LIVELY

Elaine Ashton presented at the Early Childhood Voices conference and a recording of her presentation is here: https://earlychildhoodresearch.csu.domains/early-childhood-voices-conference-2022/ecv2022-258/

Background: Bilingualism does not cause or contribute to speech, language, and communication needs (SLCN). However, bilingual children are just as likely to have SLCN as monolingual children. Most UK speech and language therapists (SLTs) are monolingual and will therefore need to work with interpreters when working with bilingual children.

Aim: To identify the enablers and barriers to delivering effective and equitable speech and language intervention for bilingual children.

Method: Part of the Language Intervention in the Early Years (LIVELY) project consisted of a series of single case studies working with bilingual children. Language intervention was delivered in the home language by an experienced SLT working with interpreters, within education settings.

Results: There were several key learning outcomes from the single case studies. Preparing appropriate assessment and intervention resources for languages other than English was time-consuming and complex. During the intervention sessions the children rarely spoke. Additional training was needed to support the interpreters in understanding their roles.

Conclusions: Working with bilingual children and interpreters can be challenging for monolingual SLTs. It is important to consider the impact of cultural differences in all aspects of the assessment and intervention process. Working in home language is essential for providing an equitable service for bilingual children.

Implications for children and families: Speaking more than one language is advantageous. If you have concerns that your child has difficulties in all the languages they speak, contact a speech and language therapist for advice and support.

Implications for practitioners: It is possible to deliver home language intervention for bilingual children even if you are a monolingual speaker. Extra time and preparation are key to helping you meet the needs of bilingual children with SLCN.

The Newcastle Phonological Awareness website, made by Speech and Language Therapists (SLT) for SLTs, teachers, teaching assistants and assistant SLTs, is available below. The website has been created by Senior Lecturer and Consultant SLT, Dr Helen Stringer and PhD student, Jo Baker. On this website you will find information about phonological awareness development and important evidence to consider. This includes information on assessment, intervention and current research projects. It is a great place to start or further your learning about phonological awareness.

On the website, you can also access the manuals and materials for the Newcastle Assessment of Phonological Awareness (NAPA) and the Newcastle Intervention for Phonological Awareness (NIPA).

Website: Newcastle Phonological Awareness | Newcastle Phonological Awareness | Newcastle University (ncl.ac.uk)

Website created by: Dr Helen Stringer and Jo Baker

Blog Author: Emily Preston

Following the closure of schools across the UK in March 2020, many Speech and Language Therapy services had to deliver assessments and interventions remotely via telehealth. For the LIVELY project, adapting and developing assessments and interventions for remote delivery was an important consideration during the pandemic. Consequently, the team sought to investigate the suitability of selected platforms and technology; the feasibility of alternative delivery methods; how to adapt assessments so they remain reliable and valid and methods of supporting children, parents and educational staff to access and engage with the remote sessions.

The aim was to develop a telehealth option that was as effective as possible within the constraints of the LIVELY project (budget, timescales, and access to schools during the pandemic). We considered research questions that fell under two headings:

1. To what degree is it possible to develop a telehealth approach for pre-school child language assessments and/or intervention?

2. What are the characteristics of approaches that yield the best outcomes?

These questions formed a basis for whether it was possible to develop a telehealth approach that had high treatment fidelity and was reliable, valid and acceptable for therapists, parent(s)/caregiver(s), children and educational staff. As part of this, we wanted to explore how and why characteristics of approaches that yield the best outcomes vary across families, children and schools.

Following a review of research, professional guidelines and discussion with Speech and Language Therapists across eight regions of the UK, the key learning and considerations about telehealth as a service delivery model is summarised below:

Creation of a telehealth assessment and intervention protocol (RCSLT, 2020) (ASHA, 2020)

• The protocol should explain and document how the assessments and interventions will be conducted and adapted for remote use
•  It will ensure high levels of treatment fidelity when delivering the interventions. Treatment fidelity ensures that the intervention is delivered in the same way, by different people, in different settings

Selecting a platform (RCSLT, 2020) (ASHA, 2020)

• The platform must ensure privacy and confidentiality
• A user-friendly guide should be created
• Trial the platform and check audio and video signals
• The LIVELY team piloted both Zoom and Microsoft teams as these had the functions of remote access and screen share. We also created set up instructions for these platforms and trialled with adults who were familiar and unfamiliar with these platforms

Facilitator role

Training sessions with facilitators in schools should focus on the following: (Grogan-Johnson et al, 2011) (Raman et al, 2019):

The LIVELY team created facilitator role sheets for various versions of the assessments and interventions. They were sent to qualified SLTs and feedback was given regarding the role sheets so they are as clear as possible for both parents and teaching staff

Feedback on the telehealth sessions (RCSLT, 2020) (ASHA, 2020)

• It is important to gather feedback on telehealth sessions. The LIVELY team created google forms for teachers and parents to evaluate the different telehealth options
• RAs kept reflective diaries regarding their experience with telehealth

For more information regarding the development of remote assessments and interventions during the LIVELY project, please see the presentation attached which was presented virtually at the Research Symposium 2021.

NESLT 2021 | Language Intervention in the Early Years | Newcastle University (ncl.ac.uk)

Authors: Emily Preston, Kate Conn, Christine Jack, Cristina McKean, Jenny Sandham

References

ASHA. “Telepractice.” Telepractice: Overview, ASHA, 2020, www.asha.org/practice-portal/professional-issues/telepractice/

Grogan-Johnson, S., Gabel, R. M., Taylor, J., Rowan, L. E., Alvares, R., & Schenker, J. (2011). A pilot exploration of speech sound disorder intervention delivered by telehealth to school-age children. Int J Telerehabil, 3(1), 31-42. doi:10.5195/ijt.2011.6064

Raman, N., Nagarajan, R., Venkatesh, L., Monica, D. S., Ramkumar, V., & Krumm, M. (2019). School-based language screening among primary school children using telepractice: A feasibility study from India. Int J Speech Lang Pathol, 21(4), 425-434. doi:10.1080/17549507.2018.1493142

RCSLT. (2020). Covid-19: Telehealth. Digitally transforming therapy – the what, why & how of telehealth in speech and language therapy. [PowerPoint slides]. https://www.rcslt.org/-/media/docs/Covid/Telehealth-webinar-final.pdf?la=en&hash=E5484323617F3C63CC3945328D3E9D8BB1D6FA1C

RCSLT. (2020) “Telehealth – Guidance.” Royal College of Speech and Language Therapists.www.rcslt.org/members/delivering-quality-services/telehealth/telehealth-guidance.

The LIVELY Team have created a booklet of best practice. This booklet has been co-produced with North East Early Years Teachers, SENCOs, Teaching Assistants and Speech and Language Therapists. This booklet has been designed with the idea of being a North East Community of practice to support sharing of best practice for early language development.

Many schools will already be doing some of the things mentioned in the booklet, however, it is a place to find some new ideas that will help to support and develop children’s communication within the Early Years settings. If you have ideas you would like to share about this, please visit our website and Padlet to find out more and add your own ideas.

Best Practice Booklet: Best Practice Booklet | Language Intervention in the Early Years | Newcastle University (ncl.ac.uk)

Website: https://research.ncl.ac.uk/lively/

Padlet: Best Practice Booklet (padlet.com)

Authors: Emily Preston, Christine Jack, Cristina McKean

Whilst scoring the Building Early Sentences Therapy (BEST) assessments, the LIVELY team noticed some small changes in the children’s language development were not being credited, for example, if a child who previously was using no agent is now using ‘mum’ for lady. An agent can be defined as the thing that causes, or instigates, the action in a sentence, e.g. ‘dad’ in the sentence ‘the dad is sitting‘. We looked at how we could increase the sensitivity of the spoken sentence scoring measure by combining the BEST scoring approach with elements from the Renfrew Action Picture Test (RAPT) scoring.

From the short, picture based BEST assessment, we wanted to be able to capture detailed and accurate measurements of vocabulary, morphology (a meaningful unit of language that cannot be further divided e.g. ‘the’ ‘ing’ ‘is’) and predicate argument structure (PAS). PAS refers to the arguments in the sentence, for example, ‘the dad is sitting’ consists of two arguments: ‘dad’ is the agent, ‘sitting’ is the verb. The team combined the scoring methods from BEST and RAPT and then went through several stages of refining the definitions and checking for inter-rater reliability.

The new combined scoring system was then used to score the children’s utterances across different time points (baseline, outcome and follow-up) and treatment conditions (BEST vs DLS) to track their progress.

Each sentence in the BEST assessment was given a total score to see what the child was getting right. For example, the target sentence ‘The teddy is sitting’, a child could score a maximum of 3/3 for morphology, 1/1 for predicate argument structure (PAS) and 2/2 for information.

The new scoring measure now captures and reflects the semantic, grammatical and morphological components of the children’s utterances and allowed us to analyse and evaluate changes in the children’s language development over time.

Our aim is that the new scoring system can be generalised to other sets of pictured-based expressive language assessments to capture meaningful information about children’s language skills.

Please see the below link for the pre-recorded lightning talk for the North East Speech and Language Therapy update meeting that was held on 7th July 2022.

https://research.ncl.ac.uk/lively/newsevents/nesltjuly2022/

Authors: Emily Preston, Elaine Ashton, Kate Conn, Christine Jack, Cristina McKean, Olivia Ridgeway, Naomi Rose

Treatment fidelity has been an important consideration in the research process of the LIVELY project, to ensure that the Research Assistants (RAs) carried out the interventions consistently, in line with the manual and in line with each other.  Treatment fidelity has implications for the internal validity of the LIVELY project; however, it also bears on the future ability to apply the interventions to real clinical settings (Hinckley & Douglas, 2013). 

We reflect on the challenges, processes and importance of standardising interventions to be used reliably by different researchers and ideally in the future by varying teaching staff, in differing locations, and with a range of children. Key are issues of developing approaches that can be individualised to support children’s specific needs.

Key areas of consideration for high treatment fidelity are:

Manualisation of the Interventions

• BEST already had a manual prior to the project. The LIVELY RAs worked with Cristina McKean, Mark Masidlover and Christine Jack to create a manual for the adapted version of the DLS
• Clear assessment and intervention protocols were created to support the RAs to deliver the interventions consistently

Consistency of resources

• The team had to ensure that all toys and resources used in the interventions were exactly the same. Resources were adapted due to the pandemic – the toys selected were wipeable to ensure they could be cleaned after each use.

Development of treatment fidelity checklists

• A stand-alone treatment fidelity tool had previously been created for the BEST intervention. A treatment fidelity checklist was created to use with the DLS intervention to ensure it was being delivered consistently.

Methods of supporting parents to access and engage with homework

The involvement of parents in a child’s speech and language intervention has been highlighted as a significant factor of its success.  Engagement of parents with homework resources can be tricky to control, however, methods of support to try and engage parents with activities were put in place:

• Simple and easy to use homework activities: lotto games, short stories, turn-taking and matching activities
• Video instructions for all homework activities
• Written instructions for all homework activities – including QR codes to access the video instructions
• Text messages sent to parents after each session with a link to the homework resources and video instructions
• Providing teachers with homework instructions so they can support any parent questions or queries

During the LIVELY project, treatment fidelity was monitored throughout the intervention period. RAs kept weekly reflections regarding any barriers and enablers, what worked well, what could be improved and how. The RAs could not see each other’s reflections during the project to ensure they remained blind to the treatment arm. Intervention sessions 3 and 4 were also video recorded, watched by the RA and then rated using the treatment fidelity checklist. The videos and self-reflections were then sent to a supervisor who also watched the videos and used the treatment fidelity tool to score the intervention session and provide feedback to the RA. The comprehensive manuals and protocols discussed earlier were put in place to try and mitigate any compromise to the treatment fidelity of the interventions.

For more information on treatment fidelity in the LIVELY project, please see the presentation attached which was presented at the virtual Research Symposium.

Staying%20Faithful_RS%20presentation.pptx – Google Drive

Authors: Emily Preston, Jo Baker, Kate Conn

References

The following list includes references from the presentation and articles that may be of further interest to you:

Bellg, A. J., Borrelli, B., Resnick, B., Hecht, J., Minicucci, D. S., Ory, M., . . . Treatment Fidelity Workgroup of the, N.I.H.B.C.C. (2004). Enhancing treatment fidelity in health behavior change studies: best practices and recommendations from the NIH Behavior Change Consortium. Health Psychol, 23(5), 443-451. Doi: 10.1037/02786133.23.5.443. https://www.ncbi.nlm.nih.gov/pubmed/15367063

Bruinsma, G., Wijnen, F., & Gerrits, E. (2020). Focused Stimulation Intervention in 4- and 5-Year-Old Children With Developmental Language Disorder: Exploring Implementation in Clinical Practice. Lang Speech Hear Serv Sch, 51(2), 247-269. doi:10.1044/2020_LSHSS-19-00069

Carroll, C., Patterson, M., Wood, S., Booth, A., Rick, J., & Balain, S. (2007). A conceptual framework for implementation fidelity. Implement Sci, 2, 40. doi:10.1186/1748-5908-2-40

Fricke et al, (2017). The efficacy of early language intervention in mainstream school settings: a randomized controlled trial. Journal of Child Psychology and Psychiatry, 58(10), 1141-1151. DOI: 10.1111/jcpp.12737

Gearing, R. E., El-Bassel, N., Ghesquiere, A., Baldwin, S., Gillies, J., & Ngeow, E. (2011). Major ingredients of fidelity: a review and scientific guide to improving quality of intervention research implementation. Clin Psychol Rev, 31(1), 79-88. doi:10.1016/j.cpr.2010.09.007:  https://www.ncbi.nlm.nih.gov/pubmed/21130938

Glogowska, M., & Campbell, R. (2000). Investigating parental views of involvement in pre-school speech and language therapy. International Journal of Language & Communication Disorders, 35(3), 391-405. doi: 10.1080/136828200410645

Hinckley, J. J., & Douglas, N. F. (2013). Treatment fidelity: its importance and reported frequency in aphasia treatment studies. Am J Speech Lang Pathol, 22(2), S279-284. doi:10.1044/1058-0360(2012/12-0092): https://www.ncbi.nlm.nih.gov/pubmed/15367063

Klatte,I. S., Harding, S., & Roulstone, S. (2019). Speech and language therapists’ views on parents’ engagement in Parent-Child Interaction Therapy (PCIT). International Journal of Language and Communication Disorders, 54(4), 553-564.  doi: 10.1111/1460-6984.12459.

McKean, C., Benson, K., Jack, C., Letts, C. A., Pert, S., Preston, E., Trebacz, A., Stringer, H., & Wareham, H. (2020). ISRCTN10974028: Language Intervention in the Early Years – comparing the effectiveness of language intervention approaches for pre-school children with language difficulties ISRCTN doi: 10.1186/ISRCTN10974028

Michie, S., Richardson, M., Johnston, M., Abraham, C., Francis, J., Hardeman, W., … & Wood, C. E. (2013). The Behavior Change Technique Taxonomy (v1) of 93 Hierarchically Clustered Techniques: Building an International Consensus for the Reporting of Behavior Change Interventions. Annals of Behavioral Medicine : a Publication of the Society of Behavioral Medicine, 46(1), 81–95. https://doi.org/10.1007/s12160-013-9486-6

Ory MG, Jordan PJ, Bazarre T. The Behavior Change Consortium: setting the stage for a new century of health behavior-change research. Health Educ Res. 2002;17(5). doi: 10.1093/her/17.5.500

Roulstone, S. (2015). Exploring the relationship between client perspectives, clinical expertise and research evidence. International Journal of Speech-Language Pathology, 17(3), 211-221. doi: 10.3109/17549507.2015.1016112.

Background

The main part of the LIVELY project compared two language intervention approaches for monolingual English-speaking children: Building Early Sentences Therapy (BEST) and an adapted version of the Derbyshire Language Scheme (DLS).  The second part of the LIVELY project focussed on working with bilingual children.  The aim was for an experienced Speech and Language Therapist (SLT) to deliver BEST intervention in home language working alongside interpreters.  We wanted to find children who were below age expectations in both English and their home language of Mirpuri (a Pakistani heritage language), Sylheti (a Bangladeshi heritage language) or Polish.  In terms of recruitment and eligibility, two children were included in the study – one Sylheti-speaking child who attended nursery, and one Polish-speaking child who was in reception class.

Research shows that delivering intervention in a child’s home language is best, however, in practice it can be difficult to do.  The following discussion includes the preparation of home language resources, what we learned from working with bilingual children and interpreters, and recommendations for clinical practice.

Resources

For this project existing resources were adapted into Mirpuri, Sylheti and Polish by native speakers who had some linguistic knowledge.  It was important to include morpheme-by-morpheme translations in all resources, particularly as some languages are more morphologically complex than English (see example in the table below).

Some words and concepts were not directly translatable across languages.  For example, in the original resources, the verb ‘to wave’ was used.  However, this is a westernised gesture and there is no direct equivalent in Sylheti.  Therefore, it was not included in the Sylheti adaptation.

Once the adaptations were completed, it was essential to pilot the resources on typically developing bilingual children working with interpreters to ensure they worked in real-life contexts.  The interpreters recommended some changes for alternative vocabulary and/or syntactic structures.  For example, the Polish resources included ‘samochód’ for ‘car’ but the Polish interpreter suggested that this was an old-fashioned version and ‘auto’ would be a more acceptable form.

Working with bilingual children

During the therapy sessions both the Sylheti and Polish-speaking children rarely, if at all, spoke Sylheti or Polish.  This may have been due to the language situation; they were both in an English-speaking environment (education setting), where their home languages were not routinely spoken.  They may also have been aware that the SLT was an English speaker, although the SLT tried not to speak English during the therapy sessions.  The SLT learned some home language words and phrases to use as greetings and during warm-up/reward activities to encourage the children to use their home language.

There may also be cultural differences why the children did not use their home language in the sessions.  In certain cultures children need to be told when to speak.  As an SLT being directive and saying, for example, “tell me” or “you say it” seems counterintuitive as typically the advice given to support adult-child interaction is to follow the child’s lead, and comment rather than question or make the child talk.

Working with interpreters

For the duration of the bilingual project the SLT worked with the same Sylheti-speaking interpreter and the same Polish-speaking interpreter.  This consistency enabled the SLT to build a good working relationship with the interpreters and gave the interpreters familiarity with the activities and resources.  Additional time was needed before and after each therapy session to prepare, explain and give feedback to the interpreters.  It was essential to practise and role-play activities with the interpreters, so they knew what was expected of them.  Although every session of BEST followed the same structure and the sessions were scripted, the interpreters often added or changed the wording during the activities.  It took time and practice for them to follow the script as directed.

Recommendations

• SLTs need to be better at helping correctly identify bilingual children who may have potential speech, language and/or communication needs.
• Working in home language is key to offering an equitable speech and language therapy service for bilingual children.
• If you need support and guidance when working with bilingual children, contact other SLTs who have this experience.
• Be brave!  To develop these skills and best meet the needs of bilingual children, you just need to do it!

Please see the link below for the pre-recorded lightning talk for the North East Speech & Language Therapy Research Update Meeting that was held on 7 July 2022.

https://research.ncl.ac.uk/lively/newsevents/nesltjuly2022/

Authors: Elaine Ashton, Sajidah Ahmed, Ewa Czaplewska, Christine Jack, Carolyn Letts, Cristina McKean, Sean Pert, Zahida Warriach

Language and communication is a high priority in early years settings and staff provide support for the growing number of children with needs in this area. The LIVELY project coincided with the pandemic, so we knew that COVID was a significant impact on all aspects of early years provision. We talked to eleven practitioners who were working with us on LIVELY to find out more. SENDCOs/early years teachers and teaching assistants were interviewed about the language and communication support they provide and how COVID impacted their children and provision.

Children were having fewer experiences; they went out less and activities were limited.  In some settings the home corner remained all year, in previous years it would have been changed into a doctor’s office or a travel agent but children were not familiar with these and staff wanted to make sure the area reflected their experiences.   

Children had less contact with other children, older children could no longer work with younger ones in schools, and they weren’t seeing friends outside of school.

Parents could not attend parent meetings or activities like ‘stay and play’ where practitioners could talk to them about how to support their children’s language and model appropriate practice. 

There was less external support and interventions in schools were also affected due to high levels of staff absence, or because staff were not able to work across different groups of children. It was more difficult to identify children with speech language and communication needs. Parents couldn’t compare their child to other children, unless there were older siblings, and there was less contact with health professionals.  

COVID had a significant impact on all aspects of children’s development with the reduction in interaction being one of the issues staff found most concerning. But COVID provided opportunities too.  

During the pandemic, especially at the start when only children of key workers and vulnerable children were going into schools, it was clear that smaller classes had a significant positive impact. Invisible children became visible, quiet children who could be overlooked in a busy classroom got more time with staff and made more progress. And some children benefited from more time at home.

Parents weren’t able to go into classrooms and settle children, but this meant that children became more independent more quickly.  Settings were concerned at this loss of contact with parents and recognised the need for strong home school links. They used technology like online learning journals for communication and to support learning at home.   

Settings have reflected on their standard practice and whether changes might be beneficial long term.   For example, rather than an individual child being able to get a snack whenever they wanted, this had to happen in groups, so it became an opportunity to chat and support language.

Priorities have been clarified, language and communication along with personal, social and emotional development are seen to be even more important than they were before.  In settings the environment had to be pared back and some settings are making decisions about whether all the resources need to be returned.  

While every setting, family and child had a different experience there are some common themes. We will continue to analyse the interviews and share our findings with schools so that they can use the information to focus on activities that will have the greatest impact on the growing numbers of children with language and communication needs.  

Author: Christine Jack, Emily Preston, Elaine Ashton, Cristina McKean

As part of the LIVELY project, members of the team have developed four CPD sessions that are available on the LIVELY website. These are still available and can be accessed by you or your colleagues. We know some schools have watched these as part of group training sessions. The CPD sessions are open access so are available for anyone to watch.

Below are the four CPD sessions available:

1. Promoting robust language development for children in the Early Years Setting – Professor Cristina McKean

https://research.ncl.ac.uk/lively/newsevents/cpdsession1robustlanguagedevelopment/cpdregistration-robustlanguage/

The development of robust language in the early years is vital for successful transition into school. The role of early years classrooms in promoting robust language development through the provision of language rich environments cannot be over-stated. The sessions will focus on defining and describing characteristics of language rich early years classrooms; sharing experiences of best practice in providing language rich experiences and considering how to develop and implement a language enrichment strategy.

• Language disorder in a bilingual context – Dr Sean Pert

https://research.ncl.ac.uk/lively/newsevents/cpdsession2bilingualcontext/

Bilingual children are no more or less likely to present with speech, language and communication needs (SLCN). However, children who speak other languages at home are often over- or underrepresented on speech and language therapy caseloads. How can we tell if a child is having difficulty acquiring speech and language skills or just needs more time to learn English? This session will explore bilingualism, myths about bilingual language acquisition, language disorder in a bilingual context and best practice when working with bilingual families.

•  Phonological Awareness. What comes before letters and sounds: getting children ready for phonics – Dr Helen Stringer

https://research.ncl.ac.uk/lively/newsevents/cpdsession3phonologicalawareness/

Phonological awareness (PA) is a crucial skill that underpins speech, vocabulary and literacy. Early syllable level stages of PA acquisition are required before children can progress to phoneme level skills (and phonics). Children who have difficulty acquiring PA skills will always have difficulty unless given help. It is never too late for children to learn PA skills. Children with good PA skills will have better vocabulary skills and learn to read more easily. These sessions will explore what is PA, how to assess PA and different types of PA intervention.

• Using technology to support language and communication in the early years – Dr Christine Jack

https://research.ncl.ac.uk/lively/newsevents/cpdsession4usingtechnology/

Educational technology can help to support language and communication, if it is used effectively. Practitioners need to decide what is appropriate for their children, their context and the content they are trying to teach.  This session talks about how to decide what technology is appropriate and provides some examples of devices and applications practitioners may like to try.

Authors: Emily Preston, Christine Jack, Cristina McKean, Sean Pert, Helen Stringer

Here is an update on the LIVELY project that has been shared with all the partner schools. We are currently busy analysing the data and will share more information once this is complete.

Authors: Christine Jack, Emily Preston, Elaine Ashton, Cristina McKean