Neurobiological Contributions to Speech and Language Interventions: Applications to Developmental Populations

You have accessThe ASHA LeaderFeature1 Dec 2008Speech and Language “Mythbusters” for Internationally Adopted Children Sharon GlennenPhD, CCC-SLP Sharon Glennen Google Scholar More articles by this author , PhD, CCC-SLP https://doi.org/10.1044/leader.FTR1.13172008.10 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In Eleven years ago the adoption of my 17-month-old son from Russia started an unexpected journey into international adoption research. His initial attempts to learn English were perplexing. Words were often unintelligible with a unique phonological rule system that didn’t match any textbook patterns. Although his language comprehension developed rapidly, his expressive language was unusual. Despite having more than 150 words in his vocabulary, he rarely combined them. As a concerned mother I combed the literature for information about speech and language development in internationally adopted children. Back then most of the “evidence” was a collection of anecdotal reports that painted a less-than-rosy, and at times quite scary, picture of his future. Evidence-based information was limited to studies of children adopted from Romania that were conducted by Eleanor Ames and her colleagues, and Michael Rutter and his colleagues. Although the information was important, their studies did not specifically examine speech and language. Thus my son’s issues planted the seeds that led to a line of research focused on speech and language development in internationally adopted children (Glennen, 2005; Glennen 2007; Glennen in press; Glennen & Masters, 2002). Since then, other colleagues including Jennifer Roberts, Kathleen Scott, Deborah Hwa-Froelich, Karen Pollock, Rena Krakow, and Jennifer Windsor have added to the growing body of research about speech and language development and disorders in internationally adopted children. Many professionals, however, aren’t familiar with this information. In our house the Discovery Channel series “Mythbusters” is a family favorite. Each episode takes popular myths based in history, legend, movies, or news and uses evidence to prove the myths as true, plausible, or busted. With 10 years of research regarding the speech and language abilities of internationally adopted children, it’s time to do some “myth-busting” of our own. What follows is a list of common myths about international adoption and speech and language. I confess that I once believed most of them, provided professional advice based on them, and wrote about some of them in early publications (Glennen, 2002). However, it’s time to set the record straight. We need to use evidence, not myths, to make clinical decisions about speech and language for internationally adopted children. Myth 1: Internationally adopted children need many years to fully “catch up” in English language acquisition. Evidence: The majority of internationally adopted children have rapid language-learning that begins within a few days of arriving home. After one year home, children adopted under the age of 24 months develop English language comprehension, production, and articulation abilities that are well within normal limits using standard norms (Glennen, 2007; see Figure 1 [PDF]). This rate of progress does not mean it takes only one year to develop full language potential; in fact, skills keep improving during the preschool years, especially in the area of expressive syntax. However, the initial surge of language “catch-up” occurs rapidly within the first year home. We know less about children adopted at older ages, but preliminary data indicate equally rapid rates of language learning. Within one year of adoption, most children adopted as 2-year-olds score within normal limits on English language tests of comprehension and expression (Glennen, in press; see Figure 2 [PDF]). Children adopted as 3- and 4-year-olds also score within normal limits on English language comprehension measures after one year, but take more time to develop expressive language abilities fully in English. More research is needed to fully understand these issues; significant English language delays after the first two years home, however, appear to be rare and should be treated as true language or speech disorders. Myth 2: Early environmental deprivation results in severe, lifelong language-learning disorders. Evidence: Adoption helps to counteract the effects of orphanage care. Orphanages are not good places to raise children. Children who remain in orphanages have significant language delays and the length of stay correlates highly with poor cognitive and language abilities (Johnson, 2000; O’Connor et al., 2000; Rutter et al., 1998; Miller, 2005; Windsor, Glaze, Koga, & the Bucharest Early Intervention Project Core Group, 2007). At birth the range of potential language abilities for all children falls along the normal curve. Some children have the potential to develop exceptional language skills; others have less potential. When children enter orphanages, environmental and nutritional deprivation gradually erodes their potential. The poorer the level of care, and the longer the length of institutionalization, the more potential in the area of language ability is lost. The result is a group of children who still have language abilities arrayed into a normal curve, but the curve has shifted downward. While many children will still fall within the “normal range,” lost potential translates into proportionately more children falling below average. Once potential is lost, the more important question is whether it can be regained when the environment improves. Research indicates that many children raised in orphanages have permanent neurobiological changes related to chronic stress within their environment (Gunnar & Quevedo, 2007; Miller, 2005). Chronic abnormal stress reactions lead to overproduction of cortisol and high levels of glucocorticoids in the brain. Prolonged exposure to glucocorticoids leads to structural changes in the brain, primarily the hippocampus, which is important for memory storage and retrieval. Other areas of the brain affected by abnormal regulation of glucocorticoids include the frontal lobe, responsible for executive function and abstract thinking; the cingulate gyrus, responsible for attention and self-control; and the amygdala, responsible for processing emotions. However, some children are genetically more resilient to the neurobiological effects of stress and are not as affected by the orphanage environment (Gunnar & Quevedo). In addition, the neurobiology of stress reactions responds to improvements in the environment, such as adoption into a nurturing home with consistent caregivers (Gunnar & Quevedo). Adoption goes a long way to counteract lost potential resulting from environmental deprivation. The majority of infants and toddlers adopted into American homes have mild to low-average delays when they first arrive, but make incredible progress during the first years at home (Glennen, 2005; Glennen 2007; Roberts et al., 2005). The incidence of speech and language disorders in children adopted before age 2 is 22% (Glennen, 2007). Although this rate is higher than the 2%–8% reported in the general preschool population (Law, Boyle, Harris, Harkness, & Nye, 2000), the overwhelming majority of internationally adopted children who are adopted before age 2 have normal English language abilities after one year home (Glennen, 2007; Roberts et al., 2005). Internationally adopted children who do not meet this benchmark have true disorders, and need to be diagnosed and treated. Myth 3:The child’s first language will affect aspects of learning the new adopted language. Evidence: Studies of internationally adopted children under age 2 have found that the first language has no inhibitory or facilitory effect on learning a new language or its phonology. Young children transitioning from Russian to English learned English-language morphological structures in the same developmental sequence as children who spoke English their entire lives (Glennen, Rosinsky-Grunhut, & Tracy, 2005). Children transitioning from Mandarin to English developed the English sound system similarly (Pollack & Price, 2005). Finally, children adopted from China learned vocabulary in patterns typical for children who spoke English (Snedecker, Geren, & Shafto, 2007). The children in these studies were all adopted under the age of 2 and likely did not have a well-developed first-language base to affect English-language learning. Based on my clinical experience, children adopted at older ages do show signs of interference and facilitation between the birth and adoptive languages. However, it is unknown whether they follow the same patterns as bilingual children or if they transition differently from one language to another. Functional MRI studies of adults who were internationally adopted as children confirm that adult adoptees no longer recognize nor understand their first language, even those who were adopted at school age (Pallier et al., 2003). However, the same fMRI studies also confirm that internationally adopted adults process their new adopted language using different areas of the brain than those of native-language speakers. Myth 4: Internationally adopted children are bilingual and should be treated like other second-language learners. Evidence: Internationally adopted children are bilingual only for a short period of time after adoption. Because most adoptive parents do not speak the child’s birth language (L1), children quickly lose their abilities in that language. According to Gindis (2003), children adopted at ages 3–4 lose most expressive use of L1 within six to 12 weeks of adoption; receptive abilities are lost within 16–22 weeks. At that point, internationally adopted children are monolingual in English, but the language is not yet fully acquired. Children who are adopted at older ages are especially affected because they begin school soon after arriving home. If they struggle academically, it is difficult to assess speech or language disorders validly until English develops further. By then, valuable intervention time is lost. Parents adopting children older than 3 years are advised to gather information about their child’s speech and language development during the adoption process. If there are reported concerns in the birth country, the educational team should consider conducting an assessment and begin to provide supports within the classroom soon after the child arrives home. Myth 5: Most internationally adopted children do well at young ages but have language-related academic difficulties in the elementary grades. Evidence: Most children adopted before age 2 have normal language abilities during the preschool years, and continue to have normal literacy and academic language abilities at school age; data on speech and language are mixed in school-age internationally adopted children. Initial teacher survey data by Dalen and Rygvold (2006) found that internationally adopted children from poor countries with third-world health care systems had worse “academic language” than nonadopted children. In contrast, children adopted from countries with good health care and economic resources were equal to—if not better than—nonadopted children. Recent assessments of children adopted at young ages from China indicate that by school age, most are performing at average to above-average levels on literacy measures (Scott, Roberts, & Krakow, 2008). Similarly, parent-reported data on children adopted at young ages from Eastern Europe found that by school age, 80% were in regular education classrooms without accommodations (Glennen& Bright, 2005). However, the same parents reported that 27% of the children were receiving speech and language intervention. One crucial factor across all studies of school-age children is the child’s age at adoption. Parent-reported data on children adopted at 3–6 years of age from Eastern Europe found that after five years home, 57% of girls and 82% of boys were diagnosed with communication disorders (Beverly, McGuiness, & Blanton, 2008). Similarly, Dalen and Rygvold (2006) found that children adopted from Colombia at older ages were more likely to have poor academic language abilities at school age than children adopted at younger ages. It is clear that children adopted at older ages are more susceptible to risk factors that impede speech and language development; more longitudinal data will help determine whether those risk factors cause a temporary gap in speech and language development or indicate a real difference in language abilities. The important fact is that most children adopted before age 2 have normal language abilities during the preschool years, and continue to have normal literacy and academic language abilities at school age. Internationally adopted children who experience difficulty with higher-level academic language tasks should be assessed and provided with appropriate supports and services based on assessment results. Myth 6: Internationally adopted children require unique speech and language diagnosis and intervention methods. Evidence: When children first arrive home, they should be assessed using methods based on guidelines developed for internationally adopted children (Glennen, 2007). Newly arrived infants and toddlers can be assessed reliably using measures of prelinguistic abilities such as vocalizations, gestures, and social pragmatic abilities (see Table 1 [PDF]). Children adopted at 12–24 months of age who initially scored within normal limits on the Communication and Symbolic Behavior Scales-Developmental Profile (Wetherby&Prizant, 2002) did well when reassessed one year later. Conversely, all but one of the children who initially scored below normal limits continued to have poor language and speech abilities one year later. The rate at which a child learns to comprehend new words is also important to consider when assessing newly arrived children (Glennen, 2007). Children who learn to comprehend new words rapidly do better than children who learn new words at a slower rate. Surprisingly, the rate of learning to express new words is not as predictive when children first arrive home. The guidelines in Table 1 [PDF] are useful for newly arrived children; however, after one year at home children adopted before age 2 can be assessed using standard English language procedures. The exception is measures of expressive syntax such as mean length of utterance (MLU). We have found that expressive syntax and morphology require additional time to develop in internationally adopted children and are not reliable measures of language abilities until children are age 4 (see Figure 1 [PDF]). Although the children catch up quickly in vocabulary—including expressive vocabulary—measures of MLU, sentence repetition, and morphology elicitation tasks indicate that expressive syntax and morphology take longer to develop to English-language norm levels. We can rule out processing difficulties as the cause of these delays because the same children score well on tasks that assess comprehension of complex directions and that test syntax and morphological comprehension. In contrast to infants and toddlers, children adopted at older ages are difficult to assess when they first arrive. Although solid guidelines for younger children help differentiate English language-learning issues from speech-language disorders, there are no similar guidelines for older children. The spoken language abilities of older children can’t be validly assessed because there is no proficient language. However, preliminary evidence based on a small number of children who were adopted between the ages of 2 and 4 indicates they can be assessed using most standard English-language comprehension measures after one year home (Glennen, in press). Expressive language emerges more slowly; children adopted at ages 3 and 4 can be assessed using expressive language measures two years after adoption (see Figure 2 [PDF]). If it is determined that a child has a speech or language delay, the process of making a diagnosis and developing intervention plans is identical to that for any other child. The internationally adopted children I follow (Glennen, 2005, 2007) provide an example of this process. One year after adoption, 22% of the children had delays in speech, language, or both. They had a variety of diagnoses including global developmental delays, expressive language delay, receptive language delay, autism, and phonological disorders. In summary, there was no unique “international adoption speech and language disorder” or unique intervention. Speech and language intervention should target each child’s diagnosis and symptoms, not the adoption status. Myth 7: Now that evidence-based information is available, professionals are making better decisions about speech and language in internationally adopted children. Evidence: Some SLPs are unaware of current research and do not use it in making treatment decisions. From 54% to 68% of internationally adopted children are referred for speech and language assessments, and 35%–50% receive intervention (Glennen, 2007; Glennen& Masters, 2002; Mason &Narad, 2005), a rate higher than the incidence of disorders in this population (22%). During the first year home, 17 of 27 (68%) newly adopted toddlers followed in my research were assessed for speech and language by early intervention teams (Glennen, 2007). Thirteen of the children (48%) were then seen for speech and language intervention. This group included five of the six children who were later diagnosed with language and speech delays—but it also included eight children who developed normal language. According to prelinguistic language assessments conducted when the children were first adopted, these eight did not need treatment; however, their parents sought services anyway. Although those children surely benefited from the intervention, many of them were functioning at the top of their peer group when they were first adopted, and continued to develop language at a rate that surpassed their peers. Reports about services for older internationally adopted children also cause concern. One child in my longitudinal study was adopted from Eastern Europe at age 4. By second grade she was struggling academically and her parents requested a school-based assessment. School officials insisted the child be tested in her birth language. The parents protested this decision, as the child had neither heard nor spoken the language for four years. They noted that the Individuals with Disabilities Education Act requires assessment in the child’s primary language and maintained that the birth language was no longer primary. Their protest delayed the assessment process until the case was finally brought to the attention of the head of English as a second language services, who asked the school to proceed with English-language testing. My son had a true expressive language and phonological disorder that required treatment, and he received the early language intervention he needed. However, some internationally adopted children are put on “wait and see” protocols for extended periods of time, or referred to programs for non-English speakers that fail to meet their extensive language-learning needs. Conversely, other children receive services even when they excel on every language measure given (Glennen, 2007). It’s time to stop providing services based on anecdotes and myths, and instead to make clinical decisions for internationally adopted children based on research. Portions of this article were previously published as Glennen, S. (2007). International adoption speech and language mythbusters. Perspectives on Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations: American-Speech-Language Hearing Association Division 14 Newsletter, 14(3), 3–8. Additional References Ames E. (1997) The Development of Romanian Children Adopted into Canada: Final Report. Burnaby, B.C.: Simon Fraser University. Funded by National Welfare Grants. Google Scholar Beverly B., McGuiness T., & Blanton D. (2008). Communication and academic challenges in early adolescence for children adopted from the former Soviet Union.Language, Speech and Hearing Services in Schools, 39, 303–313. Google Scholar Dalen M., & Rygvold A. L. (2006). Educational achievement in adopted children from China.Adoption Quarterly, 9, 45–58. CrossrefGoogle Scholar Gindis B. (2003). What should adoptive parents know about their child’s language-based school difficulties?, Retrieved May 28, 2007, from Post-Adoption Learning Center, Retrieved May 28, 2007, from http://www.adoptionarticlesdirectory.com/Article/What-should-adoptive-parents-know-about-their-children-s-language-based-school-difficulties---Part-1-/5. Google Scholar Glennen S. (2002). Language development and delay in international adoption: A review.American Journal of Speech Language Pathology, 11, 333–339. LinkGoogle Scholar Glennen S. (2005). New arrivals: Speech and language assessment for internationally adopted infants and toddlers within the first months home.Seminars in Speech and Language, 26, 10–21. Google Scholar Glennen S. (2007). Predicting language outcomes for internationally adopted children.Journal of Speech, Language, and Hearing Research, 50, 529–548. LinkGoogle Scholar Glennen S. (in press). Speech and language guidelines for children adopted from abroad at older ages.Topics in Language Disorders. Google Scholar Glennen S., & Bright B. (2005). Five years later: Language in school-age internationally adopted children.Seminars in Speech and Language, 26, 86–101. CrossrefGoogle Scholar Glennen S., & Masters G. (2002). Typical and atypical language development in infants and toddlers adopted from Eastern Europe.American Journal of Speech-Language Pathology, 11, 417–433. LinkGoogle Scholar Glennen S., Rosinsky-Grunhut A., & Tracy R. (2005). Linguistic interference between L1 and L2 in internationally adopted children.Seminars in Speech and Language, 26, 64–75. CrossrefGoogle Scholar Johnson D. E. (2000). Medical and developmental sequelae of early childhood institutionalization in Eastern European adoptees.In Nelson C.A. (Ed.), The Minnesota symposia on child psychology:The effects of early adversity on neurobehavioral development (Vol. 31, pp.113–162). Minnesota Symposium on Child Psychology. Google Scholar Law J., Boyle J., Harris F., Harkness A., & Nye C. (2000). Prevalence and natural history of primary speech and language delay: Findings from a systematic review of the literature.International Journal of Language and Communication Disorders, 35(2),165–188. CrossrefGoogle Scholar Mason P., & Narad C. (2005). International adoption: A health and developmental prospective.Seminars in Speech and Language, 26, 1–9. CrossrefGoogle Scholar Miller L. (2005). The Handbook of International Adoption Medicine. New York: Oxford University Press. Google Scholar O’Connor T. G., Rutter M., Beckett C., Keaveney L., Kreppner J. M., & theEnglish and Romanian Adoptees Study Team (2000). The effects of global severe privation on cognitive competence: Extension and longitudinal follow-up.Child Development, 71, 376–390. Google Scholar Pallier C., Dehaene S., Poline J., LeBihan D., Argenti A., Dupoux E., & Mehler J. (2003). Brain imaging of language plasticity in adopted adults: Can a second language replace the first?.Cerebral Cortex, 13, 155–161. Google Scholar Pollock K., & Price J. R. (2005). Phonological skills of children adopted from China: Implications for assessment.Seminars in Speech and Language, 26, 54–63. CrossrefMedlineGoogle Scholar Roberts J., Pollock K., Krakow R., Price J., Fulmer K., & Wang P. (2005). Language development in preschool-aged children adopted from China.Journal of Speech, Language, and Hearing Research, 48, 93–107. LinkGoogle Scholar Rutter M., & The English and Romanian Adoptees Study Team (1998). Developmental catch-up and deficit following adoption after severe global early privation.Journal of Child Psychology and Psychiatry, 39, 465–476. Google Scholar Scott K., Roberts J., & Krakow R. (2008). Oral and written language development of children adopted from China.American Journal of Speech Language Pathology, 17, 150–160. LinkGoogle Scholar J., J., & C. (2007). International adoption as a natural in language CrossrefGoogle Scholar A., & B. (2002). Communication and Developmental Google Scholar Windsor J., L., S., & Early Intervention Project Core (2007). Language with limited Romanian and of Speech, Language, and Hearing Research, 50, LinkGoogle Scholar Sharon Glennen, PhD, is and of the of Speech Language and Studies at University. adopted two children from her at Additional to in Dec times & American

Early Intervention in Children with Cleft Palate

To summarize current evidence for early identification and motor-based intervention for children aged 5 years and younger of age with/at risk of developmental coordination disorder (DCD). Using scoping review methodology, we independently screened over 11 000 articles and selected those that met inclusion criteria. Of the 103 included articles, 78 articles were related to early identification and are summarized in a companion article. Twenty-two articles focused on early intervention, with an additional three articles covering both early identification and intervention. Most intervention studies were at a low level of evidence, but provide encouraging evidence that early intervention is beneficial for young children with/at risk of DCD. Direct intervention can be provided to whole classes, small groups, or individuals according to a tiers of service delivery model. Educating and building the capacity of parents and early childhood educators are also key elements of early intervention. Evidence for early intervention for children with/at risk of DCD is emerging with promising results. Further studies are needed to determine best practice for early intervention and whether intervening early can prevent the negative developmental trajectory and secondary psychosocial consequences associated with DCD.

Developments in early intervention have paralleled those in early language intervention. Such parallels are not surprising given that general early childhood special education and language intervention practices have been influenced by the same theories of development and learning. In addition, because of the importance of communication to learning and academic achievement, and the prevalence of communication problems in children with special needs, language intervention has been fundamental to early intervention services and, reciprocally, language intervention practices have been challenged as a result of changes in early childhood services. In light of this relationship, this paper provides a focus on developments in language intervention within a framework of early intervention.

Children with cleft palate with or without cleft lip (CP±L) are at high risk of problems with early speech sound production, and these difficulties can persist into later childhood. Early intervention could help to reduce the number of children whose problems become persistent. However, much research in the field to date has focused on older children. There is a need to determine if providing intervention during the phase of early typical speech development leads to better outcomes. To review the evidence for the effectiveness of interventions targeting speech, delivered in the first 3 years of life for children with CP±L, and discuss factors such as intervention type, facilitator, dosage, outcome measures and the age of the child. The systematic review was registered with PROSPERO (CRD42019121964). Eight bibliographic databases including CINAHL and MEDLINE were searched in August 2018. Studies were included if participants received speech and language interventions before 37 months and if they reported outcomes for speech. Two reviewers independently completed inclusion reviews, quality analysis and data extraction. The review included seven papers: one pilot randomized controlled trial, one controlled trial, four cohort studies and one case series report. Interventions largely took a naturalistic approach, namely focused stimulation and milieu teaching. The findings provide preliminary support for naturalistic interventions and suggest that these interventions can be delivered by parents with suitable training. Studies included in the review provided low-strength evidence with variation in both the type of intervention, the manner of delivery and in the risk of bias in the designs used. The papers included in this review suggest that early naturalistic interventions can have positive impacts on the speech development of children with CP±L. However, the reported methodological quality of the publications overall was weak, and the current evidence lacks clarity and specificity in terms of therapy technique, delivery and optimum age of delivery. Future research should use more robust methodological designs to determine whether early speech interventions are beneficial for children born with CP±L. What is already known on the subject Children with CP±L show difficulties with early speech development and often have restricted speech sound inventories. They may reach the canonical babbling stage later than children without CP±L and studies have shown that 20% of children with CP±L have speech which is considered unintelligible or barely intelligible at age 5. It has been proposed that early intervention can lessen the impact of CP±L on speech development. However, currently, the evidence for early interventions for children with CP±L is limited, with the majority of studies focusing on children aged 3 years and older. What this paper adds to existing knowledge This paper reviews the evidence for different types of early interventions for speech provided to children born with CP±L and whether these interventions are effective in supporting speech sound development. In this review, early intervention is defined as intervention provided to children in the first 3 years of life. This review describes intervention approaches and how they are delivered for this population. What are the potential or actual clinical implications of this work? In the UK, children born with CP±L and their families are supported by National Health Service (NHS) services over a 20-year period and speech and language therapy sessions may take place over many weeks and months. If providing early intervention in the first 3 years of life is effective, there is the potential for improved speech outcomes in early childhood and a reduced burden of care on children, families and services. This review considers the evidence for early speech intervention for children with CP±L in the first 3 years of life and identifies areas for future research.

Speech and language acquisition can be a challenge for young children with Down syndrome (DS), and while early intervention is important, we do not know what early interventions exist and how effective they may be. To systematically review existing early speech, language and communication interventions for young children with DS from birth up to 6 years, and to investigate their effectiveness in improving speech, language and communication outcomes in children with DS. Other outcomes are changes in parental behaviour and their responsiveness METHODS & PROCEDURES: We conducted a systematic search of relevant electronic databases to identify early intervention studies targeting speech, language and communication outcomes in children with DS published up to May 2020. A total of 11 studies that met the inclusion criteria were synthesized and appraised for quality using the PEDro-P scale. There were a total of 242 children. We identified three types of intervention: communication training and responsive teaching, early stimulation programme, and dialectic-didactic approach. The findings from nine out of the 11 studies reported positive outcomes for children's language and communication up to 18 months following the intervention. All nine studies reported interventions that were co-delivered by parents and clinicians. However, there was also a de-accelerated growth in requesting behaviours in the intervention group reported by one study as well as a case of no improvement for the intervention group. Three studies provided some evidence of improvements to parent outcomes, such as increased parental language input and increased responsiveness. However, there was a moderate to high risk of bias for all studies included. The findings from this review suggest that interventions that have high dosage, focus on language and communication training within a naturalistic setting, and are co-delivered by parents and clinicians/researchers may have the potential to provide positive outcomes for children with DS between 0 and 6 years of age. Due to the limited number of studies, limited heterogeneous data and the moderate to high risk of bias across studies, there is an urgent need for higher quality intervention studies in the field to build the evidence base. What is already known on the subject Speech and language acquisition is usually delayed in children with DS, yet there are currently no standard interventions for children under 6. A number of research-based interventions exist in the literature, yet it is unknown how effective these are. What this study adds to existing knowledge This is the first systematic review that specifically and exclusively focuses on parent- and non-parent-mediated speech, language and communication interventions for children with DS between 0 and 6 years of age. It complements three existing recent reviews, each of which has a slightly different focus. The previously published reviews have covered only parent-mediated interventions, excluding interventions not mediated by parents, have reviewed interventions including children and adults, without any mention of what early interventions may be like or how effective these may be for young children with DS, have not always assessed risk of bias or have focused specifically on language interventions excluding those focusing on speech articulation or pre-linguistic skills. The findings from the current review suggest that interventions that have high dosage focus on language and communication training within a naturalistic setting and are co-delivered by parents and clinicians/researchers may have the potential to provide positive outcomes for children with Diwn syndrome from 0 to 6. We acknowledge that the current evidence base comes from studies with moderate to high risk of bias, hence our conclusions are not definitive. What are the potential or actual clinical implications of this work? Speech and language therapists will have synthesized information and a quick reference point on what type of interventions exist for children with DS under the age of 6, and evidence of which intervention approaches may be promising in terms of providing positive outcomes. However, it is acknowledged that, due to the limited number of studies and the moderate to high risk of bias inherent in the evidence, there is an urgent need for higher quality intervention studies in the field to build the evidence base.

How Audiologists Can Support EHDI Goals

Role of Intervention Strategies for At-risk Preterm Infants

Early identification of congenital deafness enables early intervention, but evidence on the influence of age at fitting of hearing aids (HAs) or cochlear implants (CIs) on outcomes in school-aged children who are deaf or hard of hearing (DHH) is limited. This study (1) described developmental outcomes and health-related quality of life in DHH children; and (2) examined the relationships among demographic factors, including age at fitting of HAs or CIs, and outcomes. This prospective cohort study included participants in a population-based study who were followed up at 9 years of age. Children who are DHH and who first received hearing habilitation services before 3 years of age from the government-funded national hearing service provider in the states of New South Wales, Victoria, and Southern Queensland in Australia were invited to enroll in the study. At 9 years of age, enrolled children were assessed using standardized measures of language, cognitive abilities, and speech perception. The children also completed questionnaire ratings on their quality of life. Parents provided demographic information about their child, family, and education; and completed ratings on their child's quality of life. Audiological data were retrieved from the client database of the hearing service provider and records held at CI centers. Descriptive statistics were used to report quantitative outcomes. The relationships among demographic characteristics, including age at fitting of HAs or CIs, and children's outcomes were examined using structural equation modeling. A total of 367 children, 178 (48.5%) girls, completed assessments at age 9.4 (SD = 0.3) years. On average, performance was within 1 SD of the normative mean for language, cognitive functioning, and health-related quality of life; but much below norms for speech perception. The modeling result is consistent with verbal short-term memory having a mediating effect on multiple outcomes. Better verbal short-term memory is significantly associated with no additional disabilities, earlier age at CI activation, use of an oral communication mode in early intervention, and higher maternal education. In turn, verbal short-term memory directly and positively affects speech perception, language, and health-related quality of life. Maternal education directly and positively affects language outcomes, and indirectly via its effects on nonverbal I.Q. and verbal short-term memory. Better language is directly associated with a better quality of life. This study found evidence consistent with early hearing intervention having a positive effect on speech perception and language via its effect on verbal short-term memory. Children who had better language also had better quality of life. The importance of early hearing for cognitive development lends support to early detection and early hearing intervention, including streamlining pathways for early CI activation. Strategies for intervention in language and communication development may benefit from tailoring programs to meet the needs of individuals with different memory profiles for optimizing outcomes.

Effects of different language and tDCS interventions in PPA and their neural correlates

The development of communication, speech and language follows three stages (development of the parent-child relationship, interactions and actual speech and language acquisition). Children born with cleft lip and/or palate are at increased risk of communicative problems while parents may be going through an emotionally difficult time. Early parent-implemented logopaedic intervention that supports both parents and child is important. Three systematic reviews have examined the effects of early speech and language interventions, but not their structure and content. To investigate which early parent-implemented logopaedic interventions already exist for children with cleft lip and/or palate, and to evaluate their structure, content and time of onset against the three stages of communicative development. Six databases (PubMed, Embase, Web of Science, APA PsycInfo, Cinahl and Scopus) were searched between inception and 31 March 2023 to identify published articles that reported early parent-implemented logopaedic interventions in children with cleft lip and/or palate, aged 0 to 3 years, clearly describing the strategies used to train parents. Two authors independently assessed the eligibility of the studies. Quality assessment was conducted using the Physiotherapy Evidence Database quality assessment tool, Single-Case Experimental Design tool and the National Institutes of Health pre-post-study tools. The structure and content of the interventions were analysed taking into account the needs and difficulties of both the parents and the child according to the three stages of communicative development. The systematic literature search identified four studies that met the inclusion criteria. Three of them had a Level of Evidence III and one study had a Level of Evidence IV. Strategies appropriate for Stage 1 of communicative development (parent-child relationship) are well represented in only one study, but the psychosocial needs of parents are currently not included in these programmes. However, research shows that parental emotional difficulties can adversely impact a child's communicative development. Strategies appropriate for Stage 2 (promoting social interactions) are better represented. However, strategies appropriate for Stage 3 (acquiring correct speech and language patterns) are most represented in all intervention programmes. Three out of four intervention programmes focus on Stage 3 (actual speech and language stimulation). Stage 1 is underrepresented and the psychosocial needs of parents are currently not included in existing intervention programmes. Further research is needed in close collaboration with psychologists to construct a comprehensive, longitudinal, developmentally appropriate intervention programme that equally represents the three stages of communicative development and considers the psychosocial needs of parents. What is already known on the subject Children with cleft lip and/or palate are at increased risk of speech and language problems from birth. Parents of these children often have emotional problems following their child's diagnosis. The effectiveness of early intervention to facilitate the child's speech and language development has already been proven. Early intervention is recommended for both parents and child, but little is known about early parent-implemented logopaedic interventions that also provide psychosocial support for parents. What this paper adds to existing knowledge This review has shown that existing early parent-implemented logopaedic interventions for children with cleft lip and/or palate focus mainly on facilitating responsive interactions and actual speech and language development (Stages 2 and 3 of communicative development). However, Stage 1, where the parent-child relationship develops, is currently not included, even though this stage is a prerequisite of subsequent stages. If parents are struggling with emotional problems (following their child's diagnosis) this can negatively impact their mental health, the parent-child relationship, attachment and their child's development. What are the potential or actual clinical implications of this work? A clinical implication of the findings in this review is that more attention should be paid to Stage 1 of communicative development in early parent-implemented logopaedic interventions. By working closely with the psychologist of the cleft (and craniofacial) team, any psychosocial needs of the parents can be included in the counselling. As a result, the parents and their child are seen and supported as a unit and the parent-child relationship can develop optimally.

Objective: The effectiveness of early language intervention for children with cleft lip and/or palate (CLP) was evaluated. Methodology: A systematic literature review of journal publications going back to the year 1970 was conducted in accordance with international criteria of evidence-based practice. During in-depth database research carried out in the Cochrane Library, MEDLINE, EMBASE, CINAHL, PsycInfo, and publishing house (Hogrefe, Karger, Kluwer, Springer, Thieme) databases, studies were targeted, which evaluated the effectiveness of early language intervention for children with CLP ranging from 1;6 to 4;11 years old. Search terms related to cleft lip and palate, early intervention, and language intervention were used in various combinations. The individual studies were evaluated using Cochrane criteria, and the findings were qualitatively analyzed. Results: Five studies met the inclusion criteria. Three of them dealt with therapy effectiveness with parents’ participation during the intervention process, while two of the studies investigated the effectiveness of a conventional therapy setting. All of the included studies identified an improvement in the linguistic abilities of children with CLP, although these children's abilities continued to lag behind those of a standard population used as a control group. The participation of parents during the therapy led to an increase in the children's communicative abilities, which likewise had a positive impact on the linguistic abilities of the children with CLP. Discussion: Limited empirical support for the effectiveness of early language intervention for children with CLP was found. Also, the methodological quality of the publications included in the study was very heterogeneous and, overall, not entirely convincing. Additional high-quality research utilizing transparent study designs is needed in order to collect more definitive evidence. Source of funding: No source of funding reported.

IntroductionIn the Netherlands, early language intervention is offered to children with presumed Developmental Language Disorder (DLD). The intervention is a combination of group language intervention, individual speech and language therapy and parent-implemented language intervention. During the intervention, some children show more language progress than others. It is unclear what might explain this variation. In this study, we therefore explored to what extent child, parental, and treatment factors were predictive for receptive and expressive language outcomes of young children with presumed DLD during early language intervention.MethodsFour multiple regression analyses were conducted with four child factors [pre-test receptive syntax, behavior (internalizing and externalizing), non-verbal cognitive ability and gender], one parental factor (parental stress) and one treatment factor (treatment duration) as predictors and receptive and expressive language post-test scores as outcomes. For each language post-test, the corresponding pre-test language measure was also added. Data of 183 children with presumed DLD were included.ResultsReceptive syntax problems were an important predictor of expressive language outcomes. Findings also showed a longer treatment duration to be a predictor of progress in expressive vocabulary. Internalizing behavior, externalizing behavior, non-verbal cognitive ability, gender and parental stress did not contribute to predicting language outcomes. Lower pre-intervention language scores led to lower corresponding post-intervention language scores.ConclusionsProfessionals may need to be aware that children with receptive problems may be indicative of more pervasive impairment and that it can be more difficult to improve their language problems. In fact, children with receptive language problems may need both more and different approaches. The finding that the level of the pre-intervention score has an essential influence on language outcomes underlines the importance of early diagnosis and early intervention, to prevent language problems increasing.

Bill, a 35-year-old journalist working for a local radio station, was sent to report from the scene of a bomb attack that resulted in several fatalities. What he witnessed
\nat the scene distressed him greatly. Immediately afterward, he began repeatedly to re-experience what had happened, leading him to avoid either discussing or thinking about it. He continued to work, but he lost interest in things
\naround him. He became withdrawn, irritable, and hypervigilant. These symptoms rapidly diminished over the first few weeks, but then 1 month after the attack they began to increase again for no apparent reason. What is the differential diagnosis? How should Bill’s symptoms
\nbe managed?

“How could I apply this information?” This feasibility study suggests Supporting Play Exploration and Early Development Intervention (SPEEDI) may bridge the gap in services between hospital discharge and early intervention (EI) and help families implement developmentally appropriate play and routines. Parents of infants born premature are interested and capable of implementing SPEEDI at home and want more support—both in the neonatal intensive care unit (NICU) and at home after the infant is discharged. Neonatal intensive care unit teams should consider implementing SPEEDI to help parents interpret their infants' cues and readiness for interaction, and to establish routines that include developmentally appropriate play. Therapists should prioritize and increase parents' involvement in the NICU and consider visiting the family at home after discharge to improve parent confidence and to answer questions. Supporting Play Exploration and Early Development Intervention is likely more essential in communities where EI services are delayed post-NICU discharge. For example, in some communities, delays in EI services might include not regularly referring families to EI, monitoring at-risk infants until a delay is identified, or a lack of available providers. Other barriers depending on where the family lives include challenges with scheduling the initial EI evaluation and differences in referral, intake, and eligibility procedures. “What should I be mindful about in applying this information?” Neonatal intensive care unit teams who choose to use SPEEDI should be mindful that this was a feasibility study with a small sample of infants born premature from 1 urban NICU, so it cannot be generalized to all infants. For example, infants born at term, infants with multiple special health care needs requiring extensive care postdischarge, or infants born premature in a suburban area might have different results. Determining whether SPEEDI leads to better outcomes for infants across sites and family demographics is an important next step. The SPEEDI program was developed to address barriers to initiation of services post-NICU discharge; therefore, stakeholders must also examine access to EI services in communities where barriers exist. Tricia Catalino, PT, DSc, PCS Touro University Nevada Henderson, Nevada Amanda Arevalo, PT, DSc, PCS Amanda Arevalo Physical Therapy PC Berwyn, Illinois