collaboration

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if you want models for early intervention could work more collaboratively think intensive joint provision would be too expensive

The early intervention gap can we fix it? (Yes, I CAN!)

In Alex Halls experience, most therapists assume that specialist educational placements for preschool children with persistent speech and language difficulties would have good outcomes but be too expensive to provide. Evaluation of I CANs pioneering Early Years Centres indicates otherwise, and Alex argues it is now time for us to put our money where our mouth is - and shift resources out of the clinic.

Picture from an I CAN Early Years Centre

CAN, the national educational charity for children with speech and language difficulties, started working with NHS Trusts and local education authorities over a decade ago to put some of the experience and expertise gained in its special schools into action for the benefit of younger children. At this time the development of I CAN speech and language nurseries was largely initiated in response to anecdotal evidence from teachers and speech and language therapists in the field. Experienced professionals were saying that they could identify children with persistent speech and language difficulties, who were likely to require some type of special educational provision as a result, at nursery age (usually three to four years), but were unable to provide appropriate provision until statutory school age, the few existing speech and language nurseries in existence at this time providing notable exceptions. Consequently, speech and language therapists reported, these children were often long-term members of clinic caseloads, and only started to make signifi-

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Figure 1 - Different models of provision

I CAN Centre A children enter between the ages of 2;8-3;3 years ten week programme for up to sixteen children per intake (eight morning, eight afternoon) programme carried out within mainstream nursery setting, with children spread through the nursery groups replaces attendance at playgroup or, for a few children, other nursery staffing: speech and language therapist, SEN nursery teacher, nursery nurse (all full-time), nursery nurse outreach worker (four days per week), educational psychologist (three sessions per intake, one to attend admissions panel and two for advice and support to staff and parents) the therapist, teacher and nursery nurses work as a team to support children within the nursery classrooms and carry out the individual programmes. Any one of them can carry out the group activities. I CAN Centre B children enter between the ages of 3;3-4;6 years six week intensive intervention programme for up to sixteen children per intake (eight morning, eight afternoon) intervention in a segregated area away from the mainstream nursery, in addition to the placement each child has at a mainstream nursery direct contact is four days per week with one day used for outreach, administration, planning and training team works with childs concurrent mainstream placement staffing: speech and language therapist, SEN nursery teacher, SEN special support assistant (all full-time), educational psychologist (one day per week) the staff work as a team and interchange in the carrying out of the big group activities, as well as other functions there are three staff for up to eight children for the majority of group activities Both Centres provide high levels of outreach to subsequent mainstream nursery / school placements.

cant progress once placed in language unit provision at four or five years old. Concern was also expressed about the likelihood of these children developing secondary difficulties with behaviour, literacy and social skills, which might have been prevented with appropriate early intervention. Building on this work, I CAN launched an ambitious Early Years Development Programme in 1999 with three major parts: 1.The development of 20 Early Years Centres for the provision of integrated education and speech and language therapy throughout the United Kingdom. (By April 2002, 13 will have been opened or approved.) 2.The rigorous evaluation of I CAN Centres in comparison to other early years provision for children with speech and language difficulties. 3.The development of an Accreditation Scheme, which would identify key features of high quality effective service provision and set the standard for this specialist area. This will be launched at I CANs National Conference, 4th March 2002.

Highly significant contribution

A recently completed study, undertaken by James Law (City University) and Julie Dockrell (Institute of Education) on behalf of I CAN (part funded by the Department of Health and the John Ellerman foundation) makes a highly significant contribution to the evaluation component of this programme, and is supported and reinforced by ongoing evaluations carried out by practitioners at other I CAN Early Years Centres. The objectives of the study were to: a) provide a description of I CAN Early Years Centre provision contrasted with national preschool educational provision b) analyse changes in the language and social

skills of children attending I CAN Centres in comparison to a group of children receiving local speech and language therapy and preschool education c) provide an initial economic evaluation of the services received by children attending I CAN Centres and the comparison group. Subjects came from two I CAN Early Years Centres (figure 1); local NHS trusts were approached to recruit comparison group children. The children were assessed and parents were interviewed immediately prior to the intervention, immediately after the intervention, and six months after initial assessment. Language, cognition and social development measures were collected for a total of 90 children with primary language difficulties, 58 of whom came from the I CAN Centres. The mean age of the children (in both groups) was 3;4 years. The economic evaluation was carried out by comparing the costs of the I CAN Centres with those of NHS speech and language services and preschool education as determined from national data. The evaluation study showed that children who attended the I CAN Centres made greater improvements, relative to the comparison group, in the following areas: productive vocabulary language comprehension scores as measured by the verbal subtests of the British Abilities Scales (Elliot et al, 1996) adaptive and social behaviour

Positive changes were also noticed by parents and teachers, relative to the comparison group

Positive changes were also noticed by parents and teachers, relative to the comparison group: parents reported the adaptive and social behaviours of the I CAN Centre children to have significantly improved (expressive, compliant and pro-social behaviour) parents reported a decline in disruptive behaviour for children who attended the I CAN Centres teachers indicated that there had been a significant improvement in the childrens compliance and pro-social behaviour. I CAN Early Years Centres, including the two which participated in the research, share a model with features that were not seen in the services received by children in the comparison group. It is not a prescriptive model; indeed, it is operationalised differently in all the Centres to accommodate local factors. Variation is often a result of policies such as school entry age, complementary services - for example, how much support the children will receive when and if they return to a local mainstream setting - and geography, where long travelling distances may mean attendance is for fewer sessions. The model and associated good practice are being disseminated, by I CAN, through a training cascade and accompanying materials during 2002, as well as through the I CAN Accreditation scheme. The model has the following features, which could usefully be replicated in other services: 1. The integrated delivery of speech and language therapy and preschool education, achieved through collaborative work of teachers and therapists who together plan, deliver and monitor programmes. Of particular significance is the joint preparation of Individual Education Plans and matching of activities into Early Learning Goals. 2. Parental involvement (frequent communication, child specific advice, parent workshops). 3. Participation in a mainstream nursery environment (the I CAN provision is either part of a mainstream class or attended concurrently with a mainstream placement supported by the I CAN staff). 4. Outreach activities to support the children in any concurrent placement and through the transition into subsequent educational provision. 5. The Law & Dockrell research found the I CAN Centres to excel in all dimensions of the Early Childhood Rating Scales (Harms et al, 1998) apart from space and furnishings. The one I CAN Centre which scored poorly in this area has since been relocated. Specifically, they noted: good use of language, reasoning and interaction skills, for example staff child interactions individual learning needs described for the children were of a particularly high standard emphasised social/pragmatic tasks such as greeting and departing excellent use of books and pictures to facilitate the language skills of the children.

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Five steps to better practice

1. Grasp the opportunity provided by new funding flexibilities and I CANs training and Accreditation Scheme to set up integrated early years services. 2. Respond creatively to local policies, provision and geography. 3. Prioritise children with severe language comprehension difficulties for collaborative work with nursery or playgroup staff. 4. Assess, plan, intervene and monitor collaboratively. 5. Ensure parents receive consistent information and are involved at all stages.

Prioritising
Where a model of service delivery showing these features is available, the Law & Dockrell research provides clues to assist in appropriately selecting and prioritising children for placement: Children with the most severe language comprehension difficulties at initial assessment who attended I CAN Centres made the greatest gains in this area, relative to the comparison group, and are therefore ideal candidates. Both at baseline and at six month follow-up there was no significant difference between the Centre and comparison children in intelligibility. Using the Goldman-Fristoe Test of Articulation (1986), both groups had similar improvements in the number of items they attempted to name and the number of sounds produced correctly. This suggests children whose primary difficulty is with phonology should not be given priority for these two I CAN Early Years Centres. Whilst the long-term financial benefits of effective provision (reduced need for specialist support and education, reduction of secondary difficulties and parental and child well-being) may be difficult to evaluate, the direct costs of delivering the model of service provision described and the comparative costs of a clinic based speech and language service coupled with a mainstream preschool education are easier to measure. The Law & Dockrell research has provided a useful first step for studies in this area, although the wide differences in levels of speech and language therapy provided in clinic based services and issues around costs to parents in accessing services require further investigation.

Children with the most severe language comprehension difficulties... made the greatest gains in this area

from national data) were analysed and compared to those receiving the integrated I CAN service. The provision to the comparison group was more expensive than the provision to the I CAN service group for one I CAN Centre, whilst the other I CAN Centre was moderately more expensive. Given the long-term benefits of the I CAN provision, and their likely cost implications, I CAN Early Years Centres offer a relatively cost efficient service, therefore redeployment of staff from a clinic setting to an integrated early years setting should be considered by speech and language therapy managers. It may be that the greatest obstacle to the development of integrated education and therapeutic provision for children in the early years is the organisation and management of the two services, split as they are between the NHS and education authorities. The new flexibilities for commissioning, funding, and managing services permitted through the 1999 Health Act for England and Wales provide an opportunity to be grasped for the benefit of children. In the meantime, based on these findings, my advice to therapists working with preschool children with persistent speech and language difficulties is to work collaboratively with teachers in early years settings to: Assess, so that: both have access to a fuller picture of the childs strengths and needs. Plan, so that: the child has one integrated plan which furthers both their language development and access to the curriculum priorities are agreed rather than conflicting. Intervene, so that: the therapist understands the demands of the

curriculum and preschool environment, and the teacher understands what are appropriate strategies, language demands and expectations intervention is consistent different skills and knowledge are exploited the time a child is exposed to appropriately targeted work is maximised intervention occurs in a naturalistic setting opportunities for reinforcement and generalisation are increased. Monitor, so that change or additional information is rapidly known by all intervention can rapidly reflect changes. Taken as a whole, this collaboration ensures that parents and other professionals can receive consistent information. Alex Hall is I CANs Director of Services Development. Further information on I CANs Early Years Centres, the new Accreditation Scheme, the training cascade and the Law & Dockrell research from I CAN, 4 Dyers Buildings, Holborn, London EC1N 2QP, tel. 0870 010 40 66, www.ican.org.uk.

References
Elliot, C.D., Smith, P. & McCollock, K. (1996) British Ability Scales (BAS II). Slough: NFER-Nelson. Goldman, R. & Fristoe, M. (1986) Goldman Fristoe Test of Articulation. Circle Pines USA: American Guidance Service Inc. Harms, T., Clifford, R.M. & Cryer, D. (1998) Early Childhood Environmental Rating Scales: Revised edition. New York: Teachers College Press.

Resources
For information on the1999 Health Act, see www.doh.gov.uk/jointunit/index.htm.

Surprising
When I talk to therapists, there is a general presumption that this type of intensive provision - where a therapist, teacher and assistant / nursery nurse are allocated to a relatively small number of children - will be expensive relative to provision of therapy in a clinic setting. The true picture is therefore perhaps surprising. The costs over one year for comparison children receiving separate NHS speech and language therapy and preschool education provision (obtained CORRECTION Figure 1 in Ruth Paradices article Putting partnership into practice (Winter 2001) should have appeared as shown here. Apologies for any confusion caused.

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SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2002