Child Talk phase 1 Aim
Chapter 2 The development of a typology of speech and language therapy practice
Introduction
The aim of phase 1 of the Child Talk study is to develop an evidence-based typology of SLT-led
interventions for preschool children with PSLI that also incorporates the experiences and views of families. An underpinning assumption of the research programme is that EBP is a three-pronged approach, requiring external systematic evidence, applied appropriately with expertise by therapists and in line with
patient preferences.50,56,69This chapter reports the findings of an investigation into the reported practice of
SLTs and is therefore the main chapter focusing on the clinical expertise element of EBP. The chapter first presents a typology of practice, that is, a set of themes that capture all SLT-led interventions for preschool children with PSLI. Further investigations led to the identification of specific interventions associated with the individual themes of practice. The analysis also identified a number of factors that lead to the modification of interventions. The key factors that may impact on clinical practice and policy and which require further research are drawn together in the discussion section.
The definition of EBP suggests that practice should start with the research evidence base, which is then applied to individual cases. However, practice more commonly starts before explicit research evidence is available and thus precedes research. Therapists are frequently working with children who present with complex impairments that may not necessarily have been described in the research evidence base and are thus having to construct novel combinations of interventions to meet individual child and family needs. Furthermore, as indicated in Chapter 1 (see Introduction), one of the potential barriers to the
implementation of EBP is that research does not easily map onto therapists’ existing theories of practice.
Therefore, it is helpful to understand and describe existing practice first so that research evidence can be analysed and mapped more closely onto current practice. For this reason, this research programme set out to describe the practice element first.
Descriptions of interventions in research literature vary in the level of detail provided. Indeed, a criticism levelled by reviewers of intervention studies is that it would be difficult to replicate studies because of the dearth of detail about interventions. Nonetheless, the literature does provide suggested models for how
interventions might be described. Yoder and Kent110collected assessment and intervention decision trees
that modelled the decision-making process employed by therapists when planning an intervention.
One of the decision trees cited in Yoder and Kent110sets out important factors to consider in planning
interventions for children with language impairments, suggesting that therapists should determine
linguistic input, the intervention context and the training technique. More recently, McCauley and Fey111
provided a description of seven processes involved in language intervention: the goals, the context, the
agent, the dose, the procedures, the‘goal attack’ strategy and finally the intervention activities. McCauley
and Fey111suggest that using such a model allows practitioners to identify the constituent parts of an
intervention and compare and contrast these across interventions. However, these models have not translated into a standard way of reporting interventions in the research literature. An exploration of
current practice included in the BCRP89found that participants referred to more than 150 different
interventions, including published interventions, programmes, theories of intervention and training
packages. Summarising the literature, Roulstone et al.89noted that interventions had been variously
described as actions, techniques, activities and procedures that were used to facilitate progress, prevent other problems, modify barriers and facilitate changes to the communication environment.
To provide a description of practice in this study, the aim was to develop a typology of SLT-led
interventions.‘Typology’ in this study is used to denote a systematic description of the characteristics, or
components, of practice that are used with preschool children with PSLI. The collection of data and process of analysis have been iterative, whereby the findings from one set of data collected have informed the next. Thus, the detailed structure of the typology evolved as the study progressed. Our starting point was to ask SLTs what they did with preschool children with PSLI. From their descriptions, a thematic analysis generated themes that typified the overall aims of their work. These themes formed the initial structure of the typology; all of the other studies within the research programme gradually converged on this typology, expanding the structure until a final framework was developed that encompassed the work of SLTs with this group of children. The themed descriptions of SLT-led practice do not represent similarly weighted components; some are described in greater detail than others, whereas some have a level of explicitness that is not present in others. As such, this typology can be regarded as only the beginning of a typology of SLT-led practice. However, it provides an initial framework that can be used to generate other hypotheses about practice, and also highlights the gaps in the knowledge and evidence base.
As the one of the objectives of this research programme was to understand the components of interventions, the focus has been on intervention activities and strategies rather than on published programmes or resources. Although resources and materials might be important to the success of an intervention (e.g. in terms of adding motivational value), it is the role that a resource plays in the intervention rather than the resource itself that is important. On the other hand, intervention programmes include a whole range of activities and strategies and thus need some deconstruction to identify the
individual components. The definitions used by Roulstone et al.89were used in this research programme to
differentiate activities and strategies:
l activities– specific tasks that are usually targeting a specific impairment, for example using minimal
pairs activities
l strategies– general techniques used in interaction with children that might target at the level of
impairment, activity or participation and could be used to deliver or support a specific activity such as modelling, for example examples of correct speech or language productions provided for the child. One of the concerns in focusing on clinical expertise is the issue of how far the practice described is
idiosyncratic and how far it is part of a body of knowledge.63As suggested in Chapter 1 (see Introduction),
the theories of practice that practitioners develop might seem to be particular to each individual practitioner. However, within a knowledge community such as the speech and language therapy
community, the knowledge base is built up over time through knowledge sharing, hypothesis formulation
and experimentation. Variation in practice is probably inevitable; however, Roulstone112found that
consensus seemed to be present regarding underlying theories but variation in therapists’ practice occurred
at the point of implementation of underlying theories and represented procedural interpretations. This research programme determined to investigate levels of consensus as part of the process of describing practice. To some extent, features of practice that give rise to consensus can be viewed as being validated by the profession. Features that vary may be an indication of changing practice, in which innovation is occurring or a particular practice is being phased out. An important caveat, however, is that consensus
cannot be equated with efficacy;63belief systems built up between groups of professionals are no
guarantee that the practice concerned is safe, or effective, as some notable medical research has proven
recently. An example is Spock’s113bestselling book, which became a bible for both professionals and
parents, advising that babies should sleep on their front. Later empirical studies, however, found that there is a significantly increased risk of sudden infant death syndrome associated with infants sleeping on their abdomens. Examples such as this demonstrate that systematic research is needed to confirm and challenge professional practice.
Objectives
The research presented in this chapter contributes to addressing the following Child Talk objectives:
l to determine current evidence, practice and user perspectives with regard to SLT-led interventions for
preschool children with PSLI
l to develop a model(s) of intervention that can integrate current evidence, professional expertise and
family perspectives in ways that allow the intervention to be individualised to children’s and families’
communicative, physical, social and cultural contexts.
Specifically, this chapter describes the current practice of SLTs for preschool children with PSLI, providing a typology of practice (see Study 2.1: identifying the themes of speech and language therapy practice) and interventions related to it (see Study 2.2: identifying the interventions used by speech and language therapists). Factors that give rise to SLTs’ selection of particular interventions are also described; in particular, the chapter explores the levels of consensus and variation within the profession regarding the use of the interventions by SLTs in practice.