What Can Speech and Language Therapy Offer Adolescents with Severe Language Impairments

What can speech and language therapy offer adolescents with severe language impairments?*

Victoria Joffe,

Department of Language and Communication Science,

City University

Introduction

If you are one of the many parents, teachers or speech and language therapists involved in some way with a secondary school-age child with language and communication impairments, you will most probably have at some time or another felt frustrated by the limited availability of speech and language therapy (SALT) and specialist support with this age group. You will also be aware of some of the significant difficulties the language-impaired secondary school age child experiences in the classroom.

Research into language development and disorders has routinely focused on preschool and primary children. However, while most preschool children have acquired the basic structures and functions of language, they continue to develop the understanding and use of increasingly complex and abstract language throughout older childhood and adolescence (Nippold, 1998). As Berman (2004) concluded from recent investigations of language development in older typically-developing children, ‘becoming a native speaker is a rapid and highly efficient process, but becoming a proficient speaker takes a long time’ (p. 10). The early years should be seen as the period of primary language acquisition with subsequent language development being a more gradual and protracted process (Nippold, 1998).

Fundamental changes in cognitive, social and educational development are evident during the adolescent period (Moshman, 1999) posing significant challenges for young people with language impairments using language to meet social and educational demands.

There is not a lot of research on adolescents with language impairment and there is a significant shortage of SALT with this group (Larson et al., 1993; Leahy and Dodd, 2002). Pediatric SALT services focus routinely on the preschool and primary school-age child. However, a significant number of secondary school age students have profound language and communication difficulties which impair learning in the classroom and impact on academic, social and emotional development. Few secondary school age children currently receive therapy, despite strong evidence for the long-term impact of speech, language and communication impairment into adolescence and adulthood (Clegg et al., 2005; Conti-Ramsden et al., 2001; Stothard et al, 1998).

The long term nature of language impairments and the demands of secondary school justify increasing SALT provision in this context. However, limited resources and lack of evidence for the effectiveness of therapy with this group, makes this difficult. Some studies have shown that therapy with secondary school-age children is effective (Larson et al., 1993; Leahy and Dodd, 2002). More studies however are needed to explore how we can help adolescents with language impairments and identify evidence-based SALT delivered in the education context. The study we talk about here looks at whether speech and language therapy helps secondary school children with their language. The study was funded by the Toyne Baby Triathlon and Afasic.

The Study

We need to find an effective way of improving language and communication in language impaired adolescents which takes into account the limited SALT resources, age of the children and the pervasiveness of their impairments. We set up an exploratory study, funded by Afasic, to see whether therapy could enhance language in this group. We compared two types of therapy 1)narrative/storytelling and 2) vocabulary training. The therapy was given by SALT students from City University and consisted of 12 sessions of approximately 50 minutes each over a six-week period with two sessions per week. Most of the children were seen in groups of between 2-5 children in school. Half the children received vocabulary training and the other half storytelling.

We wanted to see first whether SALT would improve children’s language, and second, whether differences would be found in the children’s language depending on the type of therapy they received.

Why narrative and storytelling?

Narrative therapy was chosen as it has been found to be effective with younger children (Davies et al, 2004). Narrative ability is required in school and in social settings as a means of gaining peer group acceptance. Key Stages 3 and 4 of the National Curriculum place great emphasis on speaking fluently and appropriately in different contexts and adapting language for a range of purposes and audiences. Storytelling makes heavy demands on receptive and expressive language, requiring more complex syntax and semantics, abstract and imaginative thinking, general knowledge, a range of pragmatic and discourse skills as well as drawing upon a set of internal organisational rules (Nippold, 1998). Individuals with language impairments have been found to have significant difficulties with storytelling (Liles, 1993) and narrative ability has been found to be a significant predictor of later academic performance (Fazio et al, 1993). It has ecological validity, can be undertaken in a highly structured way and targets a range of receptive and expressive linguistic skills. Nevertheless there is little research on the role of narrative as a therapy.

Vocabulary enrichment was chosen as the second therapy programme as the growth of vocabulary is an important aspect of development during adolescence (Nippold, 1988) and the lack of vocabulary is a significant barrier for children with language impairments (Crystal, 1986), particularly in relation to the demands made by secondary school. The demands on vocabulary growth in secondary school include the ability to retrieve words with speed and accuracy (Dockrell and Messer, 2004), use more complex and low frequency words, elaborate semantic networks to facilitate literacy (Ravid, 2004), and the ability to define complex vocabulary (Nippold, 1998). Despite its importance little direct time is devoted to vocabulary instruction in school (Dockrell and Messer, 2004). Vocabulary training has been shown to be effective in improving language performance (Sim, 1998; Parsons et al, 2004).

Details of the therapy

Storytelling:

This therapy, adapted from Shanks (2000), introduced the children to storytelling and focused on the understanding and telling of stories. The children were told a variety of stories and were taught about story structure including beginning, middle and end, when the story took place (‘when’), the setting of the story (‘where’), what happens in the story, i.e. the action (‘what’), the reason for the action (‘why’) the characters (‘who’) and the main climax of the story (see story planner, figure 1) (Shanks, 2000; Shanks and Rippon, 2003). Students were also encouraged to make their own stories using all these components and to think about sequencing their ideas in a logical order. We also encouraged the students to think beyond the literal interpretation by including more idiomatic language and inferring information from the text. For example, inferring that it was raining if the story included information about a girl coming indoors with a wet raincoat.

Vocabulary Training:

This therapy focused on teaching key concepts and vocabulary through word associations and word building. The sessions incorporated the following subjects from the national curriculum: geography, history, mathematics, information technology and science. More general topic areas relevant to this age group were also used including current affairs, famous people, seeking employment, exam preparation and the media. Students were encouraged to categorise new vocabulary into related groups (for example, fruit, furniture) through the use of brainstorming and word webs to help them remember new words more easily. For example, they categorised different occupations according to the skills required, nature of the work, place of work etc. Multiple meaning of words, antonyms, synonyms and idiomatic language were explored (see figure 2). The children were also taught how to use a dictionary and thesaurus.

The Children

A group of 54 secondary school-age children (47 boys & 7 girls) with language and communication impairments ranging in age between 10 and 15 years (mean age of 12; 8) participated in the study. They were referred from an outer London borough SALT Service or from participating schools and were not receiving SALT. The children presented with severe and complex difficulties in the understanding and use of language and communication.

Pre-and post therapy assessment

We tested the children’s language and communication skills before and after the therapy looking at their understanding and use of language, storytelling skills and reading and spelling. The students were also given a questionnaire after the therapy to explore their views on its success. There was an interval of approximately four months between the two testing sessions.

Results

We first looked to see whether the children’s language improved after the therapy when the two groups were combined into one large group. The students did significantly better in understanding vocabulary, remembering grammatically complex sentences and understanding of inferences, for example drawing a conclusion about an event from information given. Smaller improvements were found in their understanding of grammar and word relationships (for example, recognizing the relationship between ‘cup’ and ‘plate’).

What we did not find though were any differences in performance between the children who got the vocabulary training and those who got the storytelling therapy. Our prediction that the children in the storytelling group would improve more than the vocabulary group on storytelling was not upheld. In fact, neither group improved significantly in storytelling.

We also collected some interesting comments from the children about the therapy. Seventy-four percent of children said that the therapy helped them with talking and understanding. Fifty-six percent of them felt it helped with their reading and writing, 54% thought it helped them in the classroom and in getting on with friends and 33% said it helped them make new friends. A total of 41% felt they would like to have more of these lessons. Thus the majority of children reported some benefits from the therapy.

What do these results mean?

Secondary school age children showed improvements on certain language tests after a short period of therapy. They improved in understanding of vocabulary, in remembering sentences and in understanding inferences. This seems to demonstrate that therapy can benefit these children. It is pleasing to note this improvement in areas of language over a relatively short period of time, particularly when taking into account the pervasiveness and severity of the language impairments and the small changes in test scores frequently reported on in this age group. These results are encouraging and we should conduct more studies to explore the potential benefits of therapy with this group.

We cannot however be completely certain that the improvements are due to the therapy as we did not include a no-treatment control group. Thus this research needs to be followed up using a different research design, for example including a delayed treatment group as a control group. In this way we can be more certain that any improvements obtained, are the result of the therapy, and not the result of another factor. We are hoping to carry out such a project in the future and would be very interested to hear from people undertaking or interested in undertaking similar work.

We had thought that the vocabulary group would do better on vocabulary tests and the storytelling group would improve more on telling stories. This was however not the case. We think the reason for this may be that the therapy was not specific enough to individual children’s needs. The children were randomly divided into groups and this meant that children with very different language skills were given the same type of therapy. We might have seen greater improvement and differences between the two groups if the therapy had targeted the children’s specific areas of need. We are hoping to carry out another study with children with more similar language impairments to test this out.

We also feel that some of the language tests used to identify improvements over time may not be sensitive enough to small changes in language performance. We used language tests commonly used by speech and language therapists. In the future we are going to explore other ways of picking up smaller changes that more directly reflect the therapy given, for example using a measure of story structure in the format of a profile or checklist.

Due to time constraints, we did not ask the teachers if the children improved in the classroom. We want to include this in our future work as it is important to see how improvements in test scores translate into the classroom.

The Future

We are planning a series of training sessions for the SALTs and teaching staff from the participating borough. We hope that teachers and learning support assistants will be able to use the vocabulary and storytelling programmes with the support of the SALT.

This study shows that adolescents with language and communication impairments can improve in their language abilities after a relatively short period of therapy. This is encouraging and poses questions about how resources can best be used to meet the needs of this population.

We plan to carry out more therapy studies including children with more similar patterns of language impairment. We also hope to look at whether children’s language improves when the therapy is given by teaching staff. If we can show that language programmes, like the ones used in this study, are effective when given by therapy and teaching staff, then we can hopefully increase the language enhancement that secondary school children receive.

* Parts of this article first appeared in the Afasic News, Spring/Summer, 6-7 & 12

References

Berman, R. (2004). Between emergence and mastery: the long developmental route of language acquisition. In R.A. Berman (Ed.), Language Development across Childhood and Adolescence. Amsterdam: John Benjamins Publishing Company.

Clegg, J., Hollis, C., Mawhood, L. & Rutter, M. (2005) Developmental language disorders a follow-up in later adult life. Cognitive, language and psychosocial outcomes. Journal of Child Psychology and Psychiatry, 46, 2, 128-149.

Conti-Ramsden, G., Botting, N., Simkin, Z. & Knox, E. (2001). Follow-up of children attending infant language units: outcomes at 11 years of age. International Journal of Language and Communication Disorders, 36, 207-219.