The treatment components which contribute to an effective therapeutic outcome for children with specific language impairment are not commonly understood and always under hot debate. The purpose of the study was to describe the underlying factors that lead to a successful therapeutic intervention for children with specific language impairment. A qualitative research is conducted to explore how a speech therapist perceives an effective intervention session for the clients. A professional speech therapist in the clinical setting was interviewed to consider the experience with the clients and describe the attributes that cause the intervention effective in promoting positive change in the communicative ability. Results underlined the importance of implementing evidence-based practice, establishing a good client-clinician relationship and allowing the involvement of the caregivers.
Evidence-based practice, client-centred approach, specific language impairment (SLI), speech therapy.
Specific language impairment (SLI) is one of the most prevalent developmental difficulties for preschool children. It is suggested that around 8 in 100 children have speech and/or language disorders, of which a significant proportion will have specific language impairment (Boyle, 1996; Tomblin, 1997). Such conditions are often named as “specific” since there is no known aetiology1 for the impairment (Plante, 1998). The children with SLI can have a language disorder, a speech disorder or even a combination of both since these conditions commonly overlap. Fey et al. (2003) suggested that this disorder can, in fact, affect children’s performance in the areas of phonology, vocabulary, grammar, morphology, and pragmatic2 language. The implications can be far-reaching to the children that persist into their adulthood.
A bewildering range of approach of interventions is designed to improve the child’s speech and language deficits and remove their barriers to participation. The interventions should be delivered by a language specialist, most notably the speech therapists (Dwight, 2006). The reason for the inclusion is the specific nature of language deficits experienced by clients. Instead of a broad range of skills, speech therapists concentrate more on speech-language characteristics. Nevertheless, a handful of elements can be the active ingredients for the interventions. The present study is to answer the intervention components that account for effective therapeutic interventions.
Delivery agent and context
Interventions for clients with SLI can be directly or indirectly carried out and in a wide range of settings. Dwight (2016) claimed that direct interventions are delivered by speech therapists and they aim at the individual treatment of the children, or a group therapy which relies on the age and needs of the clients and the facilities readily available. Indirect interventions are more naturalistic in approach, allowing the adults proximal to the child to facilitate the interventions. This context creates an optimal environment for child’s communication. Parents are actively involved in delivering interventions for younger children but become less actively engaged in administering the intervention when the child grows older (Horvath & Symonds, 1991).
Historically, most, if not all, of intervention was about the teaching of specific behaviours such as vocabulary and speech sounds together with reinforcement. The rationale behind was that language or speech could be explicitly taught and therefore the skill gaps between normal children and children with SLI could be filled. However, the intervention has gradually changed from explicit teaching paradigms into social learning theory, assuming that children can learn most effectively when they are trained in a social context (Miller, 2011).
The key of intervention shifts to a more functional one as the child grows older, whereby children with SLI are trained with the skills that benefit them the most at the moment. The therapist usually provides alternatives and urges the children’s self-judgements based on their intrinsic phonological or grammatical awareness (Childers, 2002). They are encouraged to adopt their own repertoire. The assumption is that this process boosts the child’s ability to modify their language and/or speech. A different direction from a linguistic aspect is therefore suggested by constructivists 3or usage-based explanations.
Different research proposed different key factors that lead to a successful intervention of specific language impairment. However, little consensus can be reached about the effective intervention for extensive usage. It remains unclear in what essentials are needed for an efficacious intervention. Under this line of thinking, there appears to be a critical need to understand how speech therapists perceive an effective speech therapy treatment for children with SLI. In this study, we come up with the major components of the intervention by understanding different experiences of approach.
The participant in the study was a female speech therapist of a developmental paediatrics centre in Hong Kong, currently providing speech therapy services to children with speech or communication impairment. The speech therapist had more than 15 years of experiences working with the aforementioned children in various settings.
A qualitative approach to research design and data collection was adopted in the research. It allows the researchers to interpret and delineate the experiences form the participants’ perceptions (Higgs, 1998). This approach focuses on “how”, “what” and “why” a speech therapy treatment can be successful to a child with SLI.
Data were collected using a semi-structured interview. Such interview permits the interviewee to speak freely but also gives control to the interviewer in making the interview to proceed (Rubin & Rubin, 2012). Open-ended main questions were asked to underline the research aim. Moreover, follow-up questions were designed to elicit additional details in the response.
Client’s needs and capabilities influence the clinical decisions
This category emphasizes that an effective clinician should be flexible and client-centred in the approach of treatment. The participant described that she customized the intervention sessions to meet the ability of the client. She usually considers three developmental levels of the child, including the play level, cognitive level and comprehension level.
Prior to treatment, play level is assessed by observing the playing behaviours of the clients. The clinician indicated that the commonly adopted test was “Symbolic Play Test4”. Knowing what attracts the child the most, she can determine the activities of the therapy. Another practice she mentioned was to record the language use of the clients in the play. It helps her to see the whole picture of the clients’ language ability and their needs since SLI affects differently to each client.
The participant also indicated the effective clinician should recognize the cognitive level of the children, particularly the cognitive ability to learn. She always wants to see whether the children can recall the learned materials, apply the knowledge in new situations or do analysis and synthesis. She emphasized the importance of cognitive level for goal-setting of an intervention, be it long-term or short-term.
Another criterion the participant would consider is the comprehension level. It includes the communicative intention5 and understanding of task explanation. The clinician believed that knowing the child’s comprehension ability helps with the dynamic flow of an intervention session since she is capable to choose whether to use a one-step command, two-step command or even more complex sentence structures, such as questions to explain the task and give feedbacks.
Build a trusting client-clinician alliance
This category highlights the importance of establishing a supportive therapeutic relationship with clients. Building up alliance is to make the clients feel that they are more than just a patient to the clinicians. The participant described that she would ask about the clients’ home, past approaches of therapy and their feelings about it. It could make the clients feel more comfortable.
In the process of building alliance, it can enable the client to talk openly about the feelings and more willing to follow the instructions. Though rapport-building seems to be subtle and trivial, it determines the flow of an effective intervention.
The interviewee also suggested a few ways to link to patients who have different needs. For example, she gave her first-hand experience with a serious case of specific language impairment.
… I have once met a client who was nearly non-verbal. How could I build rapport with him? I just got to the floor to play with him and followed his lead of play. I could then gradually enter his world…
The clinician then added that the approach she used was Floor-time and it was to engage the children literally at their level. She usually uses this period of time to excite the client’s interests, draw the connections and challenge them to be curious, creative and spontaneous.
The interviewee also pointed out that effective clinicians should be emphatic and honest. Empathy was described as the ability to relate to the children. In some cases, the clinician would share personal experiences to let the clients know that she was authentic and she truly cared. The clinicians who were described as honest will not say something the client wants to hear to make them feel better but to honestly report the assessments accompanied by encouragements.
Actively involve the parents
This category underlines that the role of parents in the client’s intervention is to help communication at home. The clinician suggested that parents are the “key players” of the entire treatment since children learn from daily conversations with the people around them, especially their parents. The clinician also claimed that speech therapy has to extend to all parts of the children’s life so that the knows how to generalise the skills learnt in the therapy sessions in everyday communication.
In face of questions about how parents without professional skills can help facilitate the effectiveness of the therapy, the clinician gave the following response.
… It is not necessarily the case. We can teach the parents some important strategies that they can use whenever they are with the child. The parents can even learn some language-building skills from their children which are specific to them. It greatly benefits the real therapy session…
The children spend most of the time living with their parents or caregivers. It is therefore suggested that it improves the results of an intervention if the parent can give prompt responses to their children’s communication attempts or expand the sentences the children said.
On the other hand, the clinician stated that she would also give the parents some take-home exercises for clients to “carryover”6 so that they can have the practice outside therapy session. She emphasized that whether a parent carries out speech therapy exercises at home properly determines the effectiveness of the intervention.
The findings give more in-depth explanations to the conclusion of Childers (2002) about the importance of understanding the client’s abilities. The main goal of the intervention for children with SLI is to encourage the child’s self-judgements based on their internal awareness on speech and language. This should be guided by evidence-based practice which integrate the external evidence, clinical expertise and patient’s perspectives (Sackett, 1996). Evidence-based practice is client-centred, and therefore a clinician’s role is to provide the most effective intervention to the clients by interpreting best current research evidence in relation to an individual’s preferences and responses. It is a continuing procedure, in which the speech therapists should dynamically change the treatment goal as well as procedure based on the ever-evolving research and the individual’s performance in the intervention (Spring, 2007). With the implementation of evidence-based practice, an effective speech therapy intervention can be guaranteed.
Establishment of therapeutic alliance
Rapport building with the clients is seldom stressed in treatment of specific language impairment and hence little literature have discussions about how the client-clinician relationship influences the efficacy of the intervention. However, the findings do show that an effective therapeutic alliance leads to an effective therapy. Wampold (2001) accentuated on the relationship in which a mutual understanding is established and indicated that effective clinicians construct a productive therapeutic alliance with the clients and well understand the nature of the impairment and its treatment.
On the other hand, the findings stress the significance of empathetic listening, which accords with what Luterman (2001) stressed. When the speech therapists actively listen to the clients and try to understand them, it is easier to establish trust and hence improve the dynamic flow of the treatment. Lehay (2004) offers another convincing description of the dialogues used by effective clinicians. A typical treatment discourse is that the clinician requests, the client responds and the clinician evaluates. This can help develop interactive intervention and be accompanied by following the client’s lead. With the better relationship with the clients, it makes a substantial difference in effectiveness of intervention.
Engagement of the caregivers
The findings agree with Horvath & Symonds (1991) that parents do play a key role in speech therapy. Since most the children with SLI will have their speech therapy intervention at the early stage, whether the caregivers can be actively involved in the non-therapy time determines the effectiveness of the session. Roberts (2011) also investigated how parents affect the language development of children with SLI and found that there were positive effects on the communication development of the clients with the engagement of caregivers. Indeed, children with various language disorders could make successful progress when the parents were taught to help. Parents bear the responsibility that is as important as the speech therapists do.
As another means of teaching, speech therapy exercises can be given by the clinicians (Law, 2017). They can either be flash cards or mirror exercises to help clients to focus on the targets in which they have difficulties. More practice implemented by parents can mean significantly faster improvement in language and/or speech disorder. With active engagement of the parents, an efficient and successful treatment can be provided.
This study investigates, from the perspective of speech therapists, the components needed for an effective intervention of specific language impairment. The results indicate that intervention approached should be guided by evidence-based practice in which the clinician considers the clients’ perspective, current research and own knowledge to plan a treatment. Another vital ingredient is the supportive alliance with the clients which enhances the fluency of the intervention. The results also highlighted the importance of engagement of the caregivers. Therefore, it is beneficial for speech therapist and parents to discuss their roles and so that each person’s responsibility is well defined.
Concerning the limitations of the study, the major constraints were that only one participant was interviewed and we did not control the potential variables (e.g. experience in treatment of SLI). As such, the findings may not be representative for the perceptions of speech therapists about the effective intervention of children with SLI. Further investigation might focus on the number of outcomes emerged from this research.