This brief report presents interrater reliability data for the Focus on the Outcomes of Communication Under Six (FOCUS-34) between parents, and between parents and speech-language pathologists (SLPs). Reliability for all three raters combined was good to excellent across three assessments. Reliability for pairs of raters was variable but generally good.

BACKGROUND The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) is an international initiative that offers standardized and validated tools to guide the appraisal of patient-reported outcome measures in healthcare. AIMS To explore the use of a new set of tools from the COSMIN to appraise studies on one outcome measure available to speech and language therapists (SLTs). METHODS & PROCEDURES We used the COSMIN tools to appraise seven studies and a user manual that reported the measurement properties of the Focus on the Outcomes of Children Under Six (FOCUS), a validated measure of pre-schoolers' communicative participation that is used in various contexts around the world. OUTCOMES & RESULTS Using COSMIN guidelines, the FOCUS was categorized as a 'category A' tool because there was a sufficient level of evidence to support its content validity and internal consistency. According to the COSMIN guidelines, this means that the FOCUS can be recommended for use. The quality of evidence supporting measurement properties of the FOCUS received a rating of 'moderate', meaning users can have moderate confidence in its measurement properties. Since these ratings from the COSMIN tools may be unclear to users of the FOCUS, we have provided more specific recommendations. CONCLUSIONS & IMPLICATIONS The COSMIN tools offer detailed standards to support the appraisal of outcome measures available to SLTs. However, several limitations were observed, and recommendations to support the application of the COSMIN tools are provided. What this paper adds What is already known on the subject Collecting outcome data is essential to ensure speech and language therapy is effective. Until the development of COSMIN there was a lack of standards in the way the measurement properties of outcome measure instruments were appraised. What this paper adds to existing knowledge This paper used the FOCUS, a measure of pre-schoolers' communicative participation outcomes in speech and language therapy, as a case example to illustrate the applications of the COSMIN tools. In doing so, the strengths and limitations of the current COSMIN tools in appraising the quality of outcome measure instruments are emphasized. What are the potential or actual clinical implications of this work? The COSMIN tools offer a step-by-step, standardized approach to appraise various measurement properties in outcome instruments. Due to existing limitations of the COSMIN tools, appraisal should provide clear and specific recommendations so users of outcome measures (e.g., SLTs, researchers) can identify the appropriate uses of each instrument.

AIM:To describe uses of the Focus on the Outcomes of Communication Under Six (FOCUS) in research with children with and without various communication disorders since its publication in 2010. METHOD:Six databases were searched for the term 'Focus on the Outcomes of Communication Under Six'. With additional searches we ascertained 70 articles, of which 25 met inclusion criteria for full review and data extraction. RESULTS:The FOCUS has been used in research across multiple countries, purposes, populations, contexts, and versions. Evaluative studies have described: the development of children's communicative participation skills and factors that impact the development of communicative participation; the impact of specific interventions on communicative participation; how FOCUS captures change relative to measures of impairment; and how FOCUS performs when used at different intervals. Adaptations have included: use of the FOCUS as a descriptive or discriminative tool; use with children outside the validated age range; use of select items; and use with typically developing children. INTERPRETATION:The FOCUS is used worldwide in research and practice, and much has been learned about children's communicative participation. Future research is needed to explore the relationship between children's impairments and their communicative participation, develop a FOCUS App, and develop and validate a FOCUS for school-age children.

The present study was conducted to evaluate the reliability of the FOCUS© (Focus on the Outcomes of Communication Under Six). The FOCUS© is intended to measure the functional change in real-world communication associated with speech-language therapy. Clinicians administer this test by interviewing parents before and after treatment. The inter-rater reliability of detected change was high when evaluating preschool children (n = 13). Results indicate that this measure is reliable for both practical and research purposes. The necessity of establishing reliability is discussed, as are limitations of the FOCUS©.

BACKGROUND:The Focus on the Outcomes of Communication Under Six (FOCUS) is a 50-item outcome measure based on the framework and concepts of World Health Organization's International Classification of Functioning. The FOCUS has been shown to capture participation-level changes associated with speech and language therapy in children 18 to 72 months old and has established validity and reliability. However, there were reasons to try to reduce the measure without losing any of its proven value as a change-detecting instrument.METHODS:Using data from 18,931 preschool children, we used item response models and a test of redundancy to reduce the original 50-item FOCUS to 34 items. We then assessed the correlations between FOCUS-50 and FOCUS-34 scores on these children.RESULTS:Findings show that a shortened (34-item) version of FOCUS can be treated as equivalent to the full 50-item version.CONCLUSION:The correlation between change scores on the two versions is .98. We suggest that in situations where only a total score is of interest, the FOCUS-34 can be used in place of the full FOCUS.

Purpose: The aim of this study was to identify predictors of communicative participation outcomes for a large cohort of preschoolers with speech and language impairments.Method: A secondary analysis of longitudinal program evaluation data from Ontario, Canada’s Preschool Speech and Language Program was done. Data available for 46,872 children 18–67 months of age (M = 41.76 months, SD = 11.92; 68% boys, 32% girls) were previously used to predict children’s communicative participation skill development in 5 levels of function. Demographic and intervention-based variables were added to the models to identify new predictors of growth.Results: Three demographic and 3 intervention-based variables were statistically significant predictors of children’s communicative participation outcomes. Clinically significant predictors included participation in an early learning environment, receipt of speech-language interventions, and the amount of time spent in intervention. These variables impacted predicted outcomes differently, depending on a child’s level of communicative function.Conclusions: This population-based study of preschoolers with speech and language impairments identified predictors of growth in communicative participation skills—an outcome important and meaningful to families but not often explored. A broad picture emerged of factors that may influence the development of communicative participation skills and may be used to predict outcomes for preschoolers. Given the large sample size, these robust findings may be used to predict outcomes outside the Preschool Speech and Language Program as well.Supplemental Material S1. Predicted coefficients for the fixed and random effects for children in each Communication Function Classification System (CFCS) level from the original growth curves study.Cunningham, B. J., Hanna, S. E., Rosenbaum, P., Thomas-Stonell, N., & Oddson, B. (2018). Factors contributing to preschoolers’ communicative participation outcomes: Findings from a population-based longitudinal cohort study in Ontario, Canada. American Journal of Speech-Language Pathology, 27, 737–750. https://doi.org/10.1044/2017_AJSLP-17-0079

Purpose The aim of this study was to identify predictors of communicative participation outcomes for a large cohort of preschoolers with speech and language impairments. Method A secondary analysis of longitudinal program evaluation data from Ontario, Canada's Preschool Speech and Language Program was done. Data available for 46,872 children 18–67 months of age ( M = 41.76 months, SD = 11.92; 68% boys, 32% girls) were previously used to predict children's communicative participation skill development in 5 levels of function. Demographic and intervention-based variables were added to the models to identify new predictors of growth. Results Three demographic and 3 intervention-based variables were statistically significant predictors of children's communicative participation outcomes. Clinically significant predictors included participation in an early learning environment, receipt of speech-language interventions, and the amount of time spent in intervention. These variables impacted predicted outcomes differently, depending on a child's level of communicative function. Conclusions This population-based study of preschoolers with speech and language impairments identified predictors of growth in communicative participation skills—an outcome important and meaningful to families but not often explored. A broad picture emerged of factors that may influence the development of communicative participation skills and may be used to predict outcomes for preschoolers. Given the large sample size, these robust findings may be used to predict outcomes outside the Preschool Speech and Language Program as well. Supplemental Material https://doi.org/10.23641/asha.6024422

AimTo develop statistical models of communicative participation development of preschool children and explore variations by level of function. MethodThis was a secondary analysis of data from a longitudinal study of preschool children with speech and language impairments (n=46 872; age range 18-67mo, mean age [SD] 41.76mo [11.92]; 67% male) accessing publicly funded services in Ontario, Canada. Two measures were used: Focus on the Outcomes of Communication Under Six (FOCUS), measuring changes in communicative participation skills, and the Communication Function Classification System (CFCS), classifying communicative function into one of five levels. We used mixed effects modeling to fit growth curves for children in each CFCS level. Models allowed for variation in initial FOCUS score at 18 months, rate of growth with age, and rate of acceleration/deceleration with age. ResultsStarting FOCUS score (18mo) varied inversely with CFCS level at entry to the program. Growth was initially rapid and then leveled off for children in Levels I to III. Growth was less rapid for children in Level IV, but leveled off, and was slow but continual for children in Level V. InterpretationThis work can help us to move beyond traditional impairment-based thinking and shows that children can make meaningful communicative changes regardless of their function.

Abstract Purpose: In this paper, we present our experiences – both successes and challenges – in implementing evidence-based classification tools into clinical practice. We also make recommendations for others wanting to promote the uptake and application of new research-based assessment tools. Method: We first describe classification systems and the benefits of using them in both research and practice. We then present a theoretical framework from Implementation Science to report strategies we have used to implement two research-based classification tools into practice. We also illustrate some of the challenges we have encountered by reporting results from an online survey investigating 58 Speech-language Pathologists’ knowledge and use of the Communication Function Classification System (CFCS), a new tool to classify children’s functional communication skills. Result and conclusions: We offer recommendations for researchers wanting to promote the uptake of new tools in clinical practice. Specifically, we identify structural, organizational, innovation, practitioner, and patient-related factors that we recommend researchers address in the design of implementation interventions. Roles and responsibilities of both researchers and clinicians in making implementations science a success are presented. Implications for rehabilitation Promoting uptake of new and evidence-based tools into clinical practice is challenging. Implementation science can help researchers to close the knowledge-to-practice gap. Using concrete examples, we discuss our experiences in implementing evidence-based classification tools into practice within a theoretical framework. Recommendations are provided for researchers wanting to implement new tools in clinical practice. Implications for researchers and clinicians are presented.

AimTo evaluate construct and predictive validity of the Communication Function Classification System (CFCS) for use with preschool children with a range of speech and language disorders.MethodSeventy-seven preschool children with speech and language disorders (50 males, 27 females; mean 2y 7mo, standard deviation [SD] 1y) participated in this cohort study. Preschool children had speech and language, language-only, or speech-only disorders. Together with parent input, speech-language pathologists (SLPs) completed the CFCS at time 1. Parents and SLPs then independently completed a validated change-detecting functional communication outcome measure, the Focus on the outcomes of Communication Under Six (FOCUS), three times: at assessment (time 1), at the start of treatment (time 2), and at the end of treatment (time 3).ResultsThere was a significant negative correlation between CFCS classifications and FOCUS scores at all three measurement points for the ratings by both parents and SLPs (correlations ranged from -0.60 to -0.76). As expected, no correlations between CFCS classifications and FOCUS change scores were statistically significant.InterpretationThis study provides evidence of construct and predictive validity of the CFCS, demonstrating its value as a discriminative tool for use with preschool children with a range of speech and language disorders.

Purpose: This paper reports changes in communicative participation skillssystematically measured and describedin an empirical observational case series of eight children receiving augmentative and alternative communication (AAC) interventions.Method: The eight children (seven boys, one girl), ranging from 1 year 4 months to 4 years 11 months (mean = 2.8 years; SD = 1.32 years) received varied AAC interventions (i.e. sign language, assistive technology, PECS), averaging 15 hours of treatment over a 12-month period. Parents completed an outcome measure (FOCUS) three times: at the start, mid-point (6 months) and end of the intervention period (after 12 months). They also completed the ASQ-SE at the start and end of intervention.Result: FOCUS scores increased over the treatment interval, indicating improvement in real-world communication skills as observed by their parents. The ASQ-SE items that pertained to communication also improved, while the items that did not correspond to communication did not. This divergence suggests that the communicative participation improvements resulted from treatment rather than general developmental gains. The largest improvements were noted in receptive language/listening, pragmatics and social/play skills. Improvements in intelligibility were also measured for several children.Conclusion: These results suggest that AAC intervention facilitated improvements in communicative participation skills in pre-school children.

This study evaluates how easy the French translation of the tool for the measurement of progress in speech therapy, Focus on Outcomes of Communication Under Six (FOCUS), under the name of FOCUS-F, is to understand and use with a French-speaking population before it is rolled out to the market. FOCUS measures the changes that occurred in pre-school children in their daily communication following speech-language therapy. The participants (n= 82) responded to FOCUS-F as well as to a feedback questionnaire relying on the language skills of their own children or of children they knew very well. They concluded that the FOCUS-F items were easy to understand. The use of FOCUS-F without additional instructions therefore appears feasible since almost all participants considered the instructions to be clear and the format appropriate.

The purpose of this article is to describe communicative-participation outcomes measured by the Focus on the Outcomes of Communication Under Six (FOCUS©; Thomas-Stonell et al., 2013) for interventions provided by speech-language pathologists (SLPs) in different community settings for preschoolers with speech-language impairments (Sp/LI) with and without developmental mobility impairments (MI). The predictive relationships between communicative-participation and (1) functioning-and-disability, and (2) contextual factors, was also investigated. Sixty-one preschoolers with Sp/LI and their parents participated. Twenty-six preschoolers were identified with Sp/LI and received speech-language interventions (Group 1), 20 preschoolers were identified with Sp/LI and MI and received speech-language interventions (Group 2), and 15 preschoolers with Sp/LI awaiting intervention served as waitlist controls (Group 3). Parents completed structured interviews about children’s communicative-participation outcomes using the FOCUS© at three time points (pre-intervention, post-intervention, and 3-months post-intervention) with an SLP. Only Groups 1 and 2 experienced statistically and clinically meaningful communicative-participation outcomes over time as measured by the FOCUS©. Pre- to post-intervention communicative-participation was predicted by functioning-and-disability and contextual factors, initial social skills and intervention status, respectively. Post-intervention to 3-month post-intervention scores were also predicted by functioning-and-disability and contextual factors, risk status (Sp/LI only, Sp/LI+developmental MI) and intervention status, respectively. Significant and clinically meaningful changes in communicative-participation over time are associated with speech-language interventions for preschoolers with Sp/LI.

Background The FOCUS© is a new outcome tool for use by both parents and clinicians that measures changes in the communicative participation skills of preschool children. Changes in communicative participation skills as measured by the FOCUS were compared across three groups of children: those with speech impairments only (SI), those with language impairments only (LI) and those with both speech and language impairments (S/LI). Methods Participating families (n = 112, 75 male children) were recruited through 13 Canadian organizations. Children ranged from 10 months to 6 years 0 months (mean = 2.11 years; SD = 1.18 years) and attended speech-language intervention. Parents completed the FOCUS at the start and end of treatment. There were 23 children in the SI group, 62 children in the LI group and 27 children in the S/LI group. The average amount of the children's therapy varied from 7 to 10 h. Results The FOCUS captures changes in communicative participation for children with a range of communication disorder types and severities. All three groups of children made clinically important improvements according to their FOCUS scores (MCID ≥ 16 points). The FOCUS captured improvements in intelligibility, independent communication, play and socialization. Conclusions The FOCUS measured positive changes in communicative participation skills for all three groups of children after 7–10 h of speech-language therapy. An outcome measure that targets only specific speech and language skills would miss many of the important social function changes associated with speech-language treatment.

OBJECTIVE:The aim of this study was to establish the construct validity of the Focus on the Outcomes of Communication Under Six (FOCUS©). This measure is reflective of concepts in the International Classification of Functioning Disability and Health--Children and Youth framework. It was developed to capture 'real-world' changes (e.g. communicative participation) in preschoolers' communication following speech-language intervention.METHOD:A pre-post design was used. Fifty-two parents of 3- to 6-year-old preschoolers attending speech-language therapy were included as participants. Speech-language therapists provided individual and/or group intervention to preschoolers. Intervention targeted: articulation/phonology, voice/resonance, expressive/receptive language, play, and use of augmentative devices. Construct validity for communicative participation was assessed using pre-intervention and post-intervention parent interviews using the FOCUS© and the communication and socialization domains of the Vineland Adaptive Behavior Scales-II (VABS-II).RESULTS:Significant associations were found between the FOCUS©, measuring communicative participation, and the VABS-II domains for: (i) pre-intervention scores in communication (r = 0.53, P < 0.001; 95% CI 0.30-0.70) and socialization (r = 0.67, P < 0.001; 95% CI 0.48-0.80); (ii) change scores over-time in communication (r = 0.45, P < 0.001; 95% CI 0.201-0.65) and socialization (r = 0.39, P = 0.002; 95% CI 0.13-0.60); and (iii) scores at post-intervention for communication (r = 0.53, P < 0.001; 95% CI 0.30-0.70) and for socialization (r = 0.37, P = 0.003; 95% CI 0.11-0.50).CONCLUSIONS:The study provided evidence on construct validity of the FOCUS© for evaluating real-world changes in communication. We believe that the FOCUS© is a useful measure of communicative participation.

The present study was conducted to evaluate the reliability of the FOCUS (c) (Focus on the Outcomes of Communication Under Six). The FOCUS (c) is intended to measure the functional change in real-world communication associated with speech-language therapy. Clinicians administer this test by interviewing parents before and after treatment. The inter-rater reliability of detected change was high when evaluating preschool children (n = 13). Results indicate that this measure is reliable for both practical and research purposes. The necessity of establishing reliability is discussed, as are limitations of the FOCUS (c).

Background. Speech-language pathologists (S-LPs) use family-centred practices to implement intervention. Thus, consideration of family-based outcomes is encouraged. The International Classification of Functioning, Disability and Health - Children and Youth version (ICF-CY) framework supports S-LPs' consideration of these outcomes (e.g., parental perspectives on children's Activities and Participation and Environmental Factors associated with speech-language intervention).Purpose. To explore parents' perspectives about: (a) the child-S-LP relationship (Environmental Factors) and (b) children's functional communication (Activities and Participation)Method. Sixty-seven parents of preschoolers with communication disorders participated in this study. All 67 parents completed pre-intervention and post-intervention structured interviews about their children's functional communication. Parents of preschoolers who received intervention (n = 52) provided ratings and comments regarding the child-S-LP relationship established during intervention with the clinician (n = 7). Themes were identified using content analysis. Fifteen children were wait list controls and did not receive intervention.Results. Parents of preschoolers who received intervention reported significantly greater gains in children's functional communication compared to those who did not. Most parents (94%) provided positive/very-positive perspectives about the child-S-LP relationship. The child-S-LP rapport and the S-LPs' professional competence were common themes identified in parents' perspectives.Conclusion: (a) Significant gains in preschool children's functional communication occurred following speech and language intervention and (b) factors such as the rapport established between the child and the S-LP as well as the S-LPs' professionalism were considered by parents to be important factors for creating a positive child-S-LP relationship during speech and language intervention.

PURPOSE:The impact of a newly designed computer-assisted treatment (C-AT) program, My Sentence Builder, for the remediation of expressive-grammar deficits in children with specific language impairment (SLI) was explored. This program was specifically designed with features to directly address expressive-grammar difficulties, thought to be associated with hypothesized deficits in verbal working memory (VWM).METHOD:Thirty-four preschoolers with deficits in expressive-grammar morphology participated. Using the randomization procedure of consecutive sampling, participants were recruited. Twenty-two participants were consecutively assigned to one of two treatment groups, C-AT or non C-AT (nC-AT). The nC-AT utilized conventional language stimulation procedures containing features which have been traditionally used to address expressive-grammar deficits. A group of equivalent children awaiting treatment and chosen from the same sample of children as the treatment participants served as a control group. Blind assessments of outcomes were completed pre-, post-, and 3-months post-treatment in a formal and informal context.RESULTS:C-AT and nC-AT participants significantly outperformed controls pre-to-post to 3-months post-treatment in both assessment contexts. No significant differences in treatment gains were found between C-AT and nC-AT.CONCLUSION:Results suggested that treatments designed to directly address expressive-grammar deficits were better than no treatment for preschool SLI. Further, use of a C-AT program may be another feasible treatment method for this disorder population.LEARNING OUTCOMES:As a result of this activity, the reader will recognize that: (1) expressive-grammar treatment is better than no treatment for immediate and continued language growth, (2) use of a C-AT program containing specific features designed to directly address expressive-grammar deficits is another viable, but not necessarily a better treatment option for the remediation of expressive-grammar deficits in preschool children with SLI, and (3) different outcome contexts yield distinct yet equally important findings about growth in children's expressive-grammar skills with treatment.

AimOur aim was to develop an outcome measure, called Focus on the Outcomes of Communication Under Six (FOCUS), that captures real-world changes in preschool children's communication. Conceptually grounded in the World Health Organization International Classification of Functioning, Disability and Health framework, the FOCUS items were derived from observations of change provided by parents and clinicians after speech-language therapy.MethodParticipating families (n=165) were drawn from a convenience sample at partner institutions in Ontario, Newfoundland and Labrador, and Nova Scotia. All children had speech, language comprehension, and/or language production disorders and were receiving speech-language therapy. The age of the children ranged from 1 year 2 months to 5 years 6 months (mean=3.8y; SD=0.91y), and 119 children were male. Three test phases were completed. The measure was revised according to item analysis and parent/clinician feedback after phase 1 (n=74) and phase 2 (n=65). In phase 3 (n=26), the Pediatric Quality of Life Inventory (PedsQL), a health-related quality of life measure, was added to establish construct validity.ResultsIn phase 1, item analysis revealed high internal consistency for both parents (Cronbach's alpha=0.87) and clinicians (Cronbach alpha=0.97). These values indicated redundancy, so 31 items were cut. Five items for young children were added. In phase 2, internal consistency remained high for both parents (Cronbach alpha=0.98) and clinicians (Cronbach alpha=0.83), indicating redundancy of items. Twenty-seven items were removed. In phase 3, parents and clinicians reliably scored the FOCUS in 10 minutes. They stated that it provided an accurate snapshot of the child's communication. Internal consistency for parents remained high (Cronbach alpha=0.96). Children with higher FOCUS scores at the end of treatment had higher PedsQL total scores (r=0.466, p=0.029).InterpretationThe FOCUS is a usable measure of a child's ability to communicate and participate in his or her community. It demonstrates high internal consistency and construct validity.