CHAPTER IV - Intervention Methods for Young Children with Communication Disorders

INTERVENTION METHODS

This chapter provides evidence-based recommendations about appropriate interventions for communication disorders in young children. The panel used the available scientific evidence about the efficacy of specific intervention methods as the basis for developing these guideline recommendations. When such evidence was not available, guideline recommendations were made based on consensus opinion of the panel.

Evaluating the efficacy of interventions

Over the past decade, there has been an emphasis on outcomes research in the fields of health care, social services, and education. The primary focus of outcomes research is to evaluate how specific interventions affect functional outcomes for individuals and families. This is sometimes also known as treatment efficacy research.

A number of recent articles have systematically evaluated the research evidence on treatment efficacy of specific speech/language interventions for certain communications problems in adults (Holland, 1996; Conture, 1996) and in young children (McLean and Cripe, 1997). According to Olswang (1990), the goal of such treatment efficacy research for speech/language problems is to answer the following important questions:

1. "Does treatment work for this condition?"
2. "Does one treatment work better than another for this condition?"
3. "What specific target behaviors, associated with this condition, are altered by the treatment?"

When evaluating interventions for communication disorders, it is important that appropriate research designs be used to determine if the outcomes observed are clearly due to the intervention evaluated. Most young children, even those with communication disorders, show some improvement in speech and language abilities with time alone (this is often referred to as a maturation effect). Therefore, in evaluating the efficacy of a speech/language intervention for young children, it is important to determine if the intervention brings about improvement in a child's communication over and above what would be expected to occur by maturation alone.

Studies that have evaluated treatment efficacy of speech/ language interventions have tended to use either group study designs or single-subject study designs (McLean and Cripe, 1997). This guideline reviews treatment efficacy studies that use either of these types of study design, which are described briefly below.

Evaluating interventions using group study designs

In general, to demonstrate that a treatment is effective, the strongest evidence is provided by group studies comparing a group receiving a speech/language intervention to an equivalent group receiving no treatment (non-treatment control group). Group comparison studies that include a non-treatment group are able to control for potential bias due to maturation of the subjects.

Studies that evaluate two comparable groups receiving different treatments are useful for determining which treatments may work better. Some of these studies also include non-treatment control groups that may allow conclusions to be drawn about the overall effectiveness of each treatment. Group studies of speech/language interventions are most useful when they specify the characteristics of the children being treated and the specific intervention targets (such as grammar or vocabulary size) targeted by the intervention.

Evaluating interventions using single-subject study designs

Single-subject design studies of speech/language interventions are also useful in providing evidence about treatment efficacy (Ingham and Riley, 1998; McLean and Cripe, 1997). Single-subject design studies involve reporting data individually for each subject over time. Some single-subject design studies may report data for only one subject. However, it is considered more methodologically sound to present data for multiple subjects to evaluate if the treatment can be effective for more than one individual. For this guideline, a single-subject design study had to present data for at least three subjects to be considered adequate evidence about efficacy.

Single-subject design studies can be useful for demonstrating the overall effects of a given treatment and for investigating differential effects of individual components of a treatment program. Single-subject design studies also highlight individual differences in the effects of a treatment and can focus on the treatment's effect on specific target behaviors.

Strengths of the research literature on this topic

Recent research literature on speech/language interventions in young children that was reviewed for this guideline had many strengths. A reasonable number of well-designed scientific studies were found that evaluated speech/language interventions in young children using either group or single-subject research designs.

A number of these studies evaluated some children under 3 years old. Several other studies were reviewed that evaluated children who were slightly older than the target age group (studies that evaluated children age 4 to 6 years old) because the results were felt to be somewhat generalizable to children under the age of 3 years. In many studies, the age range of the subjects studied was fairly narrow, an important attribute since communication skills in young children can change rapidly over time.

Most of the studies used well-described assessment methods and/or appropriate standardized tests to measure both the child's baseline levels of communication skills and the outcomes of the interventions. Many studies provided detailed operational descriptions of the intervention methods. In addition, most of the studies used standardized language tests to evaluate outcomes of the intervention and took steps to control for bias in outcome assessment.

Many well-designed group studies compared outcomes for a group receiving a specific intervention with outcomes of groups receiving either no intervention or a different intervention. These studies also included appropriate measures to reduce bias and control for confounding factors in evaluating the studies' outcomes.

Many well-designed single-subject studies used various methods, such as multiple baseline designs, to ascertain if outcomes could be attributed to the intervention versus some other factors. Many of these studies also used multiple baseline approaches to determine if effects of an intervention would generalize to various subjects, behaviors, and conditions.

Limitations of the research evidence on this topic

There were also several limitations in many research studies evaluating speech/language interventions in young children. In a few studies, descriptions of intervention procedures were not detailed enough to allow others to correctly administer the therapy. In some studies, the interventions used were specific to the individual children studied rather than to standardized treatment procedures. Another problem cited by some researchers was the difficulty of acquiring and maintaining an untreated control group equivalent to the intervention group.

Weighing information on harms and costs

For all evidence-based clinical practice guidelines, the fundamental consideration when developing guideline recommendations is whether the evidence of potential benefits outweigh the evidence of potential harms enough to justify the costs of an intervention.

In evaluating the scientific evidence on the speech and language interventions for this guideline, the panel found that there were few, if any, direct (physical) harms associated with any of the interventions evaluated. For this guideline, the panel considered that the costs of an intervention method depend on the intensity, frequency, and duration of the intervention. Because these factors will vary greatly depending on the characteristics and progress of the individual child, the panel chose not to make global statements about costs for specific intervention methods. Therefore, the primary determining factor in developing guideline recommendations was evaluation of evidence about efficacy of the intervention.

Using scientific evidence as the basis for recommendations

For each speech/language intervention method evaluated, the panel considered both quality of the research studies reviewed and applicability of the findings to the guideline topic (intervention for communication disorders in children from birth to age 3 years old). When relevant and high-quality research evidence was found on the efficacy of an intervention, the panel used this evidence as the basis for guideline recommendations. When such scientific evidence about efficacy was not available, the guideline recommendations were developed through consensus opinion.

General Intervention Approach for Young Children with Communication Disorders

General Strategies for Intervention

Evidence Ratings :   [A] = Strong   [B] = Moderate   [C] = Limited   [D1] = Opinion/Studies do not meet criteria   [D2] = Literature not reviewed

Recommendations

Importance of early identification and intervention

1. It is important to identify children with communication disorders and begin appropriate interventions as soon as possible. Early intervention may help speed the child's overall language development and lead to better long-term functional outcomes. [D1]

Developing intervention strategies

2. It is important to remember that no one type of speech/ language intervention is the best for all young children. [B]

3. It is recommended that the type of intervention for a communication disorder in a young child be based upon an assessment of that child's specific strengths and needs. [D1]

4. It is particularly important to assess the child's pre-treatment developmental and language levels. [B]
5. An important goal of the initial stage of therapy is to verify and expand on the results of the initial assessment. [D1]
6. It is important that intervention goals be appropriate to the particular culture of the child and family [D2]

Selecting intervention targets

7. It is recommended that intervention targets for each individual child be clearly identified and defined with measurable outcomes and clear markers for mastery. [D1]

8. For a child to make progress in a particular component of language (such as grammar or pronunciation), it is important to focus intervention directly on that component, since improvement in one area may not necessarily generalize to improvement in other areas. [B]
9. For most young children with communication disorders, it is recommended that intervention focus first on increasing the amount, variety, and success of verbal and nonverbal communication and then, if necessary, on intelligibility. [D1]
10. While encouraging intelligible speech, it is important that progress not be slowed by focusing on speech productions that are not expected at the child's particular developmental level. [D1]
11. When speech intelligibility is significantly reduced or there are concurrent oral-motor deficits, it is recommended that intervention address these concerns. [D2]
12. For some children, it is recommended that intervention include attention to comprehension of words, sentences, and responses to commands as well as receptive identification of objects and pictures (both with and without contextual support). [D1]
13. When assessing or treating a child with a communication disorder, it is important to look for and adequately address any co-existing medical and developmental issues (such as gross motor delays, possible late-onset or progressive sensorineural hearing loss, or chronic ear problems such as otitis media). [D2]

Ongoing monitoring and appropriate modification of the intervention

14. It is recommended that any intervention be tied to ongoing assessment and modification of intervention strategies as needed. [D2]
15. It is recommended that no form of therapy be continued without documentation that the intervention is effective for the child. [D2]
16. Modification of intervention strategies might be appropriate when any of the following occur:

• target objectives have been achieved
• progress is not evident
• regression is noted
• there is an unexpected change in a child's behavior or health status
• there is a change in the intervention setting or the child's environment [D2]

Periodic comprehensive evaluation

17. In addition to ongoing monitoring and assessment, it is important to perform periodic comprehensive evaluations to assess the child's individual progress and to compare progress to age-expected development. [D2]
18. It is recommended that a comprehensive evaluation be performed at least on an annual basis. Depending on the instrument and the purpose, it may be appropriate to complete some types of assessments as often as every six months. [D2]

19. It is recommended that a comprehensive evaluation include appropriate standardized testing of the child's progress. [D2]

The Parents' Involvement in Intervention

Evidence Ratings :   [A] = Strong   [B] = Moderate   [C] = Limited   [D1] = Opinion/Studies do not meet criteria   [D2] = Literature not reviewed

Recommendations

Importance of parent involvement

1. It is important that, to the extent they are able and willing, parents be involved in the assessment and intervention for their child in order to understand:

• their child's language disorder

• intervention options and prognosis

• intervention goals, objectives, and methods [D2]

Level of parental involvement

2. It is recommended that decisions about the extent of parental involvement in interventions be made on a case-by-case basis and take into account:

• the parents' interest in and availability to participate in the intervention

• characteristics of the child's home environment

• the availability of training and professional support [D2]

3. It is important for parents to be involved in deciding their ability, availability, and willingness to participate in the intervention. [D2]

Teaching and directing parents to help with interventions

4. It is recommended that professionals teach specific techniques to parents to help facilitate their child's communication development. [B]

5. It is important to recognize that some parents can help provide intervention for their child provided that:

• adequate amounts of professional and parent time are allocated for parent training
• parents receive adequate direction from the professional
• there is ongoing monitoring of child progress by the professional [B]

6. It is recommended that the professional:

• work collaboratively with the parents to develop a home program
• elicit observations from the parents regarding the child's functioning
• share regular progress reports with the parents
• give parents regular feedback based on direct observation of the child
• help parents recognize and understand their child's verbal and nonverbal communication cues
• consider the cultural perception of the role of the family in treatment [D2]

The Professional's Involvement in the Intervention Process

Evidence Ratings :   [A] = Strong   [B] = Moderate   [C] = Limited   [D1] = Opinion/Studies do not meet criteria   [D2] = Literature not reviewed

Recommendations

Collaboration and coordination

1. It is important that there be ongoing communication and coordination of efforts among team members to accomplish agreed-upon intervention goals. [D2]

2. It is important that all professionals collaborate in coordinating and integrating techniques and approaches when working with the child and family. [D2]

3. It is recommended that the professional make some provision for regular communication and consultation with relatives, babysitters, and other child-care providers (such as daycare, toddler group, nursery school, or preschool) who function as caregivers of the child for significant amounts of time during the week. [D2]

Professional experience and qualifications

4. It is recommended that professionals involved in providing intervention services to young children who have a communication disorder have expertise and experience with infants, toddlers, and their families, and be qualified and appropriately credentialed under the professional practice acts of New York State. [D2]

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The Cultural Context of the Child's Environment

Evidence Ratings :   [A] = Strong   [B] = Moderate   [C] = Limited   [D1] = Opinion/Studies do not meet criteria   [D2] = Literature not reviewed

Recommendations

Importance of considering cultural context

1. A child's life is always embedded in culture. It is always essential to consider and respect the family's culture and primary language when providing interventions for children with communication disorders. [D2]

Determining the language to be used in the intervention

2. Although it is important to consider the parents' preference in determining the language used in the intervention, it is strongly recommended that any intervention be conducted in the primary language used in the home. This is important so that:

• natural interaction and communication can occur between child and parent at home

• the child can develop a firm foundation in a first language before any attempt is made to introduce a second language to the child [D2]

3. It is important that parent education and counseling, including written materials, be in the primary language of the family. [D2]

4. It is recommended that any direct speech/language therapy be conducted by a professional who is fluent in the language of the child and the family. [D2]

5. Because parent involvement is such an integral part of the development of speech and language of infants and young children, it is strongly recommended that professionals involved in parent education and training be competent in the language of the family and familiar with its culture. [D2]

Using a translator and/or cultural informant

6. If a professional fluent in the child's primary language is not available, it is recommended that a specially trained translator interpret for the professional providing the intervention during information sessions. [D2]
7. If the professional providing the intervention is not familiar with the culture of the family, it is important to have a cultural informant to advise the professional on issues that may cause misunderstanding during the course of therapy. [D2]
8. It is recommended that a person familiar with the culture and language of the family review intervention techniques and materials to determine if they are culturally appropriate. [D2]

Training a translator and/or cultural informant

9. It is recommended that interpreters assisting in the intervention process be trained by the professional providing the intervention to provide culturally and linguistically accurate interpretations of the child's behaviors and to participate in the specific intervention program. [D2}

10. It is recommended both that the components of interpreter/translator training include:

• a review of the intervention materials
• a discussion of the procedures
• a demonstration of the techniques to be used [D2]

11. If the interpreter serves as a cultural informant to advise the clinician on the cultural appropriateness of intervention materials or techniques, it is important that the interpreter be trained to administer stimuli accurately, judge the child's response, and make or suggest modifications in procedures when appropriate. [D2]

Major Approaches for Speech/Language Interventions

Speech and language interventions for young children with communication disorders include a variety of methods and approaches. Some interventions are focused directly on the child (often called direct interventions). Other interventions focus on teaching intervention skills to the parent or another individual who then works with the child (often referred to as indirect interventions).

Of the interventions that focus directly on the child, some involve working with the child in individual therapy sessions in which the therapist works one-on-one with the child, either alone or in a setting which includes other typically developing children. This type of intervention can occur in the home (a home-based program) or at some other location (such as professional's office, school, daycare, or community setting).

The choice of setting for individual speech/language therapy will depend on a variety of factors relating to the individual child's needs and family situation. These factors might include age and developmental level, the type and severity of the communication disorder, other developmental deficits or medical problems, the family's interest in and ability to participate in the intervention, the cultural context of the child and family, and the language used by the child and family.

Other interventions involve working with children in a group setting in which there are two or more children receiving similar interventions. Group interventions range from groups as small as two children to large classroom settings. In this guideline, group speech/language interventions are defined as interventions that involve a professional working with two or more children. The size, participants, and structure of the group may vary depending on the needs and abilities of the child, intervention techniques, and the setting. Some group interventions may include parents as well as children.

Group interventions may occur in a clinical, classroom, or community setting (such as the professional's office, day care, or preschool). More informal settings might include opportunities for children to interact at library or recreation programs. In somewhat older children, group interventions may take place in a preschool setting. Group interventions in preschool settings may be either specialized classes for children with developmental disorders or they may include peers with normal language development.

The studies reviewed as evidence to develop recommendations in this section evaluated both group and individual interventions for populations of children with different types of communication disorders. Some were studies of children with speech or language delay; some studies looked at children with specific language impairment, and other studies evaluated children who had a communication disorder associated with other developmental problems.

Individual Speech/Language Therapy Approaches

Evidence Ratings :   [A] = Strong   [B] = Moderate   [C] = Limited   [D1] = Opinion/Studies do not meet criteria   [D2] = Literature not reviewed

Recommendations

The role of individual speech/language therapy in treating communication disorders

1. Individual speech/language therapy (either as a sole intervention or in combination with group interventions) may be useful in treating young children with communication disorders. [B]

2. Individual speech/language therapy may be especially important at the beginning stages of treatment as specific targets are established and as the child becomes accustomed to the professional and use of particular techniques. [D1]

3. It is important to consider that individual speech/language therapy as the sole intervention method may produce less generalization of language skills to other situations than group interventions that involve multiple conversational partners. [B]

Working collaboratively with parents

4. It is important that professionals conducting individual speech/language interventions:

• establish good communication and rapport with the parents and family

• work collaboratively with the parents in deciding on the targets of the interventions and in monitoring progress

• provide opportunities to include parents in individual speech/language therapy sessions [D1]

Factors to consider when choosing individual treatment strategies

5. When choosing the intervention strategy for individual therapy sessions, it is important to consider a variety of factors relating to the individual child and family situation:

• the child's chronological age and developmental level

• the type and severity of the child's communication disorder

• other developmental deficits or medical problems

• strengths and interests of the child

• other therapies the child is receiving

• the family's interest in and ability to participate in the intervention

• language used by the child and the family

• community resources [D2]

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Group Speech/Language Therapy Approaches

Evidence Ratings :   [A] = Strong   [B] = Moderate   [C] = Limited   [D1] = Opinion/Studies do not meet criteria   [D2] = Literature not reviewed

Recommendations

Using group speech/language interventions

1. Depending on the age and language development level of the child, speech/language intervention in a developmentally appropriate group may be useful for young children with communication disorders (either as a sole intervention or in combination with individual therapy). [B]

2. It is important to recognize that the specific intervention techniques are often similar for both individual and group intervention settings. [D2]

3. Group speech/language interventions are useful to facilitate generalization of language skills to other settings. In contrast, interventions provided directly by a professional in individual therapy sessions may be more useful in establishing the structural aspects of language. [B]

4. For children participating in group interventions, it may be useful to add individual sessions to establish structural aspects of language. This may be particularly useful for children from 24 to 36 months. [D1]

Including parents in group interventions

5. It is important to provide opportunities for including parents in speech/language group interventions for young children because these may help:

• provide parents with support, information, and education to enhance communicative development

• facilitate generalization of the child's language skills to other settings [D1]

Selecting the type of group intervention

6. The type of group speech/language intervention which is most appropriate and useful depends upon the age (or developmental level) of the child:

• For children younger than 18 months, it is recommended that parents be active participants in the group intervention process.

• For children 18 to 24 months, it is useful to include parents in group interventions, but for some children in this age range group interventions may be useful even if their parents are not present.

• For children 24 to 36 months, small group interventions under direction of a professional may be useful. [B]

Including typically developing peers in group interventions

7. It may be useful to include typically developing peers in group interventions for young children with communication disorders because they provide an important source of language stimulation. [B]

8. Having a young child with a communication disorder interact in developmentally appropriate play settings with normal language peers can be useful in stimulating the child's language development. [B]

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Formal Parent Training Programs

Parent training, as the term is used in this guideline, refers to a formal program in which a professional instructs parents in strategies and methods for enhancing their child's speech and/or language development. Formal parent training programs provide an opportunity for parents to take a more primary role in implementing speech/language interventions for their child.

Most of the formal parent training programs evaluated by the panel and used as the basis for recommendations included group training sessions to teach parents general strategies and approaches as well as sessions in which professionals met individually with the parents of each child. In the individual sessions, professional demonstrated techniques for individualizing the interventions to the child and provided feedback on the parents' implementation of these techniques. One of the programs involved only individual training sessions with parents in the home.

Evidence Ratings :   [A] = Strong   [B] = Moderate   [C] = Limited   [D1] = Opinion/Studies do not meet criteria   [D2] = Literature not reviewed

Recommendations

The role of formal parent training programs

1. It is important to recognize that some parents can be successful primary intervention agents, provided that:

• a professional qualified to provide speech/language interventions consults with the parent on a periodic basis

• adequate amounts of professional and parent time are allocated for parent training

• there is ongoing monitoring of the child's progress by the professional providing consultation to the parent [A]

2. Formal parent training programs are strongly recommended for parents who serve as primary intervention agents for their child with a communication disorder. [A]
3. Formal parent training programs may also be useful for parents whose children are involved in either individual or group speech/language therapy (where the parent is not the primary intervention agent). [D1]

Components of parent training

4. It is strongly recommended that parent training programs include:

• instruction regarding general techniques and approaches as well as ways to individualize intervention methods to their own child's needs

• direct instruction in the treatment approach and the specific targets of the intervention

• demonstrations of the specific intervention techniques

• feedback on implementation of intervention techniques with their child [A]

5. It is recommended that parents be taught specific techniques to help facilitate their child's communication development. These techniques may include:

• the promotion of communicative interaction
• modeling of target communicative behaviors
• the use of child-oriented strategies [A]

Discussing intervention targets with parents

6. In discussing intervention targets with parents, it is important that the professional providing the intervention emphasize the following considerations:

• Focusing the intervention first on increasing the amount, variety, and success of verbal and nonverbal communication and then, if necessary, on intelligibility

• While encouraging intelligible speech, it is important that progress not be slowed by focusing on speech productions that are not expected at the child's particular developmental level [D1]

Assessing outcomes of parent training programs

7. As part of ongoing monitoring of the child's progress, it is recommended that the professional providing the intervention periodically assess outcomes of the parent training program using both:

• direct measures of the child's behavior

• information provided by parents [D1]

8. It is recommended that assessment of outcomes from parent training programs include measures of:

• changes in the parents' communication patterns when interacting with the child

• the child's progress in meeting specific language targets as well as the child's overall progress in communication [D1]

9. It is important for the professional providing the intervention to monitor the child's progress closely and modify the intervention strategy if progress is not being made as expected. [A]

Chapter IV (continued)

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