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EDITORIALS: James Law and Gina Conti-Ramsden Treating children with speech and language impairments BMJ 2000; 321: 908-909 [Full text]

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Treatment efficacy

Carole Martin   (17 October 2000)

preventing speech impairment in some children

Wendy McLean   (5 November 2000)

New Issues In Efficacy of Treatment

Carole J Martin   (5 October 2003)

Treatment efficacy 17 October 2000
Carole Martin, Adjunct, University of Wyoming Clinic Director, Scottish Rite Clinic Send response to journal: Re: Treatment efficacy	Research into efficacy of treatment in speech/language disorders is important and valuable as we move forward to delineate our areas of expertise and to justify the services we provide. The difficulty with this particular research article is that it does neither: delineate our expertise or justify our services. First, the authors did report substantial gain in auditory comprehension. Even with the six hours average treatment time, this is significant. Second, the criteria for inclusion of phonology subjects (receptive and expressive language >1.2 SD below the mean and error rate of at least 40% in production of fricatives) places these youngsters at risk for other types of problems. Children identified as phonological upon initiation of therapy may later be identified as having mild to moderate oral-motor difficulties. In therapy, we are finding some of these children are struggling with fine motor productions. Research out of the University of Colorado is also finding that approximately 30% of these youngsters are at risk for having language/literacy difficulties once they reach school age, even after the phonological problems have been remediated. Research into language/literacy difficulties are pointing to genetic causes among other possible origins. So, we are now looking at youngsters with multiple problems instead of simple phonology. In our clinic, we routinely screen ALL preschoolers who are referred for phonology problems. Our test results are similar to Colorado. We are seeing about one-third of your preschoolers having deficits in phonological awareness skills. We include remediation of these skills in our therapy program for all pre-schoolers. We are seeing success in these youngsters as they enter school. Third, the frequency of therapy sessions varied from once a week to once every two and one-half months. The researchers state:"...this trial aimed to evaluate routine therapy rather than a prescribed regimen." It would have been interesting to see if differences occurred when comparing more frequent therapy (once a week) to infrequent (every two and one-half months). Children in this age group need more intensive therapy. In our clinic, we see preschoolers 2-3 times a week for at least 30 minutes each session. And we see significant improvement in their receptive and expressive language skills as well as their phonology, based on standardized testing. My concern is that too many people are going to read this and decide speech/language therapy with preschoolers is not effective when, instead, we should be appalled that these youngsters only received an average of 6 hours. The authors cite the success of the Head Start programs (Campbell & Ramey, 1994) in the United States and several other research studies (Johnson, et al, 1999; Stothard, et al, 1998). The American Audiology, Speech/Language, and Hearing Association (ASHA)has been conducting efficacy studies over a variety of settings, ages, treatment protocols for the last two years. I will "watchfully wait" for their results. I will not wait as children 1.2 SD below their peers arrive at the clinic and need therapy. Especially not when I see the success both long and short term.
preventing speech impairment in some children 5 November 2000
Wendy McLean, retired Send response to journal: Re: preventing speech impairment in some children	One of the problems that can lead to speech impairment is glue ear. Reseach published in the BMJ in 1996 shows that about half of all ear infections could be prevented by using xylitol chewing gum, offering the prospect of a reduction in the number of children with glue ear. Xylitol nasal sprays have now been developed to allow children too young for gum to be treated and parents in America provide anecdotal reports of reduction in infection using xylitol bulk sweetener or vitamin supplements which contain it. Whether speech therapy is effective or not it would be far better to treat the problem at source, especially as the use of xylitol offers a reduction in the use of antibiotics.
New Issues In Efficacy of Treatment 5 October 2003
Carole J Martin, Adjunct, University of Wyoming Cheyenne, WY 82001 Send response to journal: Re: New Issues In Efficacy of Treatment	New issues in efficacy of treatment Carole Martin, AuD, A/SLP Adjunct, University of Wyoming Facilitator, University of Florida AuD Distance Learning As predicted, treatment efficacy research has become an important buzz word as speech/language pathologists and audiologists face the growing crisis in funding of health care both in the U.S.A. and the U.K. In a response to an editorial and a research article by Law and Conti- Ramsden (1), this author advocated for a more prudent approach to the research in treatment efficacy.(2) Citing the need to more closely examine the population Law and Conti-Ramsden targeted, I suggested that 1) language/literacy issues complicated the data of their phonology subjects and 2) the frequency of intervention in the study (once a week to once every two and one-half months) was not adequate to assess intervention in children. The research is now on the table. Early intervention works. Frequency and number of treatment units positively impact the speech/language abilities of children. Children with severe phonolgical problems are at greater risk for other types of language/literacy disorders. Early intervention. Extensive research of the Head Start program in the United States has documented the impact this program has on children from low-income families. These children are often from single-parent or very young parent families and have faced significant educational and learning challenges prior to the onset of this program in the mid 1960’s.(3) The research shows that Head Start children (ages three years old to five years old) showed significant gains in vocabulary skills against national norms in 2000-2001,(4) made considerable gains in cognitive and socioeconomic domains,(5)and spend 1.3 fewer years in some form of special education placement.(6) Typically these youngsters attend Head Start three hours a day, four days a week. The Early Head Start Program (birth to three years old) has shown additional impacts on the infants and toddlers they serve. Children completing this program perform better than their non-participating peers in cognitive and language development, need fewer special learning interventions when enrolled in regular educational environments, and have a greater probability of being read to by their parents.(7) Nearly 70,000 children in the Head Start programs annually receive comprehensive speech and/or language services and benefit from these services. Treament Intervention In a two-year study of children ages three years old to six years old, Jacoby etal, looked at a variety of factors in treatment success. They concluded that as the number of treatments units increased, the overall speech/language of the child improved. Specifically, they found 1) significant improvement for subjects with articulation/intelligibility (phonology) and spoken language disorders, 2) greatest benefit per units of therapy provided for the younger children, and 3) subjects with lower initial functional abilities and/or associated disorders or syndromes generally required more units of therapy. The American Speeh-Language- Hearing Association Functional Communication Measure (FCM) was used as the primary assessment tool. Their findings showed that over 75% of the ratings of children with at least 20 hours of therapy showed increase of at least one level on the FCM. In addition, no children showed an improvement of two levels without a minimum of 20 hours of therapy. Their conclusion: increase in time in therapy and treatment of younger children in therapy positively impact therapy outcomes. (8) Multiple disorders The Jacoby study pointed up the rarity of seeing a young child with a “simple” speech or language diagnosis. Many of their children had more than one communication diagnostic label, i.e. articulation or phonology, spoken language production or expressive language, spoken language comprehension or receptive language. Of the 234 children involved in the study, the researchers ended up with 394 ratings due to multiple diagnoses. In addition, they looked at associated factors (anoxia, hearing loss, etc.). These accounted for 46% of the subjects in the articulation group, 52% of the spoken language group, and 55% of the comprehension group. In reviewing the progress of these youngsters, the researchers concluded that "subjects with an associated factor required more units of therapy to demonstrate improvements than subjects with no associated factors."(9) The link between speech production disorders and literacy has been investigated and a strong relationship has been shown. Research shows that children with histories of severe speech/articulation/phonology disorders who attained intelligible speech through intervention displayed poorer literacy (phonological awareness, spelling, etc) skills in third grade when compared to children with normally developing speech. (10) Future of efficacy research Health agencies, insurance companies, and governmental bodies continue to press for more cost effective and efficacious strategies to handle the burgeoning health care crisis. Early and intense intervention with children with speech and language problems is proving cost effective and beneficial. Early research into cochlear implants indicate a window of opportunity for improving outcomes in pre-lingually deafened children.(11) Yet the challenge faced by most professionals is justifying appropriate intervention. Laura Barclay, M.D. summed it up well in her interview with Nancy S. Sung, Ph.D, a program research officer for Burroughs Wellcome Fund. Dr. Sung states, “Where strong-evidence-based practice guidelines exist, they are frequently not followed by physicians and other practictioners. (B)enefits may include coverage for therapies that are of questionable value or even have been proven ineffective. These problems will become more acute as the pace of medical and health sciences innovation quickens and as the need looms to find more effective approaches to preventing disease and promoting the health of the public.” (12) It is not only important that we do efficacy research, we must use it, proclaim it, and be activists to insure the best possible/most cost effective care is available to our patients. Best possible and cost effective do not have to be mutually exclusive. 1. Law, J & Conti-Ramsden, G Treating children with speech and language impairments BMJ 2000; 321:908-909 2. Martin, C Treatment efficacy http://bmj.com/cgi/eletters/321/7266/908 October 17, 2000 3. Starr, A The importance of teaching tots. Business Week, August 26, 2002 4. Head Start Bulletin Issue 74: Dept. of Health & Human Services. Administration for Children & Families. http://www.acf.dhhs.gov June 2002 5. McKey, R., Condelli, L., Ganson, H., Barrett, B., McConkey, C., & Plantz, M. 1985 The impact of Head Start on children, families, and communities: Final Report of the Head Start Evaluation,Synthesis, and Utilization Project. Washington, D.C.: US Dept of Health & Human Services 6. McKey, etal 7. Head Start Program Information Report for 2000-2001 Program Year 8. Jacoby, G.P., Lee, L., Kummer, A.W., Levin, L. & Creaghead, N.A. The number of individual treatment units necessary to facilitate functional communication improvements in the speech and language of young children AmerJSchLangPath: 2002 11:370-380 9. Jacoby, etal 10. Clarke-Klein, S. & Hodson, B. A phonologically based analysis of misspellings by third graders with disordered-phonology histories. JSpchHearRes:1995, 38, 839-849 11. Sharma, A., Dorman, M.F., & Spahr, A.J. Rapid development of cortical auditory evoked potentials after early cochlear implantation NeuroReport 2002 13:1365-1368. 12. Barclay, L Clinical practice lags behind medical research: A newsmaker interview with Nancy S. Sung, PhD. Medscape Medical News: http://www.medscape.com/viewarticle/450567 March 11, 2003. Dr. Carole Martin is currently looking at the impact of FM sound field systems on preschoolers. She may be reached at srclinic@qwest.net or Scottish Rite Childhood Language Clinic, 1820 Capitol Ave, Cheyenne, WY 82001. Competing interests:   None declared