What does a family who is "engaged" in early intervention look like? Perspectives of Australian speech-language pathologists

A randomised controlled trial of the effectiveness of parent-based models of language intervention for 2- to 3-year-old children with speech, language and communication needs (SLCN) in areas of social disadvantage

BACKGROUND

Early language delay is exacerbated by social disadvantage. Factors such as parents' low levels of literacy, confidence and self-perception can affect the capacity to act on advice received, critical to empowerment. Methods used to achieve successful health outcomes in socially disadvantaged clinical populations may need enhancing.

AIMS

To compare the impact of standard parent-based intervention (PBI) to enhanced PBI for young children with speech, language and communication needs (SCLN) and their families living in more socially disadvantaged populations.

METHODS AND PROCEDURES

A multicentre clustered blind randomised controlled trial was used to compare the effect of parent-based group interventions to improve early language development with children (mean age 27.5 months) from more socially disadvantaged populations with an expressive vocabulary of 40 or less single words. Intervention sessions were delivered by a speech and language therapist, over a 20-week period. Participants received one of two interventions: (1) Standard Care - indirect group PBI - (PBI) (2) Enhanced Care: indirect group enhanced PBI - (EPBI). Both standardised and non-standardised measures were used as outcomes. Parent engagement in the intervention was captured through analysis of attendance and the Parent Activation Measure - Speech & Language Therapy (PAM-SLT) (Insignia Health, 2014). The PAM measures a person's knowledge, skills and confidence to manage their own health and well-being (NHS England, 2018). In this study, activation referred to parents' knowledge, skills and confidence to manage their child's language development.

OUTCOMES AND RESULTS

One hundred fifty-five participants were randomised at baseline. Children in both groups made significant improvements in the outcome on MacArthur-Bates Communicative Development Inventories Sentence Length, from pre-intervention to post-intervention and 6 months post-intervention (p < 0.05). Changes in vocabulary and expressive language skills were more equivocal, showing wide variation in confidence intervals for both groups. Where parents attended at least one intervention session almost all effect sizes were in favour of the EPBI intervention. Parents' activation levels significantly increased for both groups (EPBI p < 0.001, PBI p = 0.003), with a moderate effect size in favour of EPBI (Hedges' G 0.37, confidence interval -0.02 to 0.76), although wide variation was found.

CONCLUSIONS AND IMPLICATIONS

This trial provides some evidence of facilitating the language development of children with SLCN from more socially disadvantaged areas through supporting caregivers. However, we found variation in outcomes; some children made excellent progress, whilst others did not. Further exploration of parent engagement and its relationship to child language outcomes will be valuable to understanding more about mechanisms of change in interventions that involve parents.

WHAT THIS PAPER ADDS

What is already known on the subject Speech, language and communication needs (SLCN) have a knock-on effect on emotional well-being, school readiness, literacy and school attainment, putting children at increased risk of long-term consequences such as poor literacy, mental health problems and unemployment. In disadvantaged areas, the prevalence of language difficulties is higher than elsewhere. Factors such as parents' low levels of literacy, confidence and self-perception can affect the capacity to act on advice received, critical to empowerment. What this paper adds to existing knowledge Children with SLCN from more socially disadvantaged areas can make improvements in their language development through parent intervention, although wide individual variation was found. There was some evidence that children achieve better outcomes with EPBI, which employed an interagency collaborative approach. Parent's engagement (activation levels) increased significantly over time with intervention, with the increase twice as big for EPBI. What are the potential or actual clinical implications of this work? This trial provides some evidence that it is possible to facilitate the language development of children from more socially disadvantaged areas through supporting their caregivers. Further research would be useful to determine whether increases in parent engagement are related to adherence to intervention and change in child outcomes.

Strategies Used by Professionals in Pediatric Rehabilitation to Engage the Child in the Intervention Process: A Scoping Review

AIM

To investigate strategies used by professionals in pediatric rehabilitation to engage children in every step of the intervention process, including assessment, goal setting, planning and implementation of the intervention, and results evaluation.

METHODS

A scoping literature review was conducted, and seven databases were searched, including CINAHL and MEDLINE, ProQuest Central, PsycINFO, Social Science Premium Collection, PubMed, and Web of Science. A citation search of included articles was completed. Predetermined criteria, quality standards, and PIO framework guided the selection process. Results were presented in relation to Self-Determination Theory (SDT) and the contextual model of therapeutic change.

RESULTS

In total, 20 studies were included in the review. Pediatric professionals reported that therapeutic use of self and their own engagement in the intervention facilitated the establishment of a supportive relationship. Providing clear explanations about their role and therapy rationale developed positive expectations. By making the child feel successful within-session and outside-session activities, professionals enhanced child mastery. Professionals' strategies were abstractly described.

CONCLUSIONS

Further research is needed to investigate strategies that are effective in the different steps of the intervention. More observational, longitudinal studies are required to capture fluctuations in in-session engagement.

Speech-language pathologists' practices and perceptions of parent involvement in paediatric services funded by the NDIS in Australia

Purpose: There has been concern that a shift in disability funding to the National Disability Insurance Scheme (NDIS) in Australia may have influenced paediatric speech and language intervention to involve parents less in service delivery. This study aimed to describe paediatric speech-language pathologists' (SLPs) practices and perceptions of parent involvement in NDIS-funded speech and/or language intervention.Method: Seventy-two paediatric SLPs currently practicing in Australia with NDIS-funded speech and/or language clients completed an online survey. The survey assessed SLPs' self-reported practices supporting parent involvement through Likert scale responses and included open-text questions about perceived barriers and facilitators in NDIS-funded intervention services. Results from the survey were analysed using descriptive statistics, significance testing, and thematic analysis.Result: The majority of SLPs indicated commitment to involving parents in intervention. Experienced SLPs used more family-centred practices and Department of Education (DE)-based SLPs used fewer. Barriers arose from SLP, parent, and workplace characteristics. Facilitators included communication and rapport building, utilising a family-centred model of service delivery, and parent characteristics.Conclusion: This self-selected sample of Australian SLPs utilised many techniques to facilitate parent involvement within NDIS-funded paediatric speech and language intervention. Results indicate NDIS-funded SLP services for families are family focused.

Family-centred practice in speech-language pathology practice with children and young people in out-of-home care in Australia: A scoping review

Purpose: Communication difficulties are more common in children or young people (CYP) who have lived in out-of-home care (OOHC) compared to the general population. Principles of family-centred practice (FCP) are frequently utilised by speech-language pathologists (SLPs) when working with CYP with communication difficulties. The aim of this scoping review was to describe how the principles of FCP are applied in the literature to speech-language pathology practice with CYP aged 0-18 in OOHC in Australia.Method: A scoping review protocol was applied to identify published literature related to Australian speech-language pathology practice with CYP in OOHC. Four databases were searched with no date limitations and five publications were included after quality appraisal.Result: Data extraction and thematic analysis identified several major themes: sharing information, liaison and working together, and responding to the CYP's behaviour as non-verbal communication to inform decision making. However, only one study referenced FCP explicitly.Conclusion: The review found that Australian SLPs are implementing FCP when working with CYP with communication difficulties in OOHC. However, scope for potential improvement was identified in the application of FCP principles with respect to the CYPs' birth parents and cultural representatives, as well as the goal setting and evaluation phases of the clinical cycle.

What do speech-language pathologists do to support families' active involvement in early intervention? Exploring moment-to-moment interactions in sessions

PURPOSE

There is growing emphasis on the importance of involving families in all aspects of the early speech-language pathology intervention process, however, both speech-language pathologists (SLPs) and families have reported that this can be challenging. To better understand how SLPs work together with families in intervention, this study aimed to (a) explore what SLPs do to support families to be actively involved in intervention, both inside and outside sessions, and (b) explore the perspectives of families regarding how SLPs supported their active involvement.

METHOD

Video-reflexive ethnography (VRE) was used to explore engagement with 21 matched SLP-family dyads in early intervention services. Up to three intervention appointments for each participating family were video recorded. Short video segments were selected and played to participants in individual semi-structured interviews where participants were invited to reflect on the interactions captured (i.e. "video-reflexive sessions"). Interview data were analysed using template analysis.

RESULT

Participants reported that SLPs supported families to be actively involved in sessions by (1) planning to involve families; (2) setting expectations; (3) modelling and teaching strategies; (4) inviting families to "have a go"; (5) providing feedback; and (6) problem solving together. Participants also reported that families were supported to be involved outside sessions when SLPs: (1) got them to practice in sessions; (2) made home practice achievable and provided resources; (3) asked about home practice; (4) linked home practice to progress; and (5) helped other family members get involved.

CONCLUSION

The results of this study provide an explicit understanding of how SLPs can support families to take an active role in early intervention, and support the importance of a reflective and individualised approach to supporting engagement.

A Systematic Review of Interventions for Late Talkers: Intervention Approaches, Elements, and Vocabulary Outcomes

PURPOSE

The aim of this systematic review was to examine the empirical evidence on interventions for late talkers between 18 and 42 months according to type of intervention approach (direct, indirect, and hybrid), reporting of intervention elements, and outcomes for receptive and expressive vocabulary.

METHOD

This review was registered with PROSPERO and followed Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Eleven databases were systematically searched with 34 intervention studies involving 1,207 participants meeting criteria. Studies were categorized as using a direct, indirect, or hybrid intervention approach, then examined according to intervention elements, vocabulary outcomes, as well as reported tools and type of score used to evaluate outcomes.

RESULTS

Across 34 studies, nine used a direct intervention approach, 10 an indirect intervention approach, and 14 a hybrid intervention approach. One study compared direct and hybrid intervention approaches. All indirect and hybrid approaches included parent training; direct approaches did not. The type and degree of reporting of other intervention elements, as well as the tools and type of score used to evaluate outcomes, varied within and across approaches. Overall, improvements in expressive vocabulary were reported by 93% of studies, with variable results for the nine studies reporting receptive vocabulary outcomes.

CONCLUSIONS

The direct, indirect, and hybrid intervention approaches were typified by specific intervention elements; however, there was diversity in how other elements comprising the approaches were arranged. When making decisions about which intervention approach to use, clinicians need to be mindful of the differences among approaches, how they discuss those differences with parents, and which approaches and elements might be best suited to individual children and their families.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21291405.

Co-constructing engagement in pediatric rehabilitation: a multiple case study approach

PURPOSE

To explore engagement principles and contextual conditions in high-engagement therapy sessions involving youth with disabilities and service providers.

METHOD

From a larger project on therapy engagement, a dyadic case analysis was conducted involving three youth ages 8-15 with disabilities and their service providers. Participants were interviewed about their engagement experiences after high-engagement sessions focusing on speech articulation, transition goals, and physical mobility. Data were analyzed thematically, with an emphasis on engagement principles illustrated by the cases.

RESULTS

There were four service provider engagement principles: (a) clients differ in what engages them and in how they display engagement (Individual Variation Principle), (b) there are multiple ways to engage clients (Personalizing Principle), (c) engagement is cultivated through relationship (Relationship Principle), and (d) it is important to monitor and be attuned to the client's level of engagement over a session (Monitoring Principle). Service providers' use of engagement strategies varied due to contextual conditions, including therapy type and youths' interests and preferences.

CONCLUSIONS

The findings indicate the value of providers' awareness of the dynamics of engagement, their use of personalized strategies to engage clients, and the fundamental importance of cultivating a good relationship and monitoring client engagement during therapy.IMPLICATIONS FOR REHABILITATIONService providers may benefit from being aware of common principles underlying the co-construction of engagement between service providers and clients.Service providers can use a variety of personalized strategies to heighten client engagement, and can work to cultivate a positive relationship.It is important to monitor clients' non-verbal and verbal signs of engagement and respond to signs of disengagement during therapy.Contextual conditions affecting service providers' use of engagement strategies include the nature of the therapy being provided and youths' interests and preferences.

Exploring the complexity of how families are engaged in early speech-language pathology intervention using video-reflexive ethnography

BACKGROUND

Despite being an important aspect of effective early intervention service delivery, 'engagement' has been inconsistently defined in paediatric healthcare. Previous research has identified that engagement in early speech-language pathology intervention is complex and multifaceted. However, more research is needed to understand the ways that different families may engage with intervention in different settings.

AIMS

To explore the complexity of engagement in early speech-language pathology intervention from the perspectives of both families and their speech-language pathologists (SLPs).

METHOD & PROCEDURES

Video-reflexive ethnography was used to explore engagement with 21 matched SLP-family dyads in early intervention services. Up to three intervention appointments for each participating family were video recorded. Short video segments were selected and played to participants during individual semi-structured interviews where participants were invited to reflect on the interactions captured (i.e., 'video-reflexive sessions'). Interview data were analysed using thematic analysis.

OUTCOMES & RESULTS

Results from the interview data were organized into one overarching theme 'Families may have "different levels of engagement"', and four individual themes that reflected how families engage differently in various aspects of intervention, including (1) attending sessions and coming into the room; (2) actively participating in sessions; (3) continuing to actively participate outside sessions; and (4) having open and honest communication with their SLPs.

CONCLUSIONS & IMPLICATIONS

Families may have different levels of engagement in various aspects of intervention, which contribute to their unique profile of engagement. Findings of this study prompt SLPs to move beyond using blanket statements about whether or not families are engaged, to instead describing in detail how families are uniquely engaged. What this paper adds What is already known on the subject In early speech-language pathology intervention, the term 'engagement' refers to (1) a complex, multifaceted state of families 'being engaged' in intervention both inside and outside sessions; and (2) a relational, co-constructed process where many families 'become engaged' in intervention as they work together with SLPs. Although research has acknowledged engagement may look different for each parent and family, little is known about how families are uniquely engaged in early speech pathology intervention in different settings. What this paper adds to existing knowledge This study is the first to explore engagement from the perspectives of both families and SLPs working together in intervention. Both groups of participants described the complexity of engagement in this setting and acknowledged that families engage differently in different aspects of intervention, which contribute to their unique profile of engagement. What are the potential or actual clinical implications of this work? Being able to identify potential indicators of engagement, such as the ones described in this study, provide opportunities for SLPs to take a reflexive approach to engaging with individual families, in line with principles of family-centred care. Findings of this study therefore prompt SLPs to reflect on how the families they work with are engaged in intervention, and to consider their own role in facilitating engagement. In addition, results highlight the importance of SLPs initiating open conversations with families themselves about how they would like to be engaged in intervention, and what support would be most beneficial to them.