Transcript Document

Inclusion into mainstream schools
and kindergartens
Elspeth McCartney
University of Strathclyde
Audiologopædisk forening (ALF) Yearly
Seminar, Nyborg, Denmark, 26th March
2014
Overview
 The format of this session is presentation,
and discussion
 The presentation will outline social
inclusion policies, and resulting :
• implications for SLTs’ models of working
• implications for equity of service provision
for all children.
Overview
 Research evidence, concentrating on
language impairment as the example.
 Implications for services.
Overview
 It will list three factors that support speech,
language and communication (SLC)
intervention in mainstream schools:
1 Schools sustaining a good
communication environment
2 Delivery of language-learning activities
3 Fostering good co-working relationships
Policies
 Internationally, there are policies on social
justice and social inclusion, which:
• Stress child wellbeing and outcomes
• Focus on the needs and wellbeing of all
children, not just selected children
• Stress co-working amongst practitioners
Examples
• Scotland - Getting it Right for Every Child policies (SE,
2005, 2010)
• USA – No Child Left Behind act (2001)
• England – Every Child Matters agenda (DfES, 2004)
• Northern Ireland – Extended Schools initiative (DE, NI,
2005)
• Wales – A Fair Future for Our Children (WAG, 2005)
• Eire – Giving Children an Even Break (DoES, IE,
2001)
• Denmark Folkeskole Act (2012)
Mainstream school
 Usually includes a presumption that children
are educated in their local mainstream
(normal) kindergartens and schools
 However, many children still attend special
schools, and ‘units’ in mainstream schools
 Some children have mixed placements
Implications for SLT services
 Increases potential demand for services
 Increases tension between equity of
access and SLT service capacity
 Suggests new roles, such as preventative
work, but does not remove existing roles
Implications for SLT services
 Suggests SLTs work with, and through,
others
 This is to allow the best social languagelearning environment for a child: here
within the classroom
 But also becomes a means of coping with
high demand
Who employs SLTs in school?
• US – mainstream schools services
• How and where the SLT works defined by
the school principal.
• SLTs support curriculum aims within a
child’s education plan
• Clear decision-making, but rigid
application of decisions
Affect what can be done and roles
 US - only concerned with education
 Issues if non-educational issues arise –
e.g. cleft palate
Who employs SLTs in school?.
 UK - National Health Service (NHS),
recently private SLT companies (England)
 NHS services are free a point of use
 Education Authorities may transfer funds
to NHS or company
 SLTs decide own models and interventions
– may be service-wide policies
Affects what can be done and roles
 UK – all speech, language and
communication can issues can be considered
 Medical information exchange is easy.
 Confidentiality can impede information
exchange with schools
 Limits SLT roles – e.g. re. ‘co-teaching’ and
non-referred school children
 Does not promote consistent practices
Who employs SLTs in school?
 Denmark – Local Authority, allocated to
the Pedagogic Psychological Counselling
Office.
 SLT has ‘independent responsibility for
children in need of therapy in schools and
day care centres. Overall responsibility lies
with the head of the Counselling Office,
usually the leading psychologist.’
Denmark??
 What SLC issues can be dealt with in
schools?
 What roles can SLTs fulfil?
 Confidentiality – to whom can information
be transferred?
UK models of service delivery
 UK examples: models of working in
schools and duty of care.
 Can lead to some confusions.
UK Royal College of SLT model
Specialist provision
Targeted provision
Universal provision
Children
with
additional
needs
Vulnerable
children
All children
Models of service
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Universal – general, appropriate for and offered
to all children
No SLT open duty of care.
Child not identified, so no consent needed
SLT examples leaflets, general public health information
school staff training, whole-school improvement
preventative work
education about SLT roles.
Models of service
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Targeted - for children not needing specialist
SLT input. To help ‘vulnerable’ children ‘catch up’.
No SLT open duty of care.
Child not identified, so no consent needed
SLT examplessupporting school staff in delivering language
groups within school for vulnerable children
discussion of principles without identifying child,
pre-referral/post-discharge work.
Models of service
 Specialist service – intervention planned for an
individual child (although it could be delivered in
a group).
 SLT has open duty of care.
 Parent and child consent needed (consent also
needed for assessment)
 SLT examples –
• SLT or SLT assistant works with the child, or a
small group
• SLT plans with school staff and sets goals.
School staff carry out resulting languagelearning activities, individually or in groups.
•
Episodes of care
 If a child has specialist therapy, SLTs plan
one episode of care
 Review at the end – goals met or not met
 Discharge, or begin new episode of care
Confusion for UK schools?
 May not understand ‘episodes’ or ‘discharge’
 May not understand need for ‘duty of care’ or
for parental consent
 May not understand why other school
children cannot be seen by the SLT
 The model depends upon planning and SLT
duty of care, not who does what or where.
Confusion for UK schools?
 When a child undertakes language-learning
activities in a group, in school, delivered by
school staff, it may not be clear if they are
receiving a targeted service, following SLT
general advice to a school;
 or a specialised service planed for them by an
SLT but delivered through school staff (indirect
therapy).
Managing caseloads
 The above models help to manage SLT
caseloads.
 However, they do need to be explained to
school staff, who do not use the same
concepts.
 It helps to decide jointly on levels of need,
descriptions of problems, and pathways.
An example
 Cambridgeshire SLT services via
http://www.slc.cambridgeshire.nhs.uk at
 https://www.slc.cambridgeshire.nhs.uk/At
School/DescriptorsandResponses/tabid/10
45/language/en-US/Default.aspx
Cambridgeshire
 Much work between SLTs and education
services, planning and adapting over many
years
 Developed descriptors of what a child can do
in class, matching levels of functional
difficulty;
 and responses needed from school and
SLPs.
Attention and Listening Level 1
 Descriptors
• Tires easily when listening and can
sometimes appear inattentive or distracted
 Responses
• Ensure that ‘Wave 1 Quality First Teaching’ is
embedded in classroom.
• Reduce distractions.
• Gently prompt child to listen by name
• Intersperse teacher talk with other activities.
• Support adult talk with multi-sensory resources
e.g. visual (drawings, diagrams,
photographs etc.) tactile, kinaesthetic.
Attention and Listening Level 4
 Descriptors
• Attention is fleeting and is either
unfocused or over-focused on a detail/object
• Needs constant prompting/reminders to listen
 Responses
• As before, plus
• Provide daily listening and attention practice games
• Focus on and reward
listening and attention on a daily basis.
Child: concern
identified
By parent
By educational setting
Health visitor/others
Preschool or school do
initial assessment of
needs using descriptors
Refer to speech and
language therapy
SLT report sent to
parents/educational
setting (level 1&2)
Level 1
Prioritise area of need and
cross reference to descriptors
(best fit) Consider a CAF
Level 2
Language
Responsibility for monitoring
rests with parents/carers or
educational setting
Plan intervention: guided by, e.g.
responses to need. /IDP
Implement plan
Level 2
Speech
Level 3
Level 4
If assessed by team in educational setting,
refer to SLT for assessment
SLT report sent to parents with advice.
Copy of report sent to STT, school and
other agencies involved, e.g.
paediatricians, EPS, CAMH. (Reports state
that advice on implementing strategies
may be obtained from STT)
Review intervention (reassess
concern)
Has the child made satisfactory
progress?
If yes
Repeat
cycle, or if
child has
achieved
aims, no
further
action
If further support is
required to
implement
programme
STT
Educational setting and parents
implement SLT advice
Speech and language therapist
allocated (within 18 weeks of
referral)
If no
Educational
setting to
reflect on why
programme is
not working.
Assess barriers
to progress
Progress /intervention carried out
in school and by parents reviewed
as appropriate
If there are
additional needs that
require clarification
Refer to appropriate
professional for
clarification of
needs (SLT, EPS,
STT, paediatricians)
Plan/do/
review cycle
Intervention implemented,
therapist, parents and school team
work together towards agreed
targets
Plan/do/review cycle
SLT discharge arrangements.
School continues plan/do/review
cycle
Plan/do/
review cycle
Denmark?
 What models?
 What joint planning?
 What joint working?
Evidence of effectiveness
 SLTs adopt medical approaches to developing
interventions via clinical trials.
 The aim is to develop practitioner- and client‘proof’ interventions, i.e. effective for most
clients that fulfil stated criteria.
 The aim is to construct replicable, reliable
interventions. This is important as SLTs move
towards working with others.
 This is not however an approach familiar to all
schools.
Levels of evidence: reminder
 Randomised control trials (RCTs): best
evidence as they allocate clients randomly and
so avoid undetected selection factors; a
comparison control so there is a counter-factual
case, and large-enough numbers. Therefore
results transfer to similar clients and contexts.
 Controlled cohort studies: may show client
selection bias, e.g. due to referral patterns.
Results may transfer to similar clients and
contexts unless undetected bias is present.
Levels of evidence: reminder

Case study series: no control, e.g. for
changes that would have taken place anyway.
There is therefore uncertainty about
intervention effects.
 Individual case studies: as above but
depend on one client’s characteristics.
Results cannot be assumed to transfer to
others.
 Professional opinion on good practice:
often untested.
MRC trial sequence
(2000 version)
 Pre-clinical theory: what looks promising.
 Phase I: Modelling components of interventions.
 Phase II: Exploratory trials: trying out
interventions.
 Phase III: Definitive RCT: determining efficacy.
 Phase IV: Long term implementation:
determining effectiveness under real-life
conditions. No control needed.
 Phase V: Efficiency: costs and benefits, quality of
life, reducing costs
Overall implications
 Interventions that work in trials do not
always prove effective in real-life services.
 Due to lack of fidelity to therapy
procedures, and different client
characteristics.
 SLTs lack RCTs, in many areas, and also
Phase IV Implementation studies.
The ‘What Works’ Website
 The Communication Trust ‘What Works’ website
lists commonly used interventions:
https://www.thecommunicationtrust.org.uk/schools/
what-works/whatworkssearch
 About half have ‘moderate’ evidence (RCTs)
 Rest have ‘indicative’ evidence (case studies,
cohort studies, professional opinion)
 See SpeechBITE: http://www.speechbite.com
Research on SLI in schools
 RCT – children with SLI aged 6 -11 in
mainstream primary schools (Boyle et al. 2007,
2009). Referred by SLTs.
 Specialised language therapy delivered by an
SLT or SLT assistant to children individually or in
groups. 5 SLTs and 5 SLT assistants.
 124 children undertook research therapy:
 3 times per week for 15 weeks, in 30 - 40
minute sessions,
 delivered within the child’s school, or in
another school for some grouped children.
Research on SLI in schools
 The language therapy was manulised,
(McCartney, Boyle et al 2004)
 Language therapy areas were
comprehension monitoring, vocabulary
development, later grammar and narrative.
Research on SLI in schools
 Research intervention children received
around 22 hours of specialised
intervention
 Control children received ongoing
therapy from their local SLT service,
carrying on as before the trial. They got
much less therapy than intervention
chlldren.
 A one-year follow up after research
intervention ended showed limited therapy
Outcomes
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Significant benefits for expressive language
Fewer benefits for receptive language.
No benefits for control group.
At one-year follow up, not much therapy had
been received. Intervention children were still
slightly ahead of control, but the gap was
narrowing,
Outcomes
 There were not differences in outcomes
between therapy delivered in group or
individually, or by SLTs or SLT assistants.
 Assistants were cheaper than SLTs.
 Indirect work through assistants can be
effective, if well supported and if they carry
out the intervention as planned.
 Group work can also be effective.
Costs and benefits
 The trial was further analysed in the RCSLTcommissioned ‘Matrix’ report ‘An economic
Evaluation of SLT’ (see RCSLT web-site).
 Matrix concluded, if language gains were
maintained and affected literacy levels, annual
net benefits would scale up to £623.4m in
England, £58m in Scotland, £24.2m in Northern
Ireland, and £36.1m in Wales!
 The overall economic impact of intervention
would be considerable.
The Manual
• The RCT therapy programme appears on the
Communication Trust ‘What Works’ website as
the Strathclyde Language Intervention
Programme – SLIP
• The Language Therapy Manual can be
downloaded free: search for “Language Therapy
Manual” on the Strathclyde University Website
However ….
 A cohort of children selected to the same
criteria undertook the same therapy but
delivered by school staff ( McCartney et al.
2011)
 Historical control from the RCT showed no
similar evidence of effectiveness
Why the difference?
 Not as much language-learning activity was
given.
 The cohort study therapy logs were
incomplete, but showed that the therapy had
not been delivered as planned.
 Transferring intervention to nursery/school
staff was not shown to be efficacious in this
study.
Need for more study
 There is a need for lots and lots more study.
 There are few examples of trial sequences,
working systematically towards effective
therapies.
 But – what is there is, does not support
indirect therapy in schools, despite its
widespread use by SLTs’.
Denmark?
• Experiences of working through teachers?
Three factors that are helpful
1. A communication-friendly classroom, and
very good (‘quality first’) teaching as a
universal factor
2. Sufficient language-learning opportunities
for children with problems
3. Good working relationships between SLTs
and teachers
1 - A ‘communication-friendly’
classroom
 Mainstream schools and kindergartens
should provide a learning environment that
facilitates communication: a
‘communication-friendly’ classroom.
 This may have to be augmented for
children with SLCN.
Better Communication Research
Programme (BCRP)
 BCRP research in England (Dockrell et al. 2012)
developed a Communication Supporting
Classrooms (CsC) observation tool measuring:
• Language Learning Environments (physical
aspects of the classroom, language resources);
o
Better Communication Research
Programme (BCRP)
• Language Learning Opportunities (e.g.
structured conversations with children, small
group discussions, joint book-reading), and
• Language Learning Interactions (adult talk
supporting children, e.g. repeating what a child
says, encouraging a child to use new words, and
offering clear language choices such as forced
alternatives).
•
Better Communication Research
Programme (BCRP)
 Language Learning Environment scores were
significantly higher than for Language Learning
Interactions,
 Language Learning Interactions scores were in
turn significantly higher than for Language
Learning Opportunities.
Better Communication Research
Programme (BCRP)
 The CsC tool was used to observe before and
after pre-planned SLT interventions that aimed
to improve classroom learning environments.
 No significant changes in classrooms were
shown following these interventions, but few
studies were observed.
 Much remains to be done to develop school talk
environments.
2 - Language learning opportunities
 Boyle et al. (2007, 2009) RCT children
undertaking research intervention received
a great deal more therapy than those in
the control group.
 In the follow-up year, they all reverted to
low levels of therapy.
Language learning opportunities
 In the cohort study, education staff also
failed to deliver much therapy as planned.
 It appears that amount of intervention
affected progress.
 It also appears that schools may need
help to deliver this.
Language learning opportunities
 We therefore undertook an evaluation study to
develop:
• ways to clarify procedures and expectations
about delivery of language learning for teacher ,
and
• relevant information for teachers, and
• monitoring of delivery of language interventions.
Language learning opportunities
 The outcomes are summarised in McCartney,
Boyle et al. (2010)
 Materials may be downloaded by searching
“Language Support Model for Teachers” on the
Strathclyde University website.
 Teachers were concerned about lack of time to
spend with individual children, and SLTs passing
work on to teachers, and about langauge
teaching being new to them.
Language learning opportunities
 The Language Support Model was
considered helpful in ensuring sufficient
language-learning activity is conducted with
a child – or indeed chart when things are
not going to plan!
 Although we have had very positive
feedback from SLTs using these materials
with teachers, there has been no trial.
3 - Good co-working relationships
 Many theories suggest that good coworking relationships are key to successful
co-practice.
 Some models of co-working include
‘mutual trust and respect’ in their models –
to form ‘collaborative’ models (or other
terms).
Good co-working relationships
 Despite such theories about what is required
in good SLT-teacher working relations
(Forbes & McCartney 2010), there is little
evidence on SLT-teacher working relations.
 Worries are that SLTs may use teachers as
assistants, ignoring their professionalism.
Good co-working relationships
 As well as managerial factors, interpersonal factors play a large part in good
co-working.
 SLTs should feel welcomed in schools,
and should be seen by schools as helpful
and approachable.
Good co-working relationships
 However, we know very little about how
they do feel about their roles!
 Report therefore on the one available
study to hand – again the RCT by Boyle et
al. (2007, 2009)
Good co-working relationships
 The 5 research SLTs and the 5 research
SLT assistants were asked about their
experiences in schools during the project.
 They responded about their experiences
around each child separately.
 They had worked in schools, but not in
classrooms.
Research SLT/As’ views
 The research project had planned reports and
information for teachers.
 In addition, SLT/As reported on frequency of
contact with children’s schools as:
•
every two weeks or more - 38%
•
every three to four weeks - 20%
•
about three times in the 15 week period - 26%
•
less contact/ not noted - 16%.
Research SLT/As’ views
 Forms of contact included phone calls,
packs/worksheets, notes, meetings,
diaries etc.
 Two or more forms of contact were
used with schools for 79% of children.
 Schools initiated contact with the SLT/A
for 76% of children.
Research SLT/As’ views
 SLT/As felt that for 87% of children schools
were not reluctant to have contact;
 But for 13% of children schools were reluctant
to have contact: “[I was] always chasing [the]
teacher to give information, to arrange meetings
etc.”
 (1% no response)
Research SLT/As’ views
 SLT/As felt:
• very welcomed indeed by schools for
37% of children: “I was shown the
staffroom, instructed to make coffee if I
wanted to. The head-teacher was often
around and had informal talks.”
•
welcomed by schools for 32% of
children.
Research SLT/As’ views
fairly welcomed by schools for 27% of
children: “The head-teacher [was]
occasionally critical of therapy. [I] had to
work in the main corridor (very
busy/noisy).”
•
not very welcomed by schools for 3%:
“They never remembered I was coming.”
•
(no response 1%).
•
Research SLT/As’ views
 SLT/As thought:
•
for 35% of children schools acted on
advice given:
“[The] class-teacher informed me that she
was implementing the strategies given.”
Research SLT/As’ views
for 3% of children schools did not act on
advice:
“Ideas and cue cards that I gave to the
teacher at Xmas were not used. When I met
with [the] teacher at the end of [the] block,
she had little recollection of areas that I had
previously discussed with her and many
ideas had to be re-discussed.”
•
Research SLT/As’ views
 For 61% of children the SLT/A was not
sure if advice had been acted upon:
“I met the head-teacher by chance postintervention and he commented that he has
just been reading the report and found it had
good ideas to use.”
Research SLT/As’ views
 In summary:
 A full range of views was expressed SLT/As.
 SLT/As used a variety of means of contacting
schools.
 SLT/As on the whole felt welcomed and supported
by schools.
 SLT/As were unsure if the advice given by them
was acted upon.
Good working relations?
 The last statistic is worrying.
 Were SLTs afraid to ask – too
confrontational, not wanting to know????
 But in discussion, it it not an unusual
finding.
 Can we go on not knowing what happens?
Denmark?