Procedure

The procedure for each child was spread over a three-day period. Recruitment was carried out in two-week blocks, thus day two occurred a maximum o f two weeks after day one. Days two and three were consecutive.

Day One

A fieldworker visited the child’s home to recruit the child. The study was explained

to the parent and informed consent obtained. The fieldworker arranged an

appointment with the parent for the next visit.

Day Two

The speech and language assessment team visited the child’s home for the speech and language assessment. This was carried out in a quiet area on the compound of the house, most often under a tree for shade and comfort. While the child was being assessed, a fieldworker carried out the parental questionnaires. After the assessment, the parent and child were invited to hospital the following day.

Day Three

The parent and child came into the hospital for the day. The cognitive assessment was administered in the morning. After lunch, the vision and hearing screening, EEG and neurological assessment were carried out.

After the recruitment and informed consent procedure on day one, the parent was asked whether they considered their child to have any deficits in hearing or vision. Any children whose parents gave affirmative responses underwent hearing and vision screening before the other assessments to ensure that any impairments present did not prejudice their performance on other tasks.

The field session on day tw o began w ith form al introductions and greetings, an im portant precursor to conversation in K enya and a play session involving all children at the c h ild ’s hom estead, w hich aim ed to create a relaxed en vironm ent for testing. A sm all table and tw o chairs, specifically m anufactured for the study, w ere transported to each session and set in a shaded, quiet area o f the com pound (figure 8.1). Each assessor carried their ow n portable equipm ent box w ith copies o f each assessm ent, the necessary m aterials and form s. W hen the assessor considered the child to be ready to begin, he/she invited the child to jo in him /her in the assessm ent area, obtained the ch ild ’s consent and explained the form at o f the tasks.

Figure 8. 1: Typical setting for the speech and language assessment

A t this point, it w as em phasised that the session w ould consist o f T eam ing task s’ only because m any children in the study area associate K E M R I personnel w ith injections and the taking o f blood sam ples. The dictaphone used to record the spontaneous language sam ple and the phonological assessm ent, w hich w ould be unfam iliar to the m ajority o f participants, w as then introduced to the child: he/she w as invited to record his/her voice and play it back. I f the child w as reluctant or uncooperative, other children w ould be invited to jo in in the initial session or the m other w ould be asked to sit w ith the child, although requested not to give any prom pts. The aim o f each assessm ent w as outlined and the response form at expected from the child explained

and modelled before the start of each assessment. Assessments were administered in the following order unless the child was unco-operative, in which case the session began with whichever task he/she was willing to perform: spontaneous language session, receptive language assessment, higher level language assessment, syntax assessment and word finding assessment. Each child was given one break of 10 minutes. Including the break, the average session time was 50 minutes. During the assessment, a fieldworker would administer the pragmatics, behavioural and socioeconomic questionnaires to the mother (or another relative on rare occasions when the mother was absent). At the end of the session, the parent was given the fare for transport to the hospital for day three.

On arrival at KDH on day three, the child and parent were greeted by the cognitive assessors and offered milky tea and bread for breakfast. As three children were assessed per day and siblings often accompanied them, there were invariably other children available for play. A box of toys was available for their use. Following the play session, the cognitive tasks were explained to the child and the assessments began once the assessor was confident that the child was relaxed and ready to participate. Each cognitive assessment session was held in a large tent or classroom (two assessments often occurred simultaneously) situated away from the main hospital site. Each contained a table and two chairs similar to those used on day two and the assessor’s equipment box. The assessor explained the aim of each task and modelled the response format expected from the child before the start o f each assessment. A standard assessment order was used - orientation questions from the KCBMT; construction task; remainder o f KCBMT; receptive vocabulary assessment; visual search (attention test) - unless the child was uncooperative, as above. A 10-minute break was given during administration of the battery, resulting in an average test time of 1 hour and 30 minutes.

After lunch, which was provided for each family, the three children were rotated between the vision and hearing screening, neurological assessment and EEG. Where possible, the EEG was performed last because it was the most unfamiliar and potentially unsettling procedure o f the day. The visual screening was performed in a shady area adjacent to the cognitive assessment tent to allow for the six metre distance required for testing. The child sat on a chair with the letter card on a table in front of

him/her and the assessor stood opposite on a spot marking the six metre distance. The

hearing screening was carried out in a quiet office. Before the screening, the

audiometer was introduced to the child and he/she was given the opportunity to practise responding to different tones until the assessor was confident that he/she understood the response format. During the testing procedure, the child was asked to sit with his/her back to the audiometer so it was not possible to follow the visual cues o f the assessor pressing the button for each tone. The neurological assessment and EEG were performed on the hospital site for easy access to equipment used during these procedures that was also in routine clinical use. Each item o f equipment employed in these procedures was introduced and explained to the child before use. Fares for transport home were provided for each family at the end o f the day and children received a reward for participation in each assessment on days two and three.

All assessors were blinded to the group status of each child. Before data collection commenced, the procedure was piloted on ten children from the target population and found to proceed efficiently.