategies by SLTs in survey 1
Intervention strategies n Used always/sometimes with‘all children’, %
Using praise 189 97