Child Talk phase 1 Aim
Study 2.1: identifying the themes of speech and language therapy practice
This study aimed to identify the principles and characteristics that are central to therapy for preschool children with PSLI to form a typology of SLT practice. The development of the typology was based on three data sets collected from SLTs in England: focus groups, regional SIG events and national events. Data collection activities were iterative, with findings from earlier activities informing subsequent data collection
activities, which went on to refining the themes and exploring consensus and SLTs’ practical application of
the typology. The data revealed nine themes that encompass SLTs’ practice and these themes form the
basis of the typology.
Research questions
1. Can the key characteristics of SLT-led interventions with preschool children with PSLI be mapped into a coherent theoretical model/framework (typology)?
2. What is the range of opinion, disagreement and consensus around key principles and components and
outcomes of SLTs’ practice?
3. Is the typology generated by the research feasible, acceptable and applicable to a national sample of SLTs?
Methodology summary
A summary of the methods is shown in Figure 8; these are described in detail in Chapter 1 (see Methodology overview).
Findings
A thematic analysis of the SLT focus group data initially generated 10 themes that sought to represent therapy aims or what SLTs are trying to achieve through their intervention with preschool children with PSLI. These 10 themes, which formed the first draft of the typology, are shown in Table 12. A more detailed description of the original thematic analysis, with illustrative quotes, can be found in Appendix 25. A number of adjustments were made to the draft typology and the original 10 themes following the SIG and national events using a process of constant comparison Table 12 also summarises the alterations made subsequent to the SIG and national events.
Identification of the themes of SLTs’ practice (typology)
Data were collected from SLTs (n = 40) at focus groups undertaken at six case study sites in England. The focus groups explored:
• the interventions SLTs use with preschool children with PSLI • the ways in which SLTs modify interventions
• the rationale for using these interventions
Data were analysed using thematic analysis with the focus on ‘What is the purpose of therapy?’
See Chapter 1, Speech and language therapists
Consensus on the description of the themes and their relationship Data were collected from SLTs at regional SIGs which explored:
• whether or not there were gaps in the themes identified at the focus groups, n =64
• consensus on whether or not the themes were essential, desirable or never used by the SLT participants, n =64
• how the themes fit together (modelling), n =64
• how the SLTs would describe the themes to a parents (how SLTs interpret the themes), n =37
Data were analysed quantitatively (voting) and qualitatively (constant comparison) See Chapter 1, Specific interest groups
Refining the typology and exploring its applicability to SLTs’ practice Data were collected from SLTs (n =86) at two national consensus events which explored:
• any gaps in the typology, the naming of the themes and boundaries between the themes (need for merging/expanding)
• whether or not the typology themes could be applied to preschool children with PSLI (using case study vignettes)
Data were analysed quantitatively (voting) and qualitatively (constant comparison) See Chapter 1, National consensus events
FIGURE 8 Summary of the methodology used to develop a typology of SLTs’ practice.
TABLE 12 The original themes identified and their new labels
Original theme Theme label subsequent to SIG and national events
Sound awareness Speech
Speech/articulation
Comprehension Comprehension
Structure/content Expressive language
Self-monitoring Self-monitoring
Generalisation Generalisation
Foundation skills Foundation skills
Child participation Functional communication
TABLE 13 The nine themes that characterise SLTs’ practice
Theme Characteristics
Speech Therapists described work that increases the accuracy of speech production or articulation, often focusing on specific sound(s). Therapists described a range of activities to work on speech, with work on phonological awareness being integral to this. Phonological awareness activities might include auditory bombardment, syllable counting, discrimination of sounds such as front and back sounds and minimal pairs. Production of speech sounds included activities such as drilling single sounds, working in hierarchy of sound production (C, CV, CVC), cued articulation and blending
Comprehension Therapists described work that aims to improve the children’s understanding of (receptive) language. Interventions in this area might overlap with work that focuses on expressive language, for example vocabulary development. Therapists predominantly described comprehension tasks that focused on following directions and information-carrying word activities
Expressive language Therapists described work that aims to improve the children’s expressive language, in quantity, vocabulary or structure. Therapists reported using a wide range of activities that fit into this category. For instance, work might focus on producing single words, putting words together, other aspects of grammar and morphology or learning new vocabulary, including verbs
Self-monitoring Therapists described work designed to help the children’s awareness of their speech and language difficulties and how they might be able to overcome them. Work that therapists described included some specific strategies for self-monitoring such as token systems as well as more general activities such as discrimination, which aim to encourage children to reflect on their speech and self-correct or repair a communication event
Generalisation Therapists described work to help make speech and language or therapy gains transferable to other situations and environments. Therapists rarely referred to specific activities to enforce generalisation; however, they referred to the importance of parents and other adults working with the child to use activities and strategies in different contexts to encourage generalisation
Foundation skills Therapists described work to practise and improve a range of early skills, many of which might be considered foundations for speech and language development. Activities that therapists reported using to support foundation skills included work on turn taking, play, attention, selective attention and listening; they also described work on non-verbal and social interaction skills
Functional communication Therapists described work focusing on those aspects of communication that help the child’s involvement and participation in life situations; this might be functional language, signing or the use of symbols. A wide range of relevant interventions emerged including materials and resources that help children to access language and‘make their needs known’, as well as those designed to prepare children or help them cope in life situations Adult understanding and
empowerment
Therapists described work that helps parents to understand the nature of their child’s speech and language difficulty, what helps to improve it and why. An important aspect of this is a parent’s or adult’s understanding that he or she is a ‘major tool of change’ (SLT_099). Therapists rarely reported using specific activities or tools to do this but the process of providing explanations for those in regular contact with the child (parent, carer or EYP), either in clinical sessions or training sessions, appeared to be a feature of everyday practice. Therapists referred to‘changing parent’s perception’ (SLT_106)
Adult–child interaction Therapists described work on the interaction between the parent/adult and the child. All of the changes to adult/parent–child interactions were emphasised in terms of those that encourage speech and language development. These interaction strategies range from things such as sitting and playing with the child or following the child’s lead to commenting on the child’s activities or reducing the number of questions asked of the child. Therapists also referred more generally to the importance of improving the ‘communication environment’ (SLT_095)
Building consensus on the typology themes
We wanted to explore with SLTs at the SIG and national events whether or not the draft typology was comprehensive and relevant to the work that they do. We also aimed to build consensus over adaptations to the draft typology that would lead to the final typology. The following sections present data that aimed to explore the validity of the draft typology.
Speech and language therapists at SIG events were asked whether they considered the 10 themes in the typology to be essential, desirable or not used in their work with preschool children with PSLI. Table 14
presents the findings of this exercise. Of the 64 therapists who completed this activity, 80% (n= 51)
indicated that they thought that the themes covered all aspects of their work with preschool children with PSLI.
The pattern of response was similar across the four events. For seven of the themes, all participants
agreed that they would be either essential or desirable to their work. Of the 10 themes,‘self-monitoring’
and‘speech’ achieved the lowest level of agreement that these were essential to the work. Some
participants provided explanations for not working on certain areas, for example‘speech’ work was seen
as being relevant only with older preschool children and not all SLTs worked with these older children. ‘Self-monitoring’ work was frequently associated in the discussions with ‘speech’ work and therefore similar explanations for its lack of use were given. Despite this, there was general agreement that these
two themes were legitimate parts of the SLTs’ practice with preschool children.
Explaining the themes
We next wanted to explore whether or not the initial descriptions of the typology themes were robust, inclusive and able to be accurately interpreted by SLTs. We also required the descriptions of the themes to be understandable by lay audiences. To gauge these factors, participants at the SIGs were asked to
describe how they would explain each theme to a parent. To establish SLTs’ ability to accurately interpret
the typology themes, descriptions were reviewed for their consistency, that is, the extent to which SLT descriptions were similar to, expanded or were different from the descriptions that we provided.
TABLE 14 Reporting of typology themes by SLTs as‘essential’, ‘desirable’ or ‘not used’ (n = 64)
Theme Essential, n (%) Desirable, n (%) Not used, n (%)
Speech/articulation 36 (56) 27 (42) 1 (2) Sound awareness 40 (63) 24 (38) 0 Comprehension 57 (89) 6 (9) 1 (2) Structure/content 53 (83) 11 (17) 0 Self-monitoring 26 (41) 32 (50) 6 (9) Generalisation 56 (88) 8 (13) 0 Child participation 55 (86) 9 (14) 0 Foundation skills 57 (89) 7 (11) 0 Empowering/understanding of parents/adults 59 (92) 5 (8) 0
Thirty-seven participants at SIG events completed explanations of the themes for parents. Of these, 26 provided a description for all 10 themes. For all themes, the majority of participants provided explanations that were consistent (i.e. either the same or expanded) with the given definition. However, some participants wrote explanations that were different in some way for all of the themes except comprehension. These discrepancies consisted of:
l confusion with/or inclusion of another theme
l emphasis on a concept not previously included in that theme
l poor definitions.
Table 15 indicates the numbers of participants who provided written explanations that were very close in content to the original definitions that the team provided (Child Talk definitions), the numbers who expanded on the definitions and the numbers who provided different definitions. Decisions about whether the definitions were the same, expanded or different were made by two members of the research team, who were also qualified SLTs.
Vignette exercise (final validation)
As a next step we wanted to establish whether SLTs were able to describe their interventions in relation to the typology themes. Participants attending the national events were asked to indicate the interventions used for each theme of the typology for a child from their caseload. Responses were received from 62 participants. The responses of participants were analysed by SLTs from the research team. Responses were explored for consistency of the interventions with the theme descriptions, that is, the extent to which interventions were deemed relevant to that theme. This was used as a form of validation of the themes and their descriptions. This exercise also intended to establish if the typology themes were comprehensive, that is, if SLTs were able to describe all of their work in relation to the themes.
TABLE 15 The similarity of the SLTs’ definitions of the themes to the Child Talk definitions (n = 37)
Theme Expansion of definition, n (%) Similar definition, n (%) Different definition, n (%) Total n Speech/articulation 13 (46) 6 (21) 9 (32) 28 Sound awareness 20 (69) 3 (10) 6 (21) 29 Comprehension 25 (83) 5 (17) 0 30 Structure/content 13 (39) 8 (24) 12 (36) 33 Self-monitoring 9 (29) 14 (45) 8 (26) 31 Generalisation 15 (45) 14 (42) 4 (12) 33 Foundation skills 17 (50) 14 (41) 3 (9) 34 Child participation 9 (35) 6 (23) 11 (42) 26 Empowering/understanding of parents/adults 9 (32) 16 (57) 3 (11) 28
Table 16 reports the number of therapists who provided intervention information in relation to each theme. It also provides information on the number of therapists who explicitly stated that a theme was not applicable to the work that they did with that child. Missing data, that is, when the total number of
responses for any theme is< 62, reflect the fact that some SLTs did not provide intervention information or
report that the theme was not applicable to their work.
The largest number of responses from SLTs was under the theme of‘adult understanding and
empowerment’ (n = 60). The theme with the least number of responses was ‘self-monitoring’ (n = 31),
closely followed by‘comprehension’ (n = 35). Reasons reported for not working on these areas included
that these areas were still being monitored or that they had not been worked on to date with that particular child.
All themes had relevant or consistent interventions reported for them. Most SLTs provided examples of
interventions that matched the existing descriptions of the themes. However, the theme‘participation’
included a relatively large number of intervention activities that were not consistent with the theme
(n= 10). These focused on the child’s immediate participation in the session or attendance at clinic, with
tasks being based around motivating or engaging the child in the session, for example‘child chose
favourite games or activities at beginning of session’ (B26).
There was a large amount of variance in the level at which therapists worked on‘adult–child interaction’,
although all of the intervention descriptions were consistent with the original theme descriptions. Although some therapists described targeted/detailed work, including programmes such as the Hanen programme
[see www.hanen.org (accessed 19 March 2015)], others referred to adult–child interaction as something
that they only touched on, for example‘general advice re parent–child interaction given at initial
appointment’ (B36).
Many of the responses for‘speech’ included interventions that could be categorised under ‘sound
awareness’, including phonological awareness and discrimination activities, indicating overlap of these
categories. These sound awareness activities were often described alongside speech production activities. Several participants (B13, B29 and A52) also reported the use of minimal pairs, which incorporate aspects of both sound awareness and speech production.
TABLE 16 Applicability of the themes to interventions used by SLTs in a vignette exercise (n= 62)
Themes
Completed intervention information
Reported theme was
not applicable, n (%) Total n Consistent with theme, n (%) Inconsistent with theme, n (%) Speech/articulation 38 (62) 2 (3) 21 (34) 61 Sound awareness 43 (69) 0 (0) 19 (31) 62 Comprehension 34 (57) 1 (2) 25 (42) 60 Structure/content 44 (75) 0 (0) 15 (25) 59 Self-monitoring 31 (51) 0 (0) 30 (49) 61 Generalisation 42 (69) 0 (0) 19 (31) 61 Foundation skills 46 (74) 2 (3) 14 (23) 62 Child participation 40 (66) 10 (16) 11 (18) 61 Empowering/understanding of parents/adults 60 (97) 0 (0) 2 (3) 62
The findings from the vignette activity confirmed that SLTs are able to describe their interventions in relation to the typology themes. Although not all themes were relevant for all of the vignettes used by SLTs, there were no interventions that SLTs reported that they could not describe in relation to at least one of the themes. There were a number of interventions, however, that SLTs reported in relation to several of the themes. Although this might indicate overlap of the themes, it appeared that these interventions
were broad (e.g. parent–child interaction, language groups) and were intended to target multiple aspects
of the typology at a time.
Refinement of and adaptations to the typology themes
The data gathered from the activities described were reviewed iteratively as data emerged, in terms of emerging challenges, issues and gaps in the typology. At the national events, participants were asked to directly vote on and discuss many of the issues that emerged. Three of the theme changes involved a
change of name, with‘child participation’ becoming ‘functional communication’, ‘structure and content’
becoming‘expressive language’ and ‘parent/adult–child interaction’ becoming ‘adult–child interaction’.
The other change was broader and involved merging the two themes‘speech’ and ‘sound awareness’.
The rationale behind these changes is discussed below.
Data from the SIG events indicated confusion over the theme‘child participation’, with 42% of participants
providing a description that was classified as‘different’ for this theme. In particular, many participants referred to participation in the session or in therapy rather than to the broader aspects of participating in life events, which was the emphasis in the original theme description. Similarly, at the national events, there were mixed
responses: although some therapists felt that‘participation’ was a label that captured the theme adequately,
others indicated a lack of certainty about what it encompassed. Participants used a variety of words and phrases as potential alternatives or to signal their interpretation of the concept of‘participation’, including ‘functional communication’, ‘engagement’, ‘motivation’ and ‘social use of language’. The predominant term
that was used was‘functional communication’ and thus this term was used in the final typology.
‘Structure and content’ was noted by SLTs to be an unfamiliar phrase and 36% of participants at the national events provided a description that was different from the description that we provided.
Adjustments to the term‘structure and content’ were not discussed at the national events. However, the
name of this theme was changed to‘expressive language’ to be consistent with the phrasing of the theme
‘comprehension’ and to incorporate the use of widely accepted SLT terminology.
The name‘parent/adult–child interaction’ was changed after a lack of consensus emerged from
participants regarding how best to configure this theme and its constituent concepts. A decision was made
at the level of the research team to adjust the name of the theme minimally to‘adult–child interaction’.
This distinguishes it from the specific intervention called‘parent–child interaction therapy’ and includes the
broader reference to all adults who interact with the child, that is, in addition to parents.
Two of the original themes‘sound awareness’ and ‘speech’ were merged into a broader version of the
theme‘speech’, whose new definition incorporates both speech and sound awareness. Responses from
SLTs at the SIG events with regard to explaining the themes to parents had indicated that SLTs view these two themes as overlapping. Table 17 shows all items that were taken to vote at the national event and the
results. As can be seen, the majority of SLTs felt that the two categories‘sound awareness’ and ‘speech’
should be merged.
The description of the characteristics of the theme‘speech’ with respect to sound awareness was also
adjusted to refer exclusively to phonological awareness rather than basic or environmental sound awareness. Although the original description of the sound awareness theme included both speech sound awareness and environmental sound awareness, in the descriptions that SLTs provided for parents at SIG events the majority of participants referred only to speech/sound awareness. Only five of the 29 participants who completed this exercise referred to the more basic skills of identifying and discriminating between environmental sounds.
Similarly, in the vignettes activity at the national events only 3 of 62 participants referred to more generic
listening activities in the sound awareness theme. Voting at the national events produced> 90% agreement
across both sites that more basic aspects of sound awareness were more appropriate to the theme