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Every Child's Chance of Fluency

Norbert Lieckfeldt | 01.05.2009

BSA's pre-school project has shown that with relatively minor adjustments SLT departments can dramatically improve their service. Our Chief Executive Norbert Lieckfeldt outlines the findings.

Research tells us that the best chance of addressing stammering, in terms of completely overcoming it and regaining normally fluent speech, is as close to onset as possible. Onset is usually around 2 ½ to 3 years, so intervention before a child starts nursery or primary school has the best chance of success.

providing an excellent service for pre-school children does not have to be hugely expensive.

However, from BSA's long years of working in promoting early intervention we know that the service across the UK is quite variable. As in almost everything to do with the NHS, the postcode lottery determines whether a child has the chance to gain fluent speech or whether he will be denied this opportunity.

Previous projects

For over ten years, the BSA has worked to encourage early intervention for pre-school children, to overcome the age-old paradigm of 'ignore it and it will go away'. While this is true for the majority of children, this attitude will expose a minority to a lifetime of stammering. Initially we targeted health care professionals with the message that 'early intervention prevents stammering', followed by another project aimed at parents and carers.

As a natural extension of this work, we looked at the service provided by the NHS; our project manager Margaret Evesham developed twelve criteria (see table below) that enable every speech and language therapy (SLT) department to assess the quality of their service, depending on how many of these criteria they meet.

We then assessed more than half of SLT departments in England - while 10% scored as 'outstanding', another 10% scored as 'poor' and 10% were 'inadequate', the lowest possible rating.

Our contention was that, with relatively minor adjustments in the way the services operate, they could dramatically improve their service. In the project we have just completed, Margaret has been working with six NHS Trusts across England, piloting this new way of working, implementing systems that enable these trusts to fulfil these criteria and offering basic training to all therapists who see pre-school children.

Dramatic improvements

The results of this project have been dramatic and very positive. All six NHS Trusts have seen significant improvements in their service - one even went from 'inadequate' to 'outstanding' in only nine months. As a result of this work, more children are being referred, these children are being referred at a younger age, they require less treatment in terms of number of sessions, and they get discharged more quickly after successful therapy. Also the confidence and enjoyment of therapists working with this client group has significantly increased, and the role of the therapist with a special interest has changed in that they can now plan the service, support colleagues, keep up to date with latest research and train other members of the children's workforce such as health visitors to identify children who stammer.

The final project report, with the methods and the positive outcomes described, recommending that all SLT departments implement these changes, will be distributed shortly to all managers and commissioners of services in the NHS in the UK, and will be available online at the BSA website.

One crucial effect of this project was to demonstrate how beneficial the one day training course for all general SLTs has been - most SLTs do not feel very confident in treating stammering in pre-school children, mainly based on the misguided fear that intervention will draw attention to the problem and will actually harm the child. All paediatric SLTs in the pilot trusts underwent a one-day training course in a structured model of service delivery, developed and delivered by Daniel Hunter (Highly Specialised SLT [NHS Heywood, Middleton and Rochdale]). The feedback from all Trusts was that this was the single most important feature of the project that enabled them to implement the changes and improve their services. We are currently looking at ways in which we can make this training more widely available. In addition, BSA commissioned Daniel Hunter to produce a document that summarises the latest research and the views of experts on why early intervention is beneficial - in today's NHS, resources are allocated on the basis of evidence and this document will hopefully help us and SLT managers make the case for more funding.

Through this project, we have been able to demonstrate that providing an excellent service for pre-school children, a service that will offer them the best chance of complete recovery from stammering, does not have to be hugely expensive. There really is no excuse for any SLT department not to offer the best possible service, not to offer every child the chance of fluency.

The final report and research document is available at Every Child's Chance of Fluency - Final report.

Every Child's Chance of Fluency -
Criteria for the Delivery of an Outstanding Service for Pre-School Dysfluent Children

Essential Criteria

1.  Criterion: Register of referrals coded to identify pre-school dysfluency 

Rationale: If treatment is to be given the best chance of succeeding it is important that an SLT assesses dysfluent children as near as possible to the onset of the stammer. It is, therefore, necessary to have a means of differentiating these children, at the point of referral, from those waiting for treatment for other voice, speech and language disorders.

2.  Criterion: Assessment within eight weeks of referral 

Rationale: Treatment is more effective if intervention begins as soon after onset as possible. A recent report reinforces the view that early intervention is vital. The report recommends that intervention be carried out within 6 weeks from referral, with 12 weeks as the maximum.

3.  Criterion: Intervention and monitoring begun immediately after assessment

Rationale: See 2. above

4.  Criterion: At least one specialist in dysfluency employed in the Department 

Rationale: Trusts generally have a higher standard of service if they employ a specialist SLT. These trusts also usually have a higher number of referrals.

5.  Criterion: All therapists trained to give initial advice 

Rationale: All generalist, paediatric SLTs need to feel confident they can undertake an initial risk assessment and advise parents accordingly. Even better if they can all carry out appropriate therapy.

6.  Criterion: Evaluation of outcomes of therapy 

Rationale:Evidence-based practice requires the health care professional to be able to demonstrate that their treatment model is effective.

7.  Criterion: Annual update of SLTs' knowledge and skills 

Rationale:In order to ensure that the best possible treatment is offered to dysfluent children, SLTs' knowledge and skills should be updated at least annually.

Desirable Criteria

1.  Criterion: Parents sent an acknowledgment and information about the process on referral 

Rationale: SLT Departments have found that sending information about the process is reassuring to parents and will decrease the number of those who do not attend.

2.  Criterion: Regular review of therapy offered 

Rationale: As a result of the evaluation of therapy (see essential criterion 6) the Department should review their practice to see whether they are still delivering effective therapy.

3.  Regular review of referral patterns 

Rationale: Referral patterns should be reviewed regularly in order to ascertain that all the dysfluent children in the community are being referred. It has been accepted for many years that 5% of children, under the age of 5 years, develop dysfluent speech. However, this may have to be revised as recent research shows prevalence as high as 8.5% amongst 3-year-olds.

4.  Criterion: Regular update of information given to referral agencies 

Rationale: If the pattern of referral changes it may be necessary to review and update the information given to all those working with young children about the need for early referral.

5.  Criterion: Information given to parents about the BSA 

The BSA has excellent information and support services and parents should be put in touch with the organisation so that they can benefit from the services offered.

From the Summer 2009 edition of Speaking Out, pages 8 and 9.