Audiologopædiskforening (ALF) Yearly Seminar, Nyborg, Denmark, 26th March 2014

Inclusion of children with speech and language impairments into mainstream schools and kindergartens

Elspeth McCartney, School of Psychological Sciences and Health, University of Strathclyde, Glasgow, Scotland

Abstract

European policies on social justice and social inclusion involve a presumption that children with disabilities,including childrenwithlanguage impairments,will wherever possible be educated in their local mainstream (normal)kindergartens andschools. For this to be successful, three factors should be present: schools and kindergartens should provide a facilitating communication environment; there should be opportunities for children with language impairments to learn and practise relevant language skills, and there should be positive and transparent working relationships amongst the adults concerned - school staff, therapy staff, families and others.

There is research evidence to suggest that it ispossible to developthese three factors in mainstream educational settings, but also evidence that they are not always present in real-life contexts.Thesession willreview this evidence, and where and how the mainstream educational settings investigated succeeded or fell short of meeting children's needs. This will lead to more detailed discussion of good mainstream school practice, and of theparticularimplications for therapy services in organising provision.

Synopsis

Inclusive education and co-working

Across Europe, policies on social justice and social inclusion have resulted inthe presumption that children with speech,language and communication needs(SLCN- UK umbrella term used here)will wherever possible be educated in their local mainstream kindergartens andschools (e.g. Folkeskolen Act (2012) via

There is also an expectation that a range of professionals will work together to support a child, including Speech and Language Therapists (SLTs: UK term used here). SLTs are employed by a variety of services: education services in Denmark but the National Health Service in the UK. Complex issues around co-working therefore require tobe debated, to meet the needs ofdifferent cultures, service structures and educational priorities; andfor the role of SLTs to be written into educational policies. Suchdebates musttypically take account of the fact thatSLT numbers are small, that budgets are tight, and that funding for SLT services has to be negotiated.

Government policies have required schools to review their own procedures and classroom practices in relation to inclusion, and teacher educators to prepare all teachers to support children with disabilities. This is however an on-going process. SLTs are also grappling with how best to offer services within mainstream schools. Relevant evidence will be presented here from a series of trials carried out in Scotland for children with language impairment.

Models of service provision

As a means of reaching all children, with limited resources, many SLT services have re-configured their services to provide universal, targeted and specialised services.

The UK Royal College of Speech and Language Therapists (RCSLT) guidelines (Gascoigne, 2006) define these as:

Universal [services] ensureall children have appropriate early language and communication opportunities.

Targeted [services] giveadditional support, in a meaningful, functional context, to children who are vulnerable in terms their communication.

Specialist [services] support children with specific speech, language and communication needs, delivered in the place most appropriate for the child’s learning and involvingthose who spend the most time with the child: parents, carers, teachers, support staff.

These are further defined in Scotland (Scottish Government 201) in relation to the SLT duty of care.

Universal service – general, appropriate for all children. No SLT open duty of care. The child is not identified, so no consent is needed. Examples are provision of leaflets; general public health information; school staff training; whole-school improvement; preventative work; education about SLT roles.

Targeted service - for children not needing specialist SLT input. No SLT open duty of care. The child is not identified, so no consent is needed. Examples are supporting parents/school staff; discussion of principles without identifying a child; pre-referral/post-discharge work.

Specialist service –interventionsplanned for an individual child (although the child could receive services in a group by a non-SLT). SLT open duty of care. The child is identified, so parent and child consent is needed. Examples are where an SLT or SLTassistant works directly with a child; or indirect work where an SLT plans with school staff/parents to set joint goals, but others carry out language-learning activities- ‘those who spend the most time with the child’ as RCSLT above.

Targeted and specialist models are causing some confusion for school serevices: a child undertaking language-learning activities within a peer-group in school, taught by a school teacher or classroom assistant, could be undertaking targeted therapy or specialist therapy. Some published language therapies can be used by non-SLTs for vulnerable children ‘at risk’ as targeted interventions, or tailored by SLTs into specialist interventions for referred children, albeit delivered by classroom staff or parents. Clarification of duty of careand consent are the key issues.

It is also most important for school and SLT services to know, and agree, what model is being used, and the relevant staff roles. There may be no clear rationale for deciding which children get which model of service, and fears that costs may influence decision-making. Where school and SLT services collaborate over time to produce transparent decision-making frameworks, equity and smooth-running services are facilitated. For a very good example, see Cambridgeshire SLT services via at

Service delivery by non-SLTs

Boyle, McCartney et al. (2007, 2009) used a randomised controlled trial to compare a specialist language service for children with language impairment aged 6 – 11, delivered in their mainstream schools via an SLT or SLT Assistant to children individually or in groups, with a usual-therapy control group. 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. Control children received on-going therapy from their local SLT service, carrying on as before the trial.

Children in all four research modes got much more therapy than the control group, and their expressive (but not receptive) language levels increased significantly. It made little difference whether an SLT or SLT Assistant delivered therapy, or whether children were seen in groups or individually. Assistants were on the whole cheaper (although SLTs working with groups delivered most gain on test scores per unit cost).This study has implications for extending SLT services via trained assistants in schools. The Language Therapy Manual (McCartney, Boyle et al. 2004) developed for this project can be accessed via

Three requirements for a ‘good’ service

Whereas therapy delivery mode did not markedly affect progress, three cross-cutting factors can be identified that appear to be important for children within mainstream settings:

  1. mainstreamschools and kindergartens should provide a learning environment that facilitates communication: a ‘communication-friendly’ classroom. This may have to be augmented for children with SLCN.
  1. there should be sufficient opportunity for children with language impairments to learn and practise language skills relevant to them, and this may require tailored language goals and additional learning time.
  1. there should be positive and transparent working relationships amongst the adults concerned - school staff, therapy staff, families and others.

1The‘communication-friendly’ classroom

Creating a facilitating language environment for school-aged children involves working with teachers to offer children a good language and listening experience. The Language Therapy Manualhas a section on creating a ‘Communication Friendly Classroom’for SLTs to discuss with teachers. However, more recent and extensive work was carried out in England as part of the Better Communication Research Programme (BCRP) Dockrell et al.(2012) developed theCommunication Supporting Classrooms (CsC)observation tool, and observed mainstream classrooms’ Language Learning Environment (physical aspects of the classroom and its language resources); Language Learning Opportunities (provision of structured conversations, small group discussions, joint book-reading) and Language Learning Interactions (adult talk supporting children, such as repeating what a child says, encouraging a child to use new words, and offering clear language choices such as forced alternatives).

Scores for the Language Learning Environment were significantly higher than for Language Learning Interactions, but scores for Language Learning Interactions were significantly higher than for Language Learning Opportunities. Using the CsC tool before and after pre-plannedSLT interventions that aimed to improve the classroom learning environment showed no significant effects, but numbers of studies were small. Much remains to be done on developing school talk environments.

2Language-learning opportunities

In the Boyle et al. (2007, 2009) RCT children receiving research intervention received a great deal more therapy than those in the control group. In a follow-up, cohort study, we selected mainstream-school children using the same criteria as in the RCT, and used language learning activities from the Language Support Manual, but with delivery through education staff. The children should have received the same mount of therapy, however, they received much less, and the gains observed in the RCT were not replicated (McCartney, Ellis et al. 2009; (McCartney, Boyle et al. 2011). This suggests that amount of language-learning activity is important, and that it cannot be assumed that mainstream schools can deliver sufficient time. We followed-up with an evaluation study that developed ways to make procedures and expectations clear, and provide relevant information for teachers, and monitor delivery of intervention: the Language Support Model for Teachers (McCartney, Boyle et al. 2010 and However, although we have had very positive feedback from SLTs using these materials with teachers, there has been no formal trial. Nevertheless, such mediating material could well be helpful in ensuring sufficient language-learning activity is conducted with a child – or indeed noting when things are not going to plan!

3Positive and transparent co-working relationships

Some theories of co-working suggest that good relationships are key to successful co-practice, and include ideas of ‘mutual trust and respect’ in their models – to form ‘collaborative’ approaches (or similar terms) (Forbes & McCartney, 2010). However, SLTs are often ‘visitors’ to schools (at least in the UK), and have limited opportunity to build mutual trust and respect.

SLTs should feel welcomed in schools, and should be seen as helpful and approachable. However, this is a largely undocumented area, not do we know much about how they in fact feel about their roles! Boyle, McCartney et al. (2007) therefore asked their five research SLTs and five research SLTAssistants about their experiences in schools, respondingseparately for each child on their case-load. Forms of contact with the child’s school included phone calls, packs/worksheets, notes, meetings, diaries etc., with several forms used for most children.

SLT/As reported 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.” (and 1% no response).With again no response for 1%, they reported feeling ‘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.” For 32% of children they felt ‘welcomed’ by schools, ‘fairly welcomed’ for 27%: “The head-teacher [was] occasionally critical of therapy. [I] had to work in the main corridor (very busy/noisy.)” and ‘not very welcomed’for 3%: “They never remembered I was coming.”

In terms of whether schools acted on advice given by the project, SLT/As thought this was happening for 35% of children: “[The] class-teacher informed me that she was implementing the strategies given.” 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.”And for 61% of children the SLT/A was not sure (!):“I met the head-teacher by chance post-intervention and he commented that he has just been reading the report and found it had good ideas to use.” If this is at all typical, SLTs’ experiences are very varied, but the fact that 61% had not found out if schools had acted on advicewas perhaps the most worrying statistic!

References*

Boyle, J., McCartney, E., Forbes, J. & O’Hare, A. (2007). A randomised controlled trial and economic evaluation of direct versus indirect and individual versus group modes of speech and language therapy for children with primary language impairment. Health Technology Assessment, 11 (25), 1-158.

Boyle, J., McCartney, E., O'Hare, A., & Forbes, J. (2009). Direct versus indirect and individual versus group modes of language therapy for children with primary language impairment: principal outcomes from a randomised controlled trial and economic evaluation. International Journal of Language and Communication Disorders, 44, 6, 826-846.

Dockrell, J. Backopoulou, I., Law, J., Spencer, S., Lindsay, G. (2012).Developing a Communication Supporting Classroom Observation tool. Research Report DFE-RR247-BCRP8. London: Department for Education. Access via: https://www.education.gov.uk/publications/eOrderingDownload/DFE-RR247-BCRP8.pdf

Forbes, J., McCartney, E. (2010).Social capital theory: a cross-cutting analytic for teacher/therapist work in integrating children's services? Child Language Teaching and Therapy, 26 (3). pp. 335-346.

McCartney, E., Boyle, J., et al. (2004). Becoming A Manual Occupation? The Construction Of A Therapy Manual For Use With Language Impaired Children In Mainstream Primary Schools. International Journal of Language and Communication Disorders 39, 135-148.

McCartney, E., Boyle, J., Ellis, S., Turnbull, M. & Kerr, J. (2010). Developing A Language Support Model For Mainstream Primary School Teachers. Child Language, Teaching And Therapy, 26, 3, 359-374.

McCartney, E., Boyle, J., Ellis, S., Bannatyne, S., & Turnbull, M. (2011). Indirect Language Therapy For Children With Persistent Language Impairment In Mainstream Primary Schools: Outcomes From A Cohort Intervention. International Journal of Language and Communication Disorders, 46, 1, 74-82.

McCartney, E., Ellis, S. & McCartney, J. (2009). The Mainstream Primary School As A Language-Learning Environment For Children With Language Impairment – Implications Of Recent Research. Themed Invitation Issue: ‘Social And Environmental Influences On Childhood Speech, Language And Communication Difficulties.’ Journal of Research in Special Education 9, 2, 80-90).

Gascoigne, M. (2006).Supporting Children with Speech, Language and Communication Needs within Integrated Children’s Services. London: RCSLT

Scottish Government (2010).Guidance on partnership working betweenallied health professions and education. http://www.scotland.gov.uk/Resource/Doc/313416/0099357.pdf

*McCartney references are listed on my web-page at Strathclyde University:

and where copyright allows downloadable from therevia the university archive.

Searchable Evidence BasedPractice Data-Bases on SLT

The Communication Trust: ‘What Works’

SpeechBITE