A comparison of three approaches to delivering a speech and language therapy service to people with learning disabilities

Is speech and language therapy effective at improving the communication of adults with intellectual disabilities?: A systematic review

BACKGROUND

A significant proportion of adults with intellectual disabilities (ID) experience speech, language and communication difficulties which are associated with poor physical and mental health outcomes. Speech and language therapy (SLT) interventions are an important way to address these communication difficulties, yet there is limited available evidence to provide information about the effectiveness of the different approaches used for this heterogeneous group.

AIMS

To review the evidence available for the effectiveness of SLT interventions aimed at improving communication for adults with ID.

METHODS & PROCEDURES

A systematic search across relevant databases was performed. Information on methodological details of each relevant study, along with descriptions of the SLT interventions employed, were extracted and the Crowe Critical Appraisal Tool (CCAT) was used to assess quality. Findings were discussed in a narrative synthesis grouped by target communication skill.

OUTCOMES & RESULTS

A total of 10 relevant studies met the inclusion criteria. These were predominantly interventions aimed directly at adults with ID to improve speech, increase augmentative and alternative communication (AAC) use and develop interaction skills, with one study addressing work with carers. The included studies were all rated as low quality. There is weak preliminary evidence that SLT input can improve the communication skills of adults with ID.

CONCLUSIONS & IMPLICATIONS

There is insufficient evidence to draw strong conclusions about the effectiveness of SLT in this population. Further high-level evidence across speech, language and communication domains is urgently needed. What this paper adds What is already known on the subject There is limited evidence for community health interventions used with adults with ID. Previous reviews of SLT interventions found a lack of evidence base for this population. Some areas of SLT practice such as AAC have demonstrated potential benefits and other areas including speech work, social communication skills and training for communication partners have some evidence base for children with ID but there is currently insufficient evidence for adults with ID. What this paper adds to existing knowledge The study systematically reviews the current evidence base available when considering the effectiveness of SLT intervention for adults with ID. It provides weak evidence to suggest SLT intervention can improve communication in this population and highlights the need for clinically relevant, robustly designed studies to be undertaken in this field. What are the potential or actual clinical implications of this work? The lack of high-quality studies with sufficient power to draw conclusions about effectiveness means SLTs are not able to base their intervention choices on firm evidence. There is an urgent need to conduct robust research into the effectiveness of SLT interventions for adults with ID.

Training Direct-Care Staff to Provide Communication Intervention to Adults With Intellectual Disability: A Systematic Review

PURPOSE

The aim of this review was to summarize and evaluate studies on training direct-care staff to provide communication intervention to adults with intellectual disability.

METHOD

Systematic searches identified 22 studies. These were summarized and evaluated in terms of (a) participants; (b) settings; (c) training aims and procedures; (d) research designs; (e) reliability, integrity, and social validity; (f) outcomes; (g) generalization and follow-up; and (h) certainty of evidence.

RESULTS

A total of 437 staff and 254+ adults with intellectual disability participated. Staff training most frequently involved combinations of verbal instruction, role play, modeling, practice, and feedback. Reliability was assessed in 18 studies with acceptable standards for most of these studies. Treatment integrity and social validity were assessed in 1 and 3 studies, respectively, with positive outcomes. Generalization and maintenance were assessed in 5 and 8 studies, respectively, with predominantly positive outcomes. Most studies reported positive outcomes for staff and positive or mixed outcomes for the adults with intellectual disability. Certainty of evidence was rated as conclusive in 1 study, suggestive in 14 studies, and inconclusive in 7 studies.

CONCLUSIONS

There is sufficient evidence to conclude that direct-care staff can be taught to provide effective communication intervention to adults with intellectual disability. Professionals involved in providing training and support to direct-care staff could expect positive outcomes from multicomponent training programs that include opportunities for practice and feedback.

An investigation of speech and language therapy to improve the communication environment of people with severe learning disabilities who have communication difficulties and behaviours that challenge services

The need to understand the role of communication in triggering, maintaining or exacerbating challenging behaviour is crucial when working with a client group with severe learning disabilities. Speech and language therapists are becoming increasingly involved in this process. The Royal College of Speech and Language Therapists (RCSLT 1996), recommend that the most appropriate form of intervention includes:

I. facilitating carers in the understanding of the nature and causes of challenging behaviour, particularly in relation to communication

2. facilitating carers in understanding the role of the environment and their own communication in relation to the clients challenging behaviour

3. facilitating carers in developing more appropriate ways of communicating with clients with challenging behaviour

4. Supporting carers in developing appropriate activities for the client (RCSLT I996)

This project used the above principles to investigate the effect of speech and language therapy on the communication environment in a home for people with learning disabilities and challenging behaviour. The results show an increase in: the length of interactions initiated by the staff with the service users; the use of non- verbal communication to support interactions and a decrease in the number of attempts the service users needed to make before a staff response was given. The author concludes that speech and language therapy was effective in improving the communication environment. The impact of the improved communication environment on challenging behaviours was not measured.

The Kirkpatrick model: A useful tool for evaluating training outcomes

BACKGROUND

Services employing staff to support people with disability usually provide training in a range of areas including communication and managing challenging behaviour. Given that such training can be costly and time-consuming, it is important to evaluate the evidence presented in support of such programs. Efficacy in clinical practice is measured using evidence-based practice. However, there is currently no model that is widely used to compare and evaluate training programs despite the large number of training programs reported each year.

METHOD

Six studies published in the last decade that reported the outcomes of communication-based training and six that reported on the outcomes of challenging behaviour training were evaluated using the 4-level Kirkpatrick model.

RESULTS

Comparison of the levels of evidence is made for these 12 studies.

CONCLUSION

The Kirkpatrick model provides one technique for appraisal of the evidence for any reported training program and could be used to evaluate whether a training program is likely to meet the needs and requirements of both the organisation implementing the training and the staff who will participate.

Communications between staff and adults with intellectual disabilities in naturally occurring settings

Videotapes were made of 43 staff-client dyads in small-scale residential and day service settings. Frequency counts were made of carers' communicative acts, and two experienced speech and language therapists rated these for appropriateness. Recommendations for enhancing communication were also noted. The results showed that clients were presented with few opportunities to engage as equal partners in the conversational interchanges: staff overly relied on verbal acts, even when they were communicating with predominantly non-verbal clients; they tended to favour the use of directives and questions, and the majority of staff failed to adjust their language to the client's level of understanding. The most commonly recommended changes for staff were to use simpler sentences and words, to increase their use of non-verbal signals and open questions, to provide more opportunities for clients to initiate topics, and to increase their responsiveness to client's non-verbal signals. The explanations for staff behaviour are reviewed and the implications for changing practice are discussed.

Communication skills workshops in learning disability nursing

This article investigates the effects of a combination of direct speech, language therapy and staff training on the communication skills of nursing and support staff working with people who have a severe learning disability and challenging behaviour. The approach aimed to help staff choose, prioritize and implement changes in communication. The input was effective in increasing the knowledge of the staff group with regard to challenging behaviour and communication breakdown, and in changing the communicative behaviour of staff. The changes measured were those of longer interactions occurring between staff and service users, and the use of non-verbal communication to support interactions. The implementation of the communication strategies is being audited.