The treatment components which contribute to an
effective therapeutic outcome for children with specific language impairment
are not commonly understood and always under hot debate. The purpose of the study
was to describe the underlying factors that lead to a successful therapeutic intervention
for children with specific language impairment. A qualitative research is
conducted to explore how a speech therapist perceives an effective intervention
session for the clients. A professional speech therapist in the clinical
setting was interviewed to consider the experience with the clients and
describe the attributes that cause the intervention effective in promoting positive
change in the communicative ability. Results underlined the importance of
implementing evidence-based practice, establishing a good client-clinician
relationship and allowing the involvement of the caregivers.
practice, client-centred approach, specific language impairment (SLI), speech therapy.
Specific language impairment (SLI) is one of the most
prevalent developmental difficulties for preschool children. It is suggested that
around 8 in 100 children have speech and/or language disorders, of which a
significant proportion will have specific language impairment (Boyle, 1996;
Tomblin, 1997). Such conditions are often named as “specific” since there is no known aetiology1 for the impairment
(Plante, 1998). The children with SLI can have a language disorder, a speech
disorder or even a combination of both since these conditions commonly overlap.
Fey et al. (2003) suggested that this disorder can, in fact, affect children’s performance in the
areas of phonology, vocabulary, grammar, morphology, and pragmatic2 language. The implications
can be far-reaching to the children that persist into their adulthood.
A bewildering range of approach of interventions is designed
to improve the child’s speech and language deficits and remove their
barriers to participation. The interventions should be delivered by a language
specialist, most notably the speech therapists (Dwight, 2006). The reason for
the inclusion is the specific nature of language deficits experienced by clients.
Instead of a broad range of skills, speech therapists concentrate more on
speech-language characteristics. Nevertheless, a handful of elements can be the
active ingredients for the interventions. The present study is to answer the
intervention components that account for effective therapeutic interventions.
Delivery agent and context
Interventions for clients with SLI can be directly or
indirectly carried out and in a wide range of settings. Dwight (2016) claimed
that direct interventions are delivered by speech therapists and they aim at the
individual treatment of the children, or a group therapy which relies on the
age and needs of the clients and the facilities readily available. Indirect
interventions are more naturalistic in approach, allowing the adults proximal to
the child to facilitate the interventions. This context creates an optimal
environment for child’s communication. Parents are actively involved in delivering
interventions for younger children but become less actively engaged in administering
the intervention when the child grows older (Horvath & Symonds, 1991).
Historically, most, if not all, of intervention was
about the teaching of specific behaviours such as vocabulary and speech sounds together
with reinforcement. The rationale behind was that language or speech could be
explicitly taught and therefore the skill gaps between normal children and
children with SLI could be filled. However, the intervention has gradually
changed from explicit teaching paradigms into social learning theory, assuming
that children can learn most effectively when they are trained in a social
context (Miller, 2011).
The key of intervention shifts to a more functional
one as the child grows older, whereby children with SLI are trained with the
skills that benefit them the most at the moment. The therapist usually provides
alternatives and urges the children’s self-judgements based on their intrinsic phonological
or grammatical awareness (Childers, 2002). They are encouraged to adopt
their own repertoire. The assumption is that this process boosts the child’s ability to modify
their language and/or speech. A different direction from a linguistic aspect is
therefore suggested by constructivists 3or usage-based explanations.
proposed different key factors that lead to a successful intervention of
specific language impairment. However, little consensus can be reached about
the effective intervention for extensive usage. It remains unclear in what essentials
are needed for an efficacious intervention. Under this line of thinking, there
appears to be a critical need to understand how speech therapists perceive an
effective speech therapy treatment for children with SLI. In this study, we
come up with the major components of the intervention by understanding
different experiences of approach.
The participant in the study was a female speech
therapist of a developmental paediatrics centre in Hong Kong, currently
providing speech therapy services to children with speech or communication
impairment. The speech therapist had more than 15 years of experiences working
with the aforementioned children in various settings.
A qualitative approach to research design and data
collection was adopted in the research. It allows the researchers to interpret
and delineate the experiences form the participants’ perceptions (Higgs, 1998).
This approach focuses on “how”, “what” and “why” a speech therapy treatment can
be successful to a child with SLI.
Data were collected using a semi-structured
interview. Such interview permits the interviewee to speak freely but also gives
control to the interviewer in making the interview to proceed (Rubin &
Rubin, 2012). Open-ended main questions were asked to underline the research
aim. Moreover, follow-up questions were designed to elicit additional details
in the response.
Client’s needs and capabilities influence the clinical
This category emphasizes that an effective clinician
should be flexible and client-centred in the approach of treatment. The participant
described that she customized the intervention sessions to meet the ability of
the client. She usually considers three developmental levels of the child, including
the play level, cognitive level and comprehension level.
Prior to treatment, play level is assessed by
observing the playing behaviours of the clients. The clinician indicated that
the commonly adopted test was “Symbolic Play Test4”. Knowing what attracts the child
the most, she can determine the activities of the therapy. Another practice she
mentioned was to record the language use of the clients in the play. It helps
her to see the whole picture of the clients’ language ability and their needs
since SLI affects differently to each client.
The participant also indicated the effective clinician
should recognize the cognitive level of the children, particularly the cognitive
ability to learn. She always wants to see whether the children can recall the
learned materials, apply the knowledge in new situations or do analysis and
synthesis. She emphasized the importance of cognitive level for goal-setting of
an intervention, be it long-term or short-term.
Another criterion the participant would consider is
the comprehension level. It includes the communicative intention5 and understanding of task
explanation. The clinician believed that knowing the child’s comprehension
ability helps with the dynamic flow of an intervention session since she is
capable to choose whether to use a one-step command, two-step command or even
more complex sentence structures, such as questions to explain the task and
Build a trusting client-clinician
This category highlights the importance of
establishing a supportive therapeutic relationship with clients. Building up
alliance is to make the clients feel that they are more than just a patient to
the clinicians. The participant described that she would ask about the clients’ home, past approaches
of therapy and their feelings about it. It could make the clients feel more
In the process of building alliance, it can enable the
client to talk openly about the feelings and more willing to follow the
instructions. Though rapport-building seems to be subtle and trivial, it
determines the flow of an effective intervention.
The interviewee also suggested a few ways to link to patients
who have different needs. For example, she gave her first-hand experience with
a serious case of specific language impairment.
… I have once met a client who was nearly
non-verbal. How could I build rapport with him? I just got to the floor to play
with him and followed his lead of play. I could then gradually enter his world…
The clinician then added that the approach she used
was Floor-time and it was to engage the children literally at their level. She
usually uses this period of time to excite the client’s interests, draw the connections
and challenge them to be curious, creative and spontaneous.
The interviewee also pointed out that effective
clinicians should be emphatic and honest. Empathy was described as the ability
to relate to the children. In some cases, the clinician would share personal
experiences to let the clients know that she was authentic and she truly cared.
The clinicians who were described as honest will not say something the client
wants to hear to make them feel better but to honestly report the assessments
accompanied by encouragements.
Actively involve the parents
This category underlines
that the role of parents in the client’s intervention is to help communication at home. The clinician suggested
that parents are the “key
players” of the
entire treatment since children learn from daily conversations with the people
around them, especially their parents. The clinician also claimed that speech
therapy has to extend to all parts of the children’s life so that the knows how to generalise the
skills learnt in the therapy sessions in everyday communication.
face of questions about how parents without professional skills can help
facilitate the effectiveness of the therapy, the clinician gave the following
… It is not
necessarily the case. We can teach the parents some important strategies that
they can use whenever they are with the child. The parents can even learn some
language-building skills from their children which are specific to them. It
greatly benefits the real therapy session…
The children spend most of the time living with
their parents or caregivers. It is therefore suggested that it improves the
results of an intervention if the parent can give prompt responses to their
attempts or expand the sentences the children said.
On the other hand, the clinician stated that she
would also give the parents some take-home exercises for clients to “carryover”6 so that they can have the practice outside
therapy session. She emphasized that whether a parent carries out speech
therapy exercises at home properly determines the effectiveness of the
The findings give more in-depth explanations to the
conclusion of Childers (2002)
about the importance of understanding the client’s abilities. The main goal of
the intervention for children with SLI is to encourage the child’s self-judgements
based on their internal awareness on speech and language. This should be guided
by evidence-based practice which integrate the external evidence, clinical
expertise and patient’s perspectives (Sackett, 1996). Evidence-based practice
is client-centred, and therefore a clinician’s role is to provide the most
effective intervention to the clients by interpreting best current research evidence
in relation to an individual’s preferences and responses. It is a continuing procedure,
in which the speech therapists should dynamically change the treatment goal as
well as procedure based on the ever-evolving research and the individual’s performance in
the intervention (Spring, 2007). With
the implementation of evidence-based practice, an effective speech therapy
intervention can be guaranteed.
Establishment of therapeutic alliance
Rapport building with the
clients is seldom stressed in treatment of specific language impairment and
hence little literature have discussions about how the client-clinician relationship
influences the efficacy of the intervention. However, the findings do show that
an effective therapeutic alliance leads to an effective therapy. Wampold (2001)
accentuated on the relationship in which a mutual understanding is established
and indicated that effective clinicians construct a productive therapeutic alliance
with the clients and well understand the nature of the impairment and its
On the other hand, the
findings stress the significance of empathetic listening, which accords with what
Luterman (2001) stressed. When the speech therapists actively listen to the clients
and try to understand them, it is easier to establish trust and hence improve
the dynamic flow of the treatment. Lehay (2004) offers another convincing description
of the dialogues used by effective clinicians. A typical treatment discourse is
that the clinician requests, the client responds and the clinician evaluates. This
can help develop interactive intervention and be accompanied by following the
client’s lead. With the better relationship with the clients, it makes a substantial
difference in effectiveness of intervention.
Engagement of the caregivers
The findings agree with Horvath & Symonds (1991)
that parents do play a key role in speech therapy. Since most the children with
SLI will have their speech therapy intervention at the early stage, whether the
caregivers can be actively involved in the non-therapy time determines the effectiveness
of the session. Roberts (2011) also investigated how parents affect the language
development of children with SLI and found that there were positive effects on
the communication development of the clients with the engagement of caregivers.
Indeed, children with various language disorders could make successful progress
when the parents were taught to help. Parents bear the responsibility that is as
important as the speech therapists do.
As another means of teaching, speech therapy exercises
can be given by the clinicians (Law, 2017). They can either be flash cards or
mirror exercises to help clients to focus on the targets in which they have
difficulties. More practice implemented by parents can mean significantly faster
improvement in language and/or speech disorder. With active engagement of the parents, an efficient
and successful treatment can be provided.
This study investigates,
from the perspective of speech therapists, the components needed for an
effective intervention of specific language impairment. The results indicate
that intervention approached should be guided by evidence-based practice in
which the clinician considers the clients’ perspective, current research and own knowledge to plan a treatment. Another
vital ingredient is the supportive alliance with the clients which enhances the
fluency of the intervention. The results also highlighted the importance of engagement
of the caregivers. Therefore, it is beneficial for speech therapist and parents
to discuss their roles and so that each person’s responsibility is well defined.
Concerning the limitations
of the study, the major constraints were that only one participant was interviewed
and we did not control the potential variables (e.g. experience in treatment of
SLI). As such, the findings may not be representative for the perceptions of
speech therapists about the effective intervention of children with SLI. Further
investigation might focus on the number of outcomes emerged from this research.
1 Aetiology is about the causes of a disease.
2 Mey (2001) suggested that pragmatics is the means in
which context contributes
Constructivists are the people who suggest that learners construct knowledge by
simulating their ideas and experiences (Vygotsky, 1980).
Symbolic Play Test is a test
used to identify the early skills required for language development through
Communicative intention is
the willingness to communicate.
6 Carryover refers client’s
capability to take an individual speech skill learned in the therapy
room and to apply it broadly in different speaking situations (Bahr
& Rosenfeld-Johnson, 2010).