Literature Review
by Kate Beckett, 2013
Introduction
Speech sound disorders (SSD) are the most frequently occurring communication impairments (Broomfield and Dodd 2004; Gierut 1998). In Ireland, children may wait up to two years for Speech and Language Therapy (SLT) (Children’s Rights Alliance 2011). An effective generic home programme (HP) developed by Speech and Language Therapists (SLTs) and delivered by parents within the parent-child dyad, would be a useful alternative treatment resource, as intervention could be provided immediately after diagnosis. Previous generations of this project have used traditional measures to establish significant gains in consonant accuracy (Brady et al 2011; Elomari and McElhinney 2012), suggesting a parent-led HP is effective, however, the parental perception (PP) of this intervention has yet to be fully explored.
SSD subgroups and current intervention approaches
Literature has long documented the heterogeneity of SSD and lack of universally recognised categorisation system. According to Dodd (1995; 2005) SSD can be differentially diagnosed using psycholinguistic presentations into five speech subgroups, unrestrained by severity (appendix xxx). Waring and Knight (2012) concluded that a universal system may lead to improved treatment efficacy. Dodd’s system has been utilised to select Phonological Delay (PD) and Consistent Phonological Disorder (CPD), as target populations for the current research. Both the selected subgroups are characterised by delayed developmental phonological processes typically evident in, but attributable to, children of a younger chronological age. In addition to this feature, CPD encompasses atypical (non-developmental) error patterns.
Minimal pair (MP) contrast therapy is a well-documented approach used to treat children with both PD and CPD (Williams et al 2010). Baker and McLeod (2004) suggest developmental phonological processes will benefit from MP intervention, while Gierut (2001) advocates this technique with sounds consistently in error or omitted from the phonemic inventory. This approach draws the child’s attention to homonymy and resulting communicative confusion (Gierut 2001), with the aim of reorganising the child’s linguistic system through introduction of missing phonemic contrasts and suppression of erroneous patterns (Holm et al 2005).
Phonological awareness (PA) refers to conscious knowledge about the sound structure of words at syllable and phoneme level (Hesketh 2009), and has been identified as an area of weakness in children with SSD (Gillion 2005; Hesketh et al 2007). This knowledge may be developed to support and contribute to phonological inventory reorganisation and improved speech production (Hesketh 2010; Bowen 2009). PA development has been successfully associated with early reading and spelling experiences for children with SSD (Gillon 2005).
Whole language approach is a top-down technique which has been applied, albeit somewhat controversially, to phonological impairments under the theory that phonology is an integral and interdependently linked part of language (Norris and Hoffman 2005). Tenets of this approach focuses on learning context, acquisition through rich environment immersion (Adams et al 1997), and parental assistance in learning through modelling (Sawyer 1991).
Impact of delayed intervention on quality of life
The International Classification of Functioning, Disability and Health-Children and Youth (ICF–CY) may be used to holistically measure the impact impairment has on quality of life (QOL) (WHO 2001). Reduced intelligibility addresses ICF-CY code b320: Articulation Functions, but is commonly observed to impact the activities and participation aspect of health in terms of 1) social impact of speaking and conversation, 2) influence of the impairment on learning and applying knowledge, 3) personal interaction and relationships, and finally 4) community, social and civic life (McLeod and Bleile 2004).
Parents in Glogowska and Campbell (2000) research on parental views of SLT, reported quantifying ‘getting there’ with intervention as when they perceived their child was managing typical learning, making friends and not being identifiable as different from peers. Data supporting the PP of functional communication may be captured in the therapeutic goals of ICF-CY activities and participation.
Reduced intelligibility caused by SSD may have a detrimental psychosocial impact on children (McLeod and Bleile 2004). Resulting communication breakdowns also place children at risk of literacy difficulties (Anthony et al 2011; Harrison and McLeod 2010), academic failure (Gillon 2004; Fujiki et al 2001), reduced phonological processing skills (Preston and Edwards 2010; Hesketh, 2004), and at increased risk of bullying (Marcharey and von Suchodoletz 2008). Overby et al (2007) also found teachers had lower expectations of students with SSD.
Parents as agents of therapy: the changing role of SLTs
Current demand for services has led SLTs to employ a pragmatic approach to caseload management. In particular, service delivery models are being closely scrutinised regarding e.g. agent of therapy (Dodd 2005). Law et al (2002; 2004) discuss consultative service delivery whereby an indirect approach is taken to intervention, placing emphasis on parents to carry out intervention under SLT guidance. This approach facilitates more children receiving frequent intervention (Hayes 2012) and may provide a unique opportunity to maximise therapeutic outcomes, generalisation and maintenance (Schooling et al 2010).
Research conducted on parent-led phonological intervention is limited (Glogowska and Campbell 2000; Washington et al 2012). However, when Watts-Pappas et al (2008) surveyed SLTs (n=2200) 98% responded positively that parental involvement is essential for effective speech intervention. Studies that have investigated parents as agents of therapy have involved lengthy parent training e.g. Dodd and Barker (1990) examined the efficacy of parents and teachers implementing MP following 22 hours of parent training, and found significant improvements in percentage consonants correct (PCC). Eiserman et al (1992) also found no significant difference between a clinician-led and parent-led programme, although clinical preparation time proved equally resource-heavy. Other parent-led interventions e.g. It Takes Two to Talk language intervention, equally require extensive parent training, but findings include more balanced interaction and transferable communication strategies (Konza et al 2010). However, a parallel goal of empowering parents to become their child’s primary facilitator is noteworthy.
Is a home programme needed?
In Ireland 2,406 children were registered with a speech and language disability in 2011 (Department of Children and Youth Affairs 2012) and an estimated 23,000 children were on SLT national waiting lists in 2010, with approximately 4,000 children waiting one to two years (Children’s Rights Alliance 2011). While specific Irish statistics are not available, in the UK clients aged 2-6 diagnosed with PD account for 57.5% of referrals (Broomfield and Dodd 2004).
For some children, difficulties are neither confined to speech or early childhood (McCormack et al 2009), and for this reason a generic HP may positively impact holistic development. The HP is particularly relevant as Dodd and Whithworth (2005) found children may go past the key intervention age while prevention of literacy issues through phonological intervention is recommended before starting school (Bird et al 1995; Leitao and Fletcher 1997; Nathan et al 2004).
Why measure parental perception?
SLT research tends to focus on traditional measures of child outcome ratings (i.e. PCC) instead of PP (Glogowska and Campbell 2000), and the previous generations of this research are no exception. However, an essential and unique insight is offered through inclusion and understanding of PP (Washington et al 2012). With 95% of SLTs reporting usually recruiting parents as agents of therapy through homework activities (Watts-Pappas et al 2008) PP is an understudied phenomenon. Watts-Pappas and colleagues continue that consultation and enjoyment of intervention are crucial factors in therapeutic gains and compliance. A sentiment reiterated by Brookman-Frazee (2004) who further suggests that PP may enable intervention development that will suit family routine. PP is therefore a necessary and fundamental element to development of the HP.
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My Mission
Empowering parents with an original, proactive and easy-to-use service for speech therapy at home.