1. A Systematic Review of the Interventions To Improve Pre-school Children’s Phonological Awareness and Speech Output
Yvonne Wren1, Sam Harding1, Juliet Goldbart2, Lydia Morgan1, Naomi Parker1, Elizabeth Lewis2, Julie Marshall2, Sue Roulstone1,3
1Bristol Speech and Language Therapy Research Unit, Frenchay Hospital, Bristol
2Dept of Health Professions, Manchester Metropolitan University (MMU)
3The University of the West of England, Bristol (UWE)
Good afternoon everyone.
My name is Sam Harding and with Dr Yvonne Wren, and it is my pleasure to present a component of the Child Talk What Works project; the findings from a systematic review of interventions used with Pre-school Children with Primary Speech and Language Impairment to improve phonological awareness and speech output. 1

2. This presentation summarises independent research funded by the National Institute for Health Research (NIHR) under its Programme Grant for Applied Research Programme (Grant Reference Number RP-PG ).
The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.
The research was funded by the U.K.’s National Institute for Health Research; the first Programme Grant for Applied Research Programme in the area of speech and language therapy. 2

3. Who is involved? Co-applicants Advisory Group Research team
Sue Roulstone, University of the West of England
Norma Daykin, University of the West of England
Jane Powell, University of the West of England
Jon Pollock, University of the West of England
Linda Lascelles, Afasic
Jenny Moultrie, North Bristol NHS Trust
Gaye Powell, Consultant speech and language therapist
Julie Marshall, Manchester Metropolitan University
Juliet Goldbart, Manchester Metropolitan University
Tim Peters, University of Bristol
Alan Emond, University of Bristol
Will Hollingworth, University of Bristol
Jane Coad, Coventry University
Cres Fernandes, Assessment Research limited
Advisory Group
Supportive Parents
Royal College of Speech & Language Therapists
Barnardos
NBT SLT clinical team
Bristol City Council Early Years Manager and commissioner
National Early Years Strategy
Parents from Parent Panel
UWE Early Years Education
Health Visitor Lead
Research team
Rebecca Coad
Sam Harding
Lydia Morgan
Naomi Parker
Liz Lewis
Anna Blackwell
Karen Davies
Helen Hambly
Parent panel
Heather Goddard
Rebecca Hardy
Helen Dacre
Vickie Nutt
Liz Sayles
Jacob Wilcox
Faye Langdon
This is a large project with many components and many contributors. The work we are going to talk about involves mainly the research team, here in the yellow box and some of the Co-applicants on the grant, primarily Sue Roulstone and Juliet Goldbart 3

4. Background
There have been a number of systematic literature reviews that have examined the effectiveness of interventions for children with speech sound disorders (SSD) (Baker and McLeod, 2011; Better Communication Research Project 2013; Law ,Garrett and Nye, 2004)
The results of reviews have been encouraging
BUT - Often highlighted the fact that much of the evidence is at a relatively low level
Study Design
Quality
Previous reviews of the evidence base for interventions for children with Primary Speech and language impairment (PSLI) such as Law, Garrett and Nye (2004) and the Better Communication Research project have shown:
Some evidence of effectiveness for some interventions, – for example for children with phonological or expressive vocabulary difficulties, but rather less for children with receptive difficulties
And Baker & Macloud note that at present, there are few studies that
show that one intervention approach is unequivocally superior to another with a particular client group. Clearly, if SLTs are to understand the relative benefits of the different intervention approaches reported in the literature and make well-informed, evidence-based decisions, there needs to be increased publication of rigorous, well-designed comparative investigations 4

5. Background
The relative effectiveness of one intervention over another in particular instances is not clear
The link between evidence and practice is not clear
There is less evidence for the younger age range
Evidence Based Practice model

6. Evidence based practice
Taking as our starting point Sackett et al’s conceptualisation of evidence-based practice as being made up of the best available evidence, ie the research literature, expert professional opinion and the views and values of service users and their families, We can see here how the systematic review component fits into the project as a whole.
“an approach that integrates the best external evidence with individual clinical expertise and patients’ choice’’. Sackett et al 1996 6

7. Evidence based practice
“an approach that integrates the best external evidence with individual clinical expertise and patients’ choice’’. Sackett et al 1996

8. Evidence based practice
“an approach that integrates the best external evidence with individual clinical expertise and patients’ choice’’. Sackett et al 1996

9. Aims
To compare:
The evidence base for interventions with preschool children with speech sound disorder
with
Clinical practice
Outcomes targeted/measured
Interventions used
Interventions are adapted by therapists and therapy services for both groups and individual children
The aim of the systematic review was to identify the available evidence, to assess it for quality, and also, to drill down into the evidence so we could answer the challenge posed earlier, and answer the question of what intervention works for which children, with which types of primary speech and language impairment and in which contexts or settings.
But first I will give you a quick overview of the systematic review process. 9

10. Methodology – Systematic Review
16 Databases including:
Cinahl, Embase, Medline, ERIC
Date Ranges:
January 1980 & November 2011
Search String included words pertaining to:
 Speech,  Language,  Communication,  Developmental disorders,  Paediatric,  Research design
Quality Assessment:
Physiotherapy Evidence Database - PEDro
Single-Case Experimental Design scale - SCED .
We set up a search string which included all relevant terms and ran appropriate versions through 16 databases, including Cinahl, Embase, Medline and ERIC.
The date range is as you see here.
To evaluate the quality of the papers we used the two procedures adopted by SpeechBITE, the Australian-based service which abstracts and evaluates research papers in speech and language therapy. These are PEDro-P which was designed to appraise the methodological quality of randomised non‐randomised controlled trials and SCED which is a parallel tool designed to appraise studies using single case experimental designs. 10

11. QUORUM flow chart
Potentially relevant articles identified from literature search
(N = 55,271)
Studies retrieved for more detailed evaluation
(N = 4,574)
Potentially appropriate studies to be included
(N = 473 )
Number of studies retained for inclusion in review identified
(N = 149)
Articles excluded at title review:
Duplicates (N = 17,372)
Study Design not experimental, Children’s diagnosis, Lack of therapeutic intervention, not language outcomes (N = 33,325)
Studies excluded because (N=4,101):
Does not contain 80% of children within age range 2;0-5;11
Study Design not experimental, Children’s diagnosis, Lack of therapeutic intervention, not language outcomes
Studies excluded because (N=324):
Does not contain 80% of children within age range 2;0-5;11
Study Design not experimental
Children’s diagnosis not PSLI
Lack of therapeutic intervention,
Outcomes not related to language
Quality Appraisal Using; PEDro (N = 102)
SCED (N = 47)
Number achieving >6 on quality appraisal
PEDro (N = 23)
SCED (N = 37)
QUOROM stands for the Quality of Reporting of Meta-analyses This is a flow chart that shows the sequence of steps identified for exclusion of studies in a systematic review. Using our original search strings we identified more than 55,000 papers,
We reduced this by reviewing titles, abstracts and full papers to ensure they matched our search criteria and then quality assessed 149 studies using PEDro and SCED depending on the study design. The scoring as well as all other previous steps of the review were undertaken by at least two people and resulted in the final retention of 60 studies.
The 60 papers were then reviewed by 3 SLT’s and identified as those focusing on interventions that ‘Increasing the accuracy of speech production or articulation, often focusing on specific sound(s)’ which left the review retaining 30 studies.
Studies assessed for representation within the ‘Child Talk – What Works’ typology categories
Number of studies categorised as representing ‘Speech’ (N = 30)
(adapted from Moher et al, 1999) 11

12. Methodology - Clinical practice
Focus groups with 40 speech and language therapists
Consensus group exercise with 50 different speech and language therapists

13. Results
Outcomes expected/measured
Interventions used and tested

14. Outcomes expected/measured
Outcomes in clinical practice
Examples
Speech production
Correct use of sounds
Intelligibility
Increased intelligibility to others; able to speak clearly
Speech perception (phonological awareness)
Able to discriminate sounds in words
Psychological well-being
Increased self-esteem
Readiness for school
Reduction in support needed in school; participation in the curriculum
Social skills
Improved peer interaction
Adult confidence
Reduced parental anxiety

15. Outcomes targeted/measured
Outcomes in clinical practice
Examples
Systematic review
Speech production
Correct use of sounds 29
Intelligibility
Increased intelligibility to others; able to speak clearly 1
Speech perception (phonological awareness)
Able to discriminate sounds in words 5
Psychological well-being
Increased self-esteem
Readiness for school
Reduction in support needed in school; participation in the curriculum
Social skills
Improved peer interaction
Adult confidence
Reduced parental anxiety

16. Interventions used in clinical practice
Quantity Ranking as Essential (Sum Combined Essential)
Percentage Ranking as Essential (Percentage sum combined)
Building things into a game/making it fun 46
95.8
Providing feedback 42
87.5
Using repetition 40
83.3
Adopting a hierarchy (e.g. C, CV, CVC)
Making sounds 37
77.1
Encouraging self-monitoring strategies 31
64.6
Minimal pairs 29
60.4
Traditional phonology therapy 21
43.8
Jolly Phonics 20
41.7
Picking from lots of different areas
Fishing game 18
37.5
Cued articulation 13
27.1
Nuffield Dyspraxia 9
18.8
Cycles therapy 7
14.6
Oro-motor work 6
12.5
Metaphon
Maximal pairs 3
6.3
Gap House
However, therapists don’t use those kind of terms when they describe their work on speech or on sound awareness work
For example, during focus groups (previous presentation) therapists had talked about their work on improving speech with preschool children. As you can see from the list on the left, this is a much more broad ranging way of talking about intervention, including games and activities as well as broad approaches.
We took all the interventions they had mentioned when they talked about speech work and presented them to ?n therapists and asked them which ones did they think were essential to their work on speech.
The next step in the systematic review is to investigate the levels of evidence supporting the interventions that therapists typically used in their everyday practice. Difficult because they don’t easily fit and some are not so much interventions as general activities that are used with a number of interventions – eg ‘fishing game’ it is an activity commonly used for a range of interventions (phoneme identification, minimal pairs, maximal pairs, to name but a few), but you wouldn’t expect it to be seen in the literature;
But if we take just a couple of these and look at the literature . 16

17. Interventions used in studies
Speech Typology sub-categories
Number of studies identified
Total number of children represented in all studies (Average)
Mean Average age of children in all studies (months)
Age range of children in all studies (months)
Phonemic 22
253 (11.5)
52.7
42 – 66
Articulation 1
30 (-)
42.0
33 – 61
Perception 3
74 (24.7)
53.7
Only mean ages given
Unclassifiable/Other
123 (30.8)
52.3
30 – 71
Phonemic & Perception
19 (-)
47.5
36 – 49 17

18. Interventions + Evidence
Interventions used + Supportive evidence
Minimal contrast therapy
Intervention used + Little/no evidence
Nuffield Dyspraxia Programme
Intervention not used + Supportive evidence
Maximal oppositions
Intervention use + Evidence against use - ?
Expect three scenarios 18

19. Discussion
Considerable variation in the quality of the research, with few studies meeting the highest quality standards (eg gender information)
Mismatch between practice and evidence – in terms of how things are described and in what is happening
No study investigated the youngest (2;0) children with the majority focusing on the 4;0+ age group 19

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24. Thank you Yvonne.wren@speech-therapy.org.uk