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1. PREDICTION / RISK There was a welcome emphasis on prediction. For example, Penny Roy is investigating whether very early processing skills are better predictors of outcome than existing language measures in young children referred to speech and language therapy with concerns over language. She is looking at the potential of non-word repetition as a predictive marker, but the emphasis is on the assessments being quick to complete and fun. The particular risks associated with poor comprehension are becoming clearer. For example, Gina Conti-Ramsden and Nicola Botting found that the children with specific language impairment who were bullied were more likely to have poor - as opposed to average - comprehension. Undetected comprehension problems are significant for children with emotional behavioural disorders according to James Law. And Maggie Vance found poor comprehenders struggled in their ability to cope in noise compared to quiet. Clinically, we should be cautious about specific diagnosis and prediction, particularly with children under five, and always emphasise potential for change and development. Gina Conti-Ramsden says outcome seems to depend on how, for example, IQ interacts with other factors rather than the level of IQ per se. In therapy it may help to manage the risk by supporting the resilience factors. 2. AUDITORY THERAPY Maggie Vances view is that auditory deficits are neither a necessary nor sufficient cause of specific language impairment, but may be one of a number of factors for at least some children. We should be aware that the ability to cope with speech in noise is developmental and may also be diagnostic. We need more clinical assessments, but in the meantime can deliver a combination of therapy to children whose auditory skills are weak: I. Top-down: traditional language therapy, enhancing the ability to use context to support weak speech input processing skills and the detrimental effect of background noise. II. Environmental modification: Classroom noise ranges from 35-70dB, but 35dB is desirable. Amplification to improve signal to noise ratio is commercially available but not proven effective. Clear speech (slower, more frequent and longer pauses, clear articulation, greater pitch range) is understood more easily than conversational speech. III. Bottom-up: training auditory discrimination and listening skills, including environmental sounds and minimal pair work. But be aware that computer based training has mixed efficacy results... ... Dorothy Bishop did such a study in schools with children with receptive language impairment. With no significant or generalisable effect, the study was stopped. Dorothy is now sceptical about whether phonological awareness is the key to improving literacy in such children. In general, she says whatever we are teaching them, learning occurs very, very slowly, and the children need small amounts from shorter, more regular input. 3. WORKING WITH SCHOOLS Julie Dockrell explained that good practice is a social construct which may be necessary for - but it not the same as - effective practice. Identifying impact, assessing, monitoring, auditing and changing structure are examples of good practice but outcomes are the measure of effective practice. We need to think about how the individual therapy, programmes and training we offer will improve attainment. Julie hopes to see the development of an oral language curriculum based on research evidence. She also wants a focus on developmental trajectories and identification of effective intervention. In schools with good practice in the education of children with specific speech and language difficulties, Julies findings leave us with questions: Learning support assistants play a major role with children with speech, language and communication needs - are they sufficiently supported? Educational psychologists and speech and language therapists have little contact would the children benefit from more? Parents feel teachers do not understand the impact of the difficulties. They also feel well informed but not involved ... 4. SUPPORTING PARENTS James Law believes there is a resistance around parental involvement in education from professionals, and also some parents, perhaps because of their own negative experiences of school. Teacher Jill McMinn and Gill Britten, a family learning co-ordinator, believe such parents are under huge stress and that this affects their ability to become involved. The impact on the family includes loss, guilt, denial, resentment, isolation, fear of the future and exhaustion. Supporting the child is relentless and can be repetitive and boring. Rather than language, parents are concerned about everyday issues such as tooth and hair brusing, getting dressed and going places. Anxiety and stress can mean worries are blown out of all proportion and that stress blocks clear thinking - increasing involvement could be like opening a Pandoras box. Parents rarely have switchoff time for themselves. Jill and Gill have worked incredibly hard together to reach parents of children in a language resource. They warn that the initial stages were particularly traumatic. Gill has introduced a variety of non-verbal techniques to enable parents to explore their feelings, relationships and needs. SPEC (Supporting Parents of Exceptional Children) - contact jillmcminn.public@ to order a research report. 5. CHANGING NEED MEANS CHANGING PROVISION The children with specific language impairment in Gina Conti-Ramsden and Nicola Bottings study have now reached the age of 16. Their continuing difficulties are not only to do with communication, but with quality of life. Their families also need ongoing support with a wide range of issues. In general, being bullied, poor social skills and (co-morbid) mental health problems are more likely in this group. In therapy, our assessment and support must acknowledge these wider concerns. We need to look beyond language scores and listen and ask the right questions so we can help them reach their potential. We should consider offering cooperative group experiences and peer mediated intervention as well as teaching social skills, working with the family and training teachers. We should promote opportunities for vocational studies and be reassuring that a work environment may in time serve these pupils better than a school. 6. HONESTY IS THE BEST POLICY Rather than attempting to fill in the hole for young adults with high level social communication difficulties, Helen Ortner works to bridge the gap. This means being honest about their difficulties, using video to challenge beliefs, and referring for cognitive behaviour therapy to help with rigid thought patterns. Honesty has to include allowing failure, however hard it is to do. It is also important not to tolerate unacceptable behaviours. James Law reported that reviews of social skills training are not encouraging, but that this may be because low dosage intervention is not worthwhile. Helen teaches specific social skills in context, and does social autopsies (unpicking situations that went wrong and planning for the next time). She finds she can push clients in a way that parents cant because there arent the emotional ties. But even better, sibling and peer mentoring is useful because of the level of honesty they are prepared to show. 7. THE FUTURE Dorothy Bishop believes we all have a responsibility to bring research and practice closer together. She is very keen to evaluate the effectiveness of interventions by creating randomised controlled trial conditions in clinics and schools. She says it is very important that the researcher does not know which group the client has been assigned to, and that the assignment is random, as otherwise it is too easy to deceive yourself about effectiveness. As Director of the Centre for Integrated Healthcare Research at Queen Margaret University College, James Law is keen on good quality research. As narrative reviews are biased because they start with an opinion, he favours systematic reviews that start with a predetermined research question. James recommends quoting systematic reviews when putting forward an article for publication, and looking for such evidence nationally and internationally:;; We are where we are, but its clear from this conference we have a fair idea where were going. As Gina Conti-Ramsden said, we need to remember that we are working in a relatively new area and that our understanding will keep changing with longitudinal studies that examine the wider impact of speech, language and communication needs.







The NAPLIC conference: Speech, language and communication needs: current trends in theory and practice gave editor Avril Nicoll plenty of food for thought. NAPLIC is the National Association of Professionals concerned with Language Impairment in Children. The conference was on 19-20 March, 2005 at the University of Warwick.

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