BACKGROUND:Children with speech sound disorder (SSD) are at risk of long-term adverse consequences if appropriate intervention is not provided in a timely way. Although there are interventions of proven efficacy, these are often not implemented with good fidelity in clinical practice. Children with SSD in the United Kingdom are commonly managed in care pathways within NHS and independent speech and language therapy services. It is not known which care pathways are most effective because there is currently no systematic recording or analysis of intervention outcomes for children with SSD. AIMS:The objective of the MISLToe-SSD study is to develop an evidence-based protocol for collecting routine data on a large-scale so that UK SSD care pathways can be evaluated for clinical- and cost-effectiveness. The development of the core outcome set (COS) is reported here. METHODS AND PROCEDURES:Following the Core Outcome Measures in Effectiveness Trials methodology, a modified Delphi process was used to reach a consensus on a COS for SSD interventions. The Delphi process comprised two online survey rounds and one online meeting. Anonymity between panel members was maintained during the online survey rounds. Round one required a consensus of ≥50%, rising to ≥75% in round two. OUTCOMES AND RESULTS:A group of 66 UK speech and language therapists identified as experts in SSD by their peers were recruited through specialist clinical and research networks. A long list of 30 outcome statements was reduced by consensus to a final list of seven outcomes with associated measurement instruments. Increased speech intelligibility was agreed as the primary outcome by 100% of panel members. Six secondary outcomes were identified. CONCLUSIONS AND IMPLICATIONS:The final COS can be used in future research to evaluate care pathways and intervention effectiveness for children with SSD. Furthermore, it provides a basis for measuring outcomes in future intervention trials for SSD. WHAT THIS PAPER ADDS:What is already known on this subject Speech and language therapy services in the United Kingdom are ideally placed to contribute to large-scale evaluations of services provided for children with speech sound disorder (SSD) due to the computerised routine collection of data related to client management and interventions. However, these routine data cannot currently be used to evaluate the effectiveness or efficiency of interventions for children with different subtypes of SSD due to a lack of uniformity in data collection. There are no agreed and validated outcomes, outcome measures, diagnostic protocols or agreed labels and definitions for the evidence-based interventions that can be used by services across the United Kingdom. What this study adds to existing knowledge Building on information from an umbrella review and practitioner workshops, a modified Delphi process with 66 SSD expert speech and language therapists from across the United Kingdom, was utilised to develop a core outcome set (COS) and a minimum dataset of common data elements. What are the potential or actual clinical implications of this study? The COS and minimum dataset can be used by speech and language therapy services to collect routine data in a way that can contribute to large-scale evaluations of the effectiveness and efficiency of interventions for children with SSD.

Introduction The quality of relationships between speech and language therapists (SLTs) and clients, in this case, children with speech sound disorder (SSD) of unknown origin, is a crucial factor for successful intervention. These relationships are affected by how services are configured and what SLTs are asking of the children. The public and patients' views are therefore vital in the evaluation or redesign of services. The aim of the present work was, through public and patient involvement and engagement, to gain insight into experiences of young children who had received intervention for SSD.Methods A total of seven children (seen individually) aged 4- to 7-years-old with SSD took part in four activities. The activities took place in a clinical setting with two qualified SLTs facilitating the interactions, one of whom was previously known to the children. Emotional mapping activities- drawing, using toy figurines, emojis and pictures - facilitated the children in telling us about their experiences of SSD interventions.Results Children drew, pointed and verbalised who, what, where and when they had intervention and how they felt about it. Children selected 'happy' or 'cool' emoji to indicate how they felt during therapy. Children commented on environmental factors, such as being taken out of the classroom to see the SLTs, as a positive thing as 'other children are too noisy', and said that it is 'special time' for them to 'work on my sounds'. They also mentioned that they 'liked' their SLTs and personal factors such as the 'big bag with a flower on it, that is full of toys'.Conclusions Children are able to communicate their experiences of speech and language therapy for SSD through emotional mapping activities.

BACKGROUND:Communicating effectively in everyday life is a key outcome for children with speech, language and communication difficulties. However, we lack a clear way to describe children's everyday communication functioning-their communicative participation. Communicative participation is defined for adults, as 'taking part in life situations where knowledge, information, ideas, or feelings are exchanged', and included how communicative participation is achieved, with whom and for what purposes. AIM:This study aimed to consider communicative participation for children and young people, by using an existing definition regarding adults' communicative participation to elicit meaning from children and young people with speech, language and communication needs, and that of their parents and clinicians. METHODS AND PROCEDURES:Three focus groups with young people with speech, language, and communication needs (n = 6, ages 14-16 year old), parent carers (n = 5), and speech and language therapists (n = 19) and two semi-structured interviews, one with a parent of a young child with complex communication needs and one with a parent and their daughter with developmental language disorder, were conducted online, audio recorded and transcribed verbatim. Participants were shown an existing definition of communicative participation (originally intended to be applied to adults) and discussed the appropriateness of each section of the definition for children and young people. Transcripts were analysed following the Framework Analysis Approach. RESULTS:Participants broadly agreed with the existing definition but highlighted the changing nature of communicative participation throughout childhood. They thought that a definition of communicative participation should include interaction for joy, where closeness rather than meaning is shared, and reference to play and education as key communicative participation situations. Participants highlighted the importance of skilled partners in meaning making for children with developmental communication difficulties, and the fundamental role of technology in communicative participation. They also discussed the impacts of successful communicative participation on children's social and emotional development, seeing communicative participation as a driver to protect mental health and wellbeing, build independence, develop trusting relationships and stay safe. CONCLUSIONS AND IMPLICATIONS:Communicative participation develops across childhood and differs to that in adulthood in some important respects. The broad boundaries of the construct provided in this study can inform further development of the construct with potential impact for developing assessments and interventions related to communicative participation for children. WHAT THIS STUDY ADDS:What is already known on this subject Communicative participation has been defined as 'taking part in life situations where knowledge, information, ideas, or feelings are exchanged' (Eadie et al. 2006, 311) and 'understanding and being understood in a social context, by applying verbal and nonverbal communication skills' (Singer et al. 2020, 1801) What this paper adds to the existing knowledge Communicative participation changes across childhood. It includes interaction for closeness, without a message being conveyed; play; education; and social and emotional development. Skilled interaction partners are vital for the development of communicative participation for children and young people with speech, language and communication needs (SLCN). The extended boundaries for communicative participation developed in this study can inform the development of new measurement tools. What are the potential or actual clinical implications of this work? Communicative participation is a prized outcome for children and young people with SLCN and their parents. Speech and language therapists should investigate children's communicative participation and intervention should be directed toward participation goals.

BACKGROUND:Children born with cleft palate ± lip (CP ± L) are at risk of speech sound disorder (SSD). Up to 40% continue to have SSD at age 5-6 years. These difficulties are typically described as articulatory in nature and often include cleft speech characteristics (CSC) hypothesized to result from structural differences. In non-CP ± L SSD comorbidity with language difficulties is often reported. There is growing evidence of concomitant language difficulties in children with CP ± L and of a higher prevalence of developmental speech errors in children compared with non-CP ± L peers. The impact of underlying phonological and language skills on speech production in children with CP ± L is poorly understood. AIMS:To investigate language outcomes in children with CP ± L and the relationship to speech production, by answering the following research questions: (1) Does the profile of language skills in children with CP ± L differ from normative samples? (2) Do children with CP ± L and SSD have poorer language skills than those with typically developing speech? (3) Is there an association between language skills and speech profile in children with CP ± L at age 5-8 years? METHODS & PROCEDURES:In this prospective cross-sectional, observational study, 95 participants were recruited from regional cleft lip and palate services in the UK. They were aged 5;0-7;11 with non-syndromic CP ± L. Those with a syndromic diagnosis, global learning disability, sensorineural hearing loss and first language other than English were excluded. Assessments of speech (Diagnostic Evaluation of Articulation and Phonology-DEAP) and language (Clinical Evaluation of Language Fundamentals-5th UK edition-CELF) were completed. Language outcomes were analysed and compared with normative samples and according to speech error analysis. OUTCOMES & RESULTS:Average language scores were within the expected range. For those presenting with SSD, language scores were significantly lower than those with typically developing speech. Analysis of speech errors showed four distinct speech profiles: typical speech, CSC only, developmental speech characteristics (DSC), and combined CSC + DSC. Language scores were lower for participants with DSC (±CSC). A significant association was found between the presence of CSC + DSC and expressive language outcomes (odds ratio (OR) = 10.82; 95% confidence interval (CI) = 2.42, 48.32, p = 0.002). CONCLUSIONS & IMPLICATIONS:An association between language skills and speech production was observed. The distribution of speech errors in children with CP ± L varied with a high level of DSC as well as CSC. Those with CSC + DSC had significantly lower language scores than those with typically developing speech or CSC only. Speech and language therapists working with this caseload should be alerted to potential ongoing phonological and language difficulties in children presenting with this profile. WHAT THIS PAPER ADDS:What is already known on this subject Children born with CP ± L are known to be at risk of SSD. There is also evidence of language delay in the early years. Evidence for persistent language difficulties is equivocal but some studies have shown a higher than average prevalence of developmental phonological errors in addition to cleft articulation errors in speech production. What this paper adds to the existing knowledge This study investigates links between speech development and language skills in children aged 5-8 years with non-syndromic CP ± L. It adds to our understanding of the nature of SSD in children with CP ± L and in particular the relationship between language skills and speech production. It shows that children with CP ± L have varied speech profiles and that those presenting with delayed phonological processes are also at risk of language difficulties. What are the potential or actual clinical implications of this work? Speech and language therapists working with children with CP ± L should be aware of the varied nature of SSD in this population. They should be alert to the need for additional assessment of language for those presenting with delayed phonological processes and the implications this has for educational attainment.

INTRODUCTION:Although frequently seen in clinical services, there are few interventions which have been developed specifically to meet the needs of pre-school children with co-occurring features of a phonological speech sound disorder (P-SSD) and developmental language disorder (DLD). This study aims to achieve consensus on the core elements of a novel intervention for pre-school children with co-occurring features of P-SSD and DLD ("SWanS"- Supporting Words and Sounds), where expressive vocabulary and speech comprehensibility are joint outcomes of interest. METHODS:Forty-seven potential core intervention elements, based on a priori findings and the wider literature, were generated by a diverse steering group of professionals and people with lived experience within a systematic co-design process. This was followed by a modified, two round, e-Delphi with expert Speech and Language Therapists (SLTs) to achieve consensus on the elements. Consensus was defined as over 75% of participants (minimum 30 SLTs) rating the elements as either appropriate or very appropriate on a Likert of 1-5, with an inter-quartile range of one or below. If consensus was not achieved in round 1, free text comments were used to generate amended statements for the second round. RESULTS:Consensus was achieved on 42/47 statements in round 1. During the revision process, one statement was discarded; six statements which did not achieve consensus were re-worded; two statements which required further clarity had examples added; four statements were merged into two statements. Consensus was reached on 8/8 statements presented in round 2, resulting in 44 final statements achieving consensus in total. CONCLUSIONS:Core elements of a novel intervention have been identified through co-design with a diverse group of stakeholders followed by consensus with expert SLTs. Additional flexibility was required within some core elements in order to achieve consensus. Implications for future implementation are discussed.

BACKGROUND:There is no single classification system or diagnostic protocol for speech sound disorder (SSD). This makes it difficult to collect large-scale outcome data and determine which interventions work best for which subtypes of SSD. The United Kingdom is unique in that its publicly funded healthcare system allows the collection of such outcome data across large numbers of children; however, a necessary first step towards this is to agree on a consistent diagnostic protocol and classification system for SSD that is feasible for use in the UK healthcare system. AIMS:This study aimed to achieve an initial clinician-led UK consensus on a diagnostic protocol and classification system for SSD of unknown origin. METHODS AND PROCEDURES:A mixed methods participatory design was used. Five UK health services provided SSD paperwork such as local guidelines and protocols for content analysis. Two participatory workshops were used to agree on: (1) a classification system, (2) subtype labels and definitions, and (3) a feasible diagnostic protocol for SSD. The finalised consensus was presented to a national meeting of 283 SLTs to determine the feasibility of the protocol for clinicians across the whole of the United Kingdom. OUTCOMES AND RESULTS:Workshop participants agreed that the Differential Diagnostic Classification System was preferred for the United Kingdom. A minimum diagnostic protocol, with additional assessment for complex SSD, was agreed. Over 90% of the national SLT meeting agreed that they could implement the definitions and protocol. CONCLUSIONS AND IMPLICATIONS:A preliminary diagnostic protocol, classification system, and subtype names and definitions were agreed upon and are broadly in line with those proposed by Dodd (2014). Future work will trial the consensus protocol and classification system in the United Kingdom to investigate treatment outcomes and refine the protocol. WHAT THIS PAPER ADDS:What is already known on this subject There are three main classification systems for speech sound disorder (SSD) that are popular globally: the Speech Disorder Classification System (SDCS) (Shriberg et al. 2019); the Differential Diagnostic Classification System (Dodd 2014); and the Psycholinguistic Framework (Stackhouse and Wells 1993). It is not clear which of these, if any, is most used in the United Kingdom. Moreover, previous research suggests that clinicians employ a wide range of different terms for subtypes of SSD and different diagnostic methods to arrive at these subtypes. This lack of consistency, even within the United Kingdom, is confusing for parents, carers, and practitioners and makes it difficult to compare outcomes. What this study adds We showed that most clinicians in the United Kingdom use the Differential Diagnostic Classification System (Dodd 2014). We therefore suggest that this is now used consistently in the United Kingdom, with some modifications. A feasible diagnostic protocol which includes using the assessment designed specifically for this classification system, the Diagnostic Evaluation of Articulation and Phonology (Dodd et al. 2002), was agreed for clinical use. What are the clinical implications of this work? Clinicians in the United Kingdom can use the subtype labels and diagnostic protocol described here to diagnose subtypes of SSD in a consistent manner. Children with more complex SSD or concomitant disorders will require additional assessments.

Objective: To describe attention skills in children with cleft lip and palate across auditory and visual domains and investigate associations with cleft subtype, biological sex, socioeconomic status, and speech and language. Design: A cross-sectional observation study. Setting Participants from regional cleft lip and palate centers seen in schools and home. Participants: Eighty-one children aged 5 years 0 months to 7 years 11 months with non-syndromic cleft palate +/- lip. Main outcome measure Auditory and visual attention skills including measures of distractibility, impulsivity and focus across both domains. Results: Mean average scores for all measures of auditory and visual attention were below one standard deviation from the normative average (standard score <85). There was no main effect of cleft subtype. Boys had significantly lower scores for visual distractibility than girls. There was no statistically significant effect of socioeconomic status, but those from higher socioeconomic groups had scores up to 10 standard points higher in some measures than those in the middle or lower groups. Weak, significant correlations were observed between language skills and measures of attention. Conclusions: A range of both auditory and visual attention skills were low in this group raising the question of potential generalised attention difficulties in children with CLP. Attention skills were correlated with language. Professionals working with children with CLP should be aware that attention difficulties are prevalent and advise families and educators accordingly. Further research including intervention studies would increase our understanding.

BACKGROUND:Children's language abilities set the stage for their education, psychosocial development and life chances across the life course. AIMS:To compare the efficacy of two preschool language interventions delivered with low dosages in early years settings (EYS): Building Early Sentences Therapy (BEST) and an Adapted Derbyshire Language Scheme (A-DLS). The former is informed by usage-based linguistic theory, the latter by typical language developmental patterns. METHODS:We conducted a pre-registered cluster randomized controlled trial in 20 EYS randomized to receive BEST or A-DLS. Children aged 3;05-4;05, who were monolingual, with comprehension and/or production scores ≤ 16th centile (New Reynell Developmental Language Scales-NRDLS) and no sensorineural hearing impairment, severe visual impairment or learning disability were eligible. A total of 102 children received the intervention. Speech and language therapists delivered interventions with high fidelity in 15-min group sessions twice weekly for 8 weeks. Baseline (T1), outcome (T2), and follow-up (T3) measures were completed blind to the intervention arm. Outcomes were NRDLS comprehension and production standard scores (SS), measures of language structures targeted in the interventions and communicative participation (FOCUS-34). RESULTS:Both interventions were associated with significant change from T1 to T2 and from T1 to T3 in all outcomes. There were no differences between interventions in gains in NRDLS comprehension SS at T2 or T3. BEST produced greater gains in NRDLS production SS between T1-T2 (d = 0.40) and T1-T3 (d = 0.55) and in BEST-targeted sentences (d = 0.77). Children receiving BEST made significantly more progress after intervention (T2-T3) in both comprehension and production. Both interventions were associated with large, clinically significant changes in communicative participation as measured by teacher reports (FOCUS-34). CONCLUSIONS:A low-dosage intervention can produce language gains with moderate to large effects. The accelerated progress after the BEST intervention underscores the significant potential of interventions designed with reference to usage-based theory, which precisely manipulates language exposure to promote the specific cognitive mechanisms hypothesized to promote language learning. WHAT THIS PAPER ADDS:What is already known on the subject Early language development sets the stage for children's educational and psychosocial development and their life chances into adulthood. Early language interventions can be effective; however, there is a need to develop and evaluate early interventions which bring large effects and which can be delivered within the constrained resources of early years provision. Usage-based linguistics have not been explicitly applied to the design of early language interventions. There is evidence that the Derbyshire Language Scheme (DLS) promotes positive outcomes in comprehension abilities and BEST in production. What this paper adds to the existing knowledge Findings from a cluster-randomized controlled trial demonstrate that BEST, an 8-week, 15-min, small-group intervention, delivered twice weekly can produce moderate to high effects in expressive language outcomes for 3-4-year-old children with low language. A-DLS and BEST bring similar gains in comprehension standard scores but BEST leads to larger and more sustained progress in expression. Faster progress after intervention for BEST supports the hypothesis that it promotes the development of abstract representations of predicate-argument structures, supporting generalization and accelerating language learning. What are the potential or actual clinical implications of this work? BEST, a low-dosage, manualized intervention delivered with high fidelity can be effective for children from a range of socio-economic backgrounds bringing moderate to high effects. Effective and efficient intervention can be delivered through the precise manipulation of active ingredients within intervention sessions (in this case, the cognitive mechanisms hypothesized to promote language learning and abstract knowledge in usage-based theory).

Objective Speech sound disorder (SSD) describes a 'persistent difficulty with speech sound production that interferes with speech intelligibility or prevents verbal communication'. There is a need to establish which care pathways are most effective and efficient for children with SSD. Comparison of care pathways requires clearly defined, evidence-based, interventions and agreement on how to measure the outcomes. At present, no definitive list of assessments, interventions or outcomes exists. The objective of this umbrella review paper is to provide a rigorous and detailed list of assessments, interventions and outcomes which target SSD in children.Design In December 2022, a systematic search of Ovid Medline, OVID Embase, CINAHL, PsycInfo and Cochrane and a number of grey literature platforms were undertaken. 18 reviews were included, and subsequently 415 primary research articles were assessed for data related to assessments, interventions or outcomes. The AMSTAR (Assessing the Methodological Quality of Systematic Reviews) framework was used to assess the quality of the retained reviews.Setting Reviews were retained which took place in any setting.Participants The population is children of any age with a diagnosis of SSD of unknown origin.Primary and secondary outcome measures Reviews reporting outcomes, assessment and interventions for children with SSD.Results Extraction and analysis identified 37 assessments, 46 interventions and 30 outcome measures used in research reporting of SSD. Not all of the listed outcomes were linked to specific outcome measurement tools, but these were measurable through the use of one or more of the assessments extracted from the retained reviews.Conclusions The findings of this review will be used to develop a Core Outcome Set for children with SSD. The findings are part of a rigorous process essential for advancing healthcare research and practice in the specific area of speech and language therapy for children with SSD.PROSPERO registration number CRD42022316284.

COVID-19 impacted all aspects of children's lives. Research showed that teachers were most concerned about Communication and Language, and Personal, Social and Emotional Development, two of the three Prime Areas of the Early Years Foundation Stage which underpin all learning. The pandemic had a significant impact on early years settings. Practitioners reacted quickly, adapting the way they worked with children and families to ensure all children were supported, whether at home or in the education setting. This paper examines these short-term responses and reflects on what the disruption tells us about what is important to early years practitioners and parents. The Language Intervention in the Early Years (LIVELY) project, focusing on language and communication skills in the Early Years Foundation Stage, started just before the first lockdown and was therefore ideally placed to investigate changes that resulted from the pandemic. We interviewed 11 practitioners, from 10 schools and 1 nursery in the North East of England. Within the group, the experiences of children, families and practitioners varied; our aim was to identify common themes. Parental engagement, the relationships between schools and parents/caregivers which enable children's learning, became even more central and much of the support provided by settings focused on how parents and carers interacted with their children to support language and communication. This paper identifies some of the benefits of the imposed changes and how these could continue in early years settings post-pandemic.

BACKGROUND:The aim of many interventions used by speech and language therapists (SLTs) is to change behaviours related to communication and interaction. Parent-led language interventions for children in the early years (0-5 years) rely on SLTs supporting parents to change their behaviour in child-focused interactions to effect a change in the child's communication. Therapeutic techniques used by SLTs in parent-led language interventions are largely underspecified, impacting on intervention reporting, replication, trialling and development. The Behaviour Change Technique Taxonomy Version 1 (BCTTv1) offers a method of describing intervention techniques developed for use in public health interventions, but with several examples of its application to speech and language interventions.AIMS:To identify behaviour change techniques (BCTs) from the BCTTv1 occurring in parent-led language interventions for children in the early years.METHODS & PROCEDURES:A literature search identified relevant descriptions of parent-led language interventions. These were coded using the BCTTv1. A reliability check was carried out on 10% of the descriptions. To confirm the use of identified BCTs in clinical practice, results of the literature search were triangulated with an online survey of SLTs, and observations of SLTs delivering parent-led language intervention.OUTCOMES & RESULTS:A total of 84 papers containing descriptions of 45 interventions were coded; 62 SLTs responded to the survey and three SLTs were observed delivering parent-led language intervention. A total of 24 BCTs were identified in the literature search, replicated in the observations and verified by SLTs in the survey. BCTs were identified at two levels: Level 1 SLT implemented to change parent interactive behaviour; and Level 2 parent implemented to change child communicative behaviour.CONCLUSIONS & IMPLICATIONS:The BCTTv1 is a useful starting place for describing parent-led language interventions. With some additions and adjustments, BCTs identified in this study were immediately recognized by practitioners and can easily be adopted into practice.WHAT THIS PAPER ADDS:What is already known on this subject Techniques used in SLT interventions are often not clearly described. The BCTTv1 has been used to clarify technique descriptions with success in a small number of SLT disciplines, but not yet in parent-led language interventions for preschoola children. What this paper adds to the existing knowledge This paper constitutes the first research into quantifying the techniques used in parent-led language interventions using the BCTTv1. What are the potential or actual clinical implications of this work? This paper provides a clear list of techniques used by SLTs implementing interventions for preschool children, which can be immediately adopted and used in practice. It also highlights potential adjustments and gaps in the BCTTv1 in relation to SLT which can contribute to future iterations.

BACKGROUND Treatment fidelity refers to the degree to which an intervention is implemented as intended. Promoting treatment fidelity is important to achieve a valid comparison in intervention research. However, it is often underreported: few studies detail the use and development of fidelity measures. This study aims to promote the treatment fidelity of a modified version of the Derbyshire Language Scheme (M-DLS), a manualised intervention for children with language difficulties, by exploring participants' opinions on training and intervention delivery. Results inform development of a checklist and scoring system to monitor and promote treatment fidelity in a comparison trial. METHOD Ten student speech and language therapists (SLTs) and two research assistants (RAs) participated in the study. All received training on the M-DLS, and 10 were video-recorded completing role-plays of an M-DLS session in small groups. Feedback was gathered after training and role-plays in focus groups and interviews. Feedback was interpreted using the constructs of the Theoretical Domains Framework (TDF). A treatment fidelity checklist was then developed using the feedback. The first author and two RAs rated role-play videos using the checklist to trial it to inform amendments and to promote interrater reliability. Interrater agreement was calculated using Spearman's test of correlation. RESULTS Participants discussed the importance of having clear materials and time to practise sessions. They suggested amendments to the materials and training to promote treatment fidelity. The checklist and scoring system accounted for participants' suggestions, with amendments detailed in a log. Spearman's correlation results suggested agreement between the raters was strong. CONCLUSIONS Results emphasise the importance of training quality, practice and reflective opportunities and clear materials to promote treatment fidelity. The construction of the checklist and scoring system was described in detail, informing the development of future checklists. After further trialling, the checklist can be used to ensure the M-DLS is delivered with high treatment fidelity in the comparison trial. WHAT THIS PAPER ADDS What is already known on this subject Treatment fidelity is an essential component of intervention effectiveness and efficacy studies, ensuring the intervention is delivered as intended. It is also an essential component of evidence-based clinical practice. However, few research studies report the treatment fidelity process or publish the checklists used, depriving clinicians of useful information for implementation. What this study adds This study describes in detail the iterative process of treatment fidelity checklist development, engaging those implementing the intervention in development. This ensured clarity and interrater reliability of the checklist. Furthermore, a novel scoring system was developed so that accuracy of implementation can be easily compared across users and across practice attempts. What are the clinical implications of this work? The importance of treatment fidelity when implementing effective and efficacious interventions cannot be overstated. The treatment fidelity checklist developed for research can be easily adopted to support accurate implementation in clinical practice through an audit process.

BackgroundThe publication of phase 2 of the CATALISE project in 2017 clarified terminology for children with developmental language disorder (DLD) or delay but unintentionally muddied the water for children with unintelligible speech. A diagnostic label of DLD (phonology) indicates poor prognosis and phonological disorder that persists into middle childhood. However, in contrast to other diagnostic labels that fall under the overarching term of speech sound disorder (SSD), DLD (phonology) does not elucidate the characteristics of the child’s speech nor does it point us in the direction of appropriate intervention. AimsThe aim of this paper is to discuss terminology in SSD leading to an evidence based model which builds on the model of DLD developed in CATALISE, supports descriptive diagnosis and signposts intervention. MethodsFollowing a focused review of literature proposing or describing terminology for SSD, an expert group of researchers in developmental SSD proposed a revised model of existing terminology. Groups of UK speech and language therapists (SLTs) who provide services for children with SSD were asked to comment on its acceptability and feasibility. Discussion A three level terminology model was developed. This comprised an overarching Level 1 term; Level 2 terms that differentiated SSD of unknown origin from SSD with associated or underlying conditions; and specific diagnostic terms at Level 3 to support further assessment and intervention decisions. Consulted SLTs generally expressed agreement with the proposed terminology and a willingness to adopt it in practice.ConclusionsExisting terminology for childhood SSD provides a good basis for clinical decision-making. A modified version of Dodd’s (2005) terminology was found to be acceptable to UK SLTs. There is an evident overlap of SSD with CATALISE terminology. However more detailed and specialist terminology than “DLD (phonology)” is required to support clinical decision-making. It is proposed that endorsement by the UK Royal College of Speech and Language Therapists (RCSLT) would obviate the need for a Delphi process.

Purpose: This study aimed to achieve a consensus on a diagnostic protocol, classification system, and subtype definitions for the differential diagnosis of speech sound disorder of unknown origin in the United Kingdom. Method: A mixed methods participatory design was used. Five services from the UK provided all paperwork, including guidelines and care pathways, related to Speech Sound Disorder for content analysis. Two participatory workshops with six speech and language therapists from these five services were used to discuss and agree: 1. A classification system, 2. Subtype labels and definitions, and 3. A diagnostic protocol for speech sound disorder suitable for use in the UK context. Result: Participants agreed that the Differential Diagnosis System (Dodd, 2014) was suitable for use in the UK. This system comprises five speech sound disorder subtypes. Participants suggested minor changes to the definitions of these subtypes to make them more suitable for implementation in a clinical context. A minimum diagnostic protocol, with additional assessment for children with more complex or severe speech sound disorder, was agreed. Conclusion: A consensus diagnostic protocol, classification system, and subtype names and definitions was reached and is broadly in line with Dodd (2014). Future work will implement this in the national health service in the UK

BACKGROUND:Early intervention is recommended for pre-school children with low language. However, few robustly evaluated language interventions for young children exist. Furthermore, in many interventions the theoretical underpinnings are underspecified and the 'active ingredients' of the interventions not tested. This paper presents a quasi-experimental study to test the efficacy and examine the active ingredients of Building Early Sentences Therapy (BEST): an intervention based on usage-based theory designed to support young children to understand and produce two-, three- and four-clause element sentences. BEST manipulates the input children hear to support them to harness the cognitive mechanisms hypothesized in usage-based theories to promote the development of abstract linguistic representations. One such input manipulation is the use of signing alongside verbal input signalling both content and morphology of target sentences.AIMS:To examine whether (1) BEST is more efficacious than treatment as usual (TAU); and (2) signing of content and morphology is an active ingredient of the intervention.METHODS & PROCEDURES:A quasi-experimental study recruited children aged 3;5-4;5 years from 13 schools. Schools were assigned to receive either BEST with sign, BEST without sign or TAU. The TAU group received their usual classroom provision. Across arms schools were matched with respect to classroom oral language environment and indices of deprivation. Participants were 48 children (28 boys) with expressive and/or receptive language abilities ≤ 16th centile measured using the New Reynell Developmental Language Scales (NRDLS). Outcomes gathered by researchers blind to treatment arm were NRDLS production and comprehension standard scores and measures of production of targeted sentence structures.OUTCOMES & RESULTS:Primary outcomes indicate that BEST with sign was significantly more efficacious than TAU with respect to NRDLS production standard score, but not comprehension. The advantage for production was maintained at follow-up. BEST without sign was significantly more efficacious than TAU on measures of targeted vocabulary, sentence structure and morphology. The results from this quasi-experimental study provide evidence for the efficacy of a usage-based intervention on expressive language outcomes for preschool children with low language abilities. There is also evidence to support the inclusion of sign as an active ingredient, and so efforts to train interventionists in its use are worthwhile.CONCLUSIONS & IMPLICATIONS:Patterns of findings across outcomes suggest signing of content and morphology may support the development of abstract linguistic representations and accelerate language learning. Given these positive results and the scale of this study, a fully powered randomized controlled trial is warranted.WHAT THIS PAPER ADDS:What is already known on the subject Robust language skills are crucial for positive social, emotional, academic and economic outcomes across the lifespan. There is a paucity of robustly evaluated interventions for preschool children with language difficulties. The development of such interventions is crucial for ameliorating language difficulties and promoting positive educational and psychosocial outcomes. What this study adds to the existing knowledge This paper evaluates BEST, a novel usage-based language intervention targeting children with language difficulties in the early years. Findings indicate that a usage-based intervention is efficacious for treating language difficulties. In particular, BEST benefited expressive language development, bringing benefits to both treated and untreated language structures and improving standard scores. The role of sign as an active ingredient is also supported. Further evaluation is warranted. What are the practical and clinical implications of this work? Findings suggest that BEST may be effective for targeting children who have been identified as having language difficulties. In particular, expressive language may be improved when the intervention is delivered as it was originally manualized, including a signing system to represent content and grammatical morphology. More broadly, these findings also provide preliminary evidence that the use of a signing system does not hinder oral language development in children with language difficulties and may conversely support their expressive language. Future research exploring the role and underpinning mechanisms of sign in language intervention is warranted.

BACKGROUND:Speech and language therapists (SLTs) provide interventions for inducible laryngeal obstruction (ILO) despite a current lack of evidence to inform intervention delivery. This study is the first step to develop an evidence-based intervention for ILO, using behaviour change theory and the Behaviour Change Technique Taxonomy version 1 (BCTTv1). Outcomes will inform the early development stage of a complex speech and language therapy intervention for ILO, enabling more precise reporting of ILO intervention studies, as per CONSORT guidelines.AIMS:(1) To identify whether the BCTTv1 is a useful tool for characterising speech and language therapy interventions for ILO, based on existing literature, current practice and patient interviews. (2) To identify key behaviour change techniques (BCT) used within existing complex speech and language therapy interventions for ILO METHODS AND PROCEDURES: A five-phase study was conducted: (1) a systematic literature search of six electronic databases (Medline, EMBASE, CINAHL (EBSCO), Scopus, Trip, Web of Science) and grey literature between 2008 and 2020; (2) observations of six speech and language therapy intervention sessions; (3) a semi-structured interview with an SLT to validate the observed BCTTs; (4) consensus from four national expert SLTs regarding application of synthesised BCTT data to their own experiences of ILO interventions; and (5) patient engagement to review and comment on findings.OUTCOMES AND RESULTS:Forty-seven BCTs in total were coded across all three sources. Thirty-two BCTs were identified in clinical observations; 31 in interviews with SLTs and 18 in the literature. Only six BCT were identified in all three sources. Expert SLTs confirmed clinical application and relevance. Patients reported finding the concept of BCT challenging but highlighted the value of psychoeducation to support their understanding of symptoms and in turn to understand the rationale behind speech and language therapy intervention recommendations.CONCLUSION:This study indicates that the BCTTv1 is a suitable framework to identify and describe intervention components used within speech and language therapy interventions for ILO. A practice-research gap exists, reinforcing that existing literature does not capture the complexity of speech and language therapy intervention for ILO. Further research is needed to develop our understanding of the BCTs that support optimal behaviour change for this patient group.WHAT THIS PAPER ADDS:What is already known on the subject There is growing recognition for the value of speech and language therapists (SLTs) in delivering complex interventions for patients with inducible laryngeal obstruction (ILO), including evidence to suggest that their intervention can improve quality of life for patients and reduce excessive healthcare use. There are, however, no randomised controlled trials in this field; thus it is unclear what constitutes the most effective intervention. What this study adds This study demonstrates the complexity of speech and language therapy interventions for ILO and highlights the practice-research gap. It identifies a range of behaviour change techniques that are used in existing practice and captures patient views relating to the components identified within this study. What are the clinical implications of this work? Findings highlight the value of providing education about factors that might be driving ILO symptoms and in turn the importance of sharing with patients the rationale for treatment recommendations that necessitate a change in their behaviours. Identified behaviour change techniques can be used when developing and implementing SLT interventions for ILO.

Parental responsiveness is vital for child language development. Its accurate measurement in clinical settings could identify families who may benefit from preventative interventions; however, coding of responsiveness is time-consuming and expensive. This study investigates in a clinical context the validity of the Parental Responsiveness Rating Scale (PaRRiS): a time- and cost-effective global rating scale of parental responsiveness. Child health nurse (CHN) PaRRiS ratings are compared to a detailed coding of parental responsiveness. Thirty parent-child dyads completed an 8-min free-play session at their 27-month health review. CHNs rated the interaction live using PaRRiS. Videos of these interactions were then blindly coded using the more detailed coding system. PaRRiS ratings and detailed codings were compared using correlational analysis and the Bland-Altman method. PaRRiS and the detailed coding showed a moderate-strong correlation (rs (28) = 0.57, 95% CI [0.26, 0.77]) and high agreement (Bland-Altman). CHNs using PaRRiS can capture parental responsiveness as effectively as trained clinicians using detailed coding. This may allow (1) increased accuracy and efficiency in identifying toddlers at risk for long-term language difficulties; (2) more accurate allocation to speech and language therapy (SLT) services; (3) decreased burden on SLT resources by empowering CHNs to make more informed referral decisions.