Thursday, 1 September 2011

Early intervention: What's not to like?

If a child has language problems, when would be the best age to intervene? At 18 months of age, when they’re just at the outset of learning language, or at five years, when they’re in school? Most people would say this is a no-brainer, with early intervention being preferred on two counts:
  • There are all kinds of secondary consequences of language difficulties: effects on self-esteem, educational outcomes and social interactions. Potentially, early intervention can avoid these.
  • It is easier to influence the course of development while the brain is still plastic. An analogy can be made with vision, where it is well-recognised that amblyopia (or "lazy eye") needs to be corrected early in life, because otherwise visual pathways in the brain do not develop normally, and the potential for good vision in the lazy eye is lost.
Currently, interest by policy-makers in early intervention has focussed mainly on children’s social and emotional outcomes, with a report by MP Graham Allen emphasising the benefits, not just for children’s outcomes, but also in economic terms. The argument is that by preventing problems from developing, we have the potential to save millions of pounds that would otherwise be spent in dealing with problems that manifest later in childhood.
The Allen report does not say much about children’s language development, but similar arguments are often made, and in some areas of the country, speech and language therapy services put most of their resources into intervention with preschoolers.
There is, however, a problem with early intervention that is easily overlooked, but which is well-documented in the case of children’s language problems. This is the phenomenon of the "late bloomer". Quite simply, the earlier you identify children’s language difficulties, the higher the proportion of cases will prove to be "false positives" who spontaneously move into the normal range without any intervention. We’ve known about this phenomenon for many years: For instance, a study conducted by Fischel et al in 1989 followed 26 two-year-olds recruited because their parents reported that they understood complete sentences but could say only a few words. Five months after initial assessment, one third still had problems, one third had made some improvement, and one third were in the normal range. Another study by Thal et al in 1991 followed ten children who scored in the bottom 10% for expressive vocabulary at the age of 18 to 29 months. One year after initial assessment, six had caught up, whereas the remaining four still had delayed language. These early small-scale studies have since been confirmed by much larger population-based studies in the Netherlands and Australia.
The late-bloomer phenomenon was neatly demonstrated in a study just published in the British Medical Journal by an Australian team headed by paediatrician Prof Melissa Wake and speech pathologist Prof Sheena Reilly. They recruited children from a large population-based study, where parents were asked to complete a Sure Start vocabulary screening measure when their child was 18 months of age, as well as a child behaviour checklist. Around 20 per cent of children were reported as having no or very limited spoken words. 301 of these children were randomly allocated to intervention or control groups. The intervention, "Let's Learn Language", was based on a widely-used approach where parents are trained to adopt strategies to enhance communicative interactions with their child. The children were then given a detailed assessment at two years of age, and again at three years. Results were striking: there were no hints of any difference between children in the intervention group and control group on any language or behavioural measures, either at 2 years or at 3 years.
The study authors noted various strengths and weaknesses of their study. Among these they discussed the possibility that the intensity of the intervention (six weekly sessions, each lasting 2 hours) may not have been enough. But they went on to note that “the normal mean language and vocabulary scores achieved by both intervention and control children by age 3 years suggest that natural resolution, rather than our intervention’s intensity being too low, explains the null findings.”
They then point out the sobering conclusion to be drawn: quite simply, if you intervene with children who are likely to improve spontaneously, there will considerable waste of government’s and families’ resources.
Does this mean we should give up on early intervention? No. But it does mean that we need to target such intervention much more carefully. At present, one of the big questions for those of us investigating late talkers is to find characteristics that will allow us to identify those children who won’t make spontaneous progress. This has proved to be surprisingly difficult.
Another important message applies to intervention studies more generally. If you provide an intervention for a condition that spontaneously improves, it is easy to become convinced that you’ve been effective. Parents were very positive about the intervention program. There was remarkably good attendance, and when asked to rate specific features of the program and its effects, around three quarters of the parents gave positive responses. This may explain why both parents and professionals find it hard to believe such interventions have no impact: they do see improvement. Only if you do a properly controlled trial will the lack of effect become apparent, not because treated children don’t improve, but rather because the control group gets better as well.

Reference: (Open Access) :-)
Wake M, Tobin S, Girolametto L, Ukoumunne OC, Gold L, Levickis P, Sheehan J, Goldfeld S, & Reilly S (2011). Outcomes of population based language promotion for slow to talk toddlers at ages 2 and 3 years: Let's Learn Language cluster randomised controlled trial. BMJ (Clinical research ed.), 343 PMID: 21852344

18 comments:

  1. Interesting paper and good post. I wonder how you'd go about targeting the early intervention? How do we know who's going to be a late bloomer and who's not?

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  2. Hi Neuroskeptic
    Short answer is, we're looking hard, but it's a bit of a mystery. The Generation R Study (Dutch one referred to in my post) found that, though there were highly significant correlations between expressive vocabulary at 18 months and 30 months, the sensitivity and specificity of late talker status was very poor for predicting language status at 30 months, and inclusion of parental, perinatal and demographic variables did not substantially improve prediction. The Australian study found significant predictors of outcome at 4 yr were male gender, maternal education, socio-economic status, family history of speech and language problems and maternal vocabulary. But prediction still not brilliant. I’m hoping to publish some results on this later this year, but our study much smaller than these two.

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  3. How do you distinguish between ‘blooming late’ and moving to a more enabling environment?

    There is no discussion of gender difference in the free to air papers that you cite yet I believe that there is a surfeit of boys in the ‘at risk’ group The staff in the UK Sure Start scheme seems to be almost entirely female. In my local authority the nine Children’s Centres which administer the scheme list 75 staff members. There are 74 unambiguously female names and 1 “Sam”. I have been visiting Children’s Centre as part of my job for three years and have hardly ever met a male teacher or teaching assistant. This imbalance is slightly less marked in primary schools and seems to disappear in secondary schools. At the other end of the scale is the Army which is about 88:12 male/female. It is an environment in which many young men with poor educational records manage to thrive, following a very short training period. Despite language that is bad in all senses, the military has exemplary communication skill and social cohesion.

    How do you separate those boys that develop late from ones that may have an early aptitude for context specific language, be it military commands or mathematical formulae, and then find their way into a different (and more male) social and linguistic niche?

    Robin Cousins

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  4. In terms of early intervention and the broader issue of child development, rather than just language development (which cant really be separated from the bigger picture of overall child development), perhaps we should be looking at social communication as the marker for possible problems? Social communication competencies such as referencing, joint attention and experience-sharing are all precursors of language development. Researchers have concluded that joint attention is a pivotal skill in child development http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1693124/pdf/12639329.pdf
    and that individual differences in joint attention are related to the intensity of social symptoms, responsiveness to interventions, and long-term social outcomes in children with autism. I have written about this (with particular reference to children with autism) in my blog if you want to take a look: http://notnigellanotjamie.blogspot.com

    Zoe Thompson

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  5. Thanks for another excellent post. I wonder if we need to be even more radical in our admission of the enormous gaps in our knowledge of what actually constitutes language competence, let alone how it is acquired.

    I know precious little about the clinical side of things but every time I look, I see large disconnects between the practical knowledge and the various theories available to explain and generalise it. That, as much as the research mentioned, makes me sceptical of large scale early intervention or even this whole early start agenda.

    One element that is completely missing is cross-cultural research. I think if we knew more about how the disparity between speech onset are dealt with across (non-literate and differently literate) cultures, we might get some surprising insights. I'm always reminded of Clifford Geertz's study on common sense where he showed the completely different perspectives of hermaphroditism. We know that there are significant (and for us counter intuitive) differences in how different cultures facilitate child speech. But as far as I know, we know very little about actual development in the different circumstances beyond the fact that competence is eventually developed. But I suspect knowing this would show a lot of the common sense we rely on with respect to linguistic competence to be no sense at all.

    Perhaps such knowledge might then temper this pedagogic race ad utero happening in the western world. I wonder whether if we shifted the start of formal education to 8 years of age, many of these late speech onset fears might not dissipate.

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  6. I am not sure I follow the logic behind the late bloomers "problem".

    Is it "bad" for a kid to get an early intensive intervention if he is a "late bloomer"?

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  7. Hi Jorge
    There is no evidence that early intervention does the children any harm: in the big study I reviewed, there was no difference at all between those who received and did not receive intervention.
    The problem is really one of resources; the authors of the study concluded: "This study shows the wisdom of doing rigorous trials to avert the considerable waste of governments’ and families’ resources that may otherwise occur."
    Here in the UK where our National Health Service is under great pressure, this is particularly relevant.

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    Replies
    1. My experience with Early Intervention services in the UK was very negative.
      My son is a late talker who displays some autism-like behaviours. However, he does not lack desire to communicate, has no cognitive delays, is an affectionate and empathetic child who has great imagination and perception of the world around him – which all indicates that he does not have autism. I had approached our local speech therapy services hoping that he would get speech therapy. My son was not offered any speech therapy sessions. Instead, I got numberless reports from various 'professionals' from Early Intervention services, filled with insinuations that my child was autistic. I ended up in a sort of twilight zone where I could not reconcile the image I had of my child and the image suggested by the reports I was getting. On the one hand I knew that my kid was intelligent and loving; on the other hand I thought: 'How come that all these professionals are suggesting otherwise?'
      There was no way I could communicate my idea with the EI people. If I said something that contradicted their 'observations', the only response we would get was a patronising head nodding with the look which said 'poor parent in denial'. I went through a period of major depression (I had never been depressed before) and my whole family suffered as a consequence.
      The moment I managed to regain some peace of mind, I went on to educate myself on the speech therapy methods and started working with my child on my own. Speech therapy isn't rocket science. Any parent can learn it, provided they have the right literature. My son's language developed rapidly. He went on from no words at the age 2y 6m, to almost 1000 words at the age 3 and now, at the age 3y 6m speaks in 7-8 words sentences in our mother language. He is still lagging behind his peers, though, especially in English, which is his second language.
      We believe that my son's problem is language related and that his delays in social communication skills are the consequence of his language delay, rather than the other way around. However, I realised that if we went along with a formal evaluation process, our son would probably end up with an inaccurate label, due to all those reports from the EI people which had been sent to the paediatrician who was supposed to assess him. (continued in the following post)

      Delete
    2. (continued from previous post)
      That is my experience with the Early Intervention. They never did anything helpful for my son. The only thing that they managed to do is to cause unnecessary anxiety and frustration for the parents and to instigate lowered expectations from his nursery teachers. For example, the nursery refused to take part in our potty training efforts (which they normally do) claiming that it was too early and that our son showed no awareness that he was ready. Even though he was fully potty trained at home (when he was 2y 7m), the nursery refused to ditch the nappies. Only after they realised that he was completely dry every time they tried to change him, did they agree to switch to knickers. He never had a single 'accident' after we potty-trained him, which they said was 'amazing', but they never apologised for not wanting to work together with us. This was just one among numerous frustrating episodes we had to deal with due to the inaccurate evaluations of our son's skills by the whole EI team. The problem is that we agreed for information to be shared among all the people who were involved with our son, hoping that it would make it easier to co-ordinate help and support we hoped he would get. What this information sharing caused, instead, is that these people read each other's reports which had informed their opinion of our child before they even saw him and we ended up with a parroting set of evaluations which misrepresented our child's problem and his abilities.
      We never managed to get our son seen by a professional who was willing to look beyond the behavioural check-lists and provide any helpful suggestion in terms of therapies and services which may aid him in his development.

      Delete
  8. Sigh...Where do I begin? First let me start by saying that unlike many, I live in the United States. I'm "African-American" whatever that means, I was born and raised in Brooklyn, NY and my parents are from the Caribbean. I'm left handed. I was diagnosed with "Tongue Tie" at age 7. From the inception I was placed in a special education classroom in elementary school (1st through 5th grade). No operation was performed to fix the "Tie Tongue". In the entire school both special education and main stream I always scored in the top three in the state wide math test and above average in reading every year. I always had the highest grades within my classroom. But yet I was in Special Ed. Upon completion of Special Ed. I was evaluated and it was found that I was smart enough to be placed in mainstream classes but I would still take a speech class everyday. So from sixth to 12th grade I took speech classes. I went to college and I received a B.S. in Computer Engineering and a M.S. in Telecommunications. So that's the background.


    Now if you are in Spec. Ed., it's natural for people to think that you have emotional/mental problems. So I also saw a counselor. Then a psychiatrist and because I'm a natural introvert the shrink felt that I had emotional issues. And since I was skinny that also hinted to my emotional problems in his eyes. So what's the course of action? Describe medicine. Obviously I never took one pill and thank God my mother knew better.


    Let me explain how the system works. When you are poor and you have no daddy, and you live in the "hood" the "ghetto" and your household receive public assistance and section 8 that's your livelihood. Now to get more such as a social security check and to continue these benefits you play along with the system so that you can have some kind of close to "normal" lifestyle. Now granted if the parent knows nothing is wrong with the child and is using the child that's wrong. It's called exploitation. But when you live in a society where your race is at the bottom of the totem pole there's no such thing as wrong.


    Now fast forward, I'm a grown man now. I got a couple degrees, well articulated (thanks to those darn speech classes) and I go to interview with federal agencies to get a job. I need to list if I ever saw psychiatrist, special education and any legal or illegal drugs.


    Long story short. They say that marijuana is the "gateway drug" that's how I see "Early Intervention". Now my "speech problem" could it be that my mother was a single parent and from age 0 - 3 yrs. had to leave me with relatives when she went to work 12 hrs a day. Then 3 -7 sent me to the Caribbean so that I could be raised by my grandmother until she was capable of supporting me. Now at age 7 who son is a natural extrovert and is very expressive? Wouldn't I naturally feel awkward in a new environment and picked up an accent which would make me a quiet boy. But no one could see that.


    See what people fail to understand is that this world we live in is an institution. In the 1970/80s the government said to school districts you have to start integrating your schools. The white school districts weren't fond of this directive. So the government said how about if we allow you to re-segregate them within your schools aka special education. The school district said NO!. So the government said how about if we give you seven times as much for a special education child as we do for a regular education child and you don't have to tell us how you spent the money. End of story.

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  9. So forget all the tangents I ran off on but remember this. For me it started with "Tongue Tie" then Special Ed. then speech classes, then medicine, then no government jobs. Not to mention what it did to my self esteem.


    So how did I stumble upon this site. The mother of my child believes that my son have a "speech delay" so she started early intervention sessions without telling me (and without my consent). They told her he may have the "Einstein Syndrome" because he knew and can identify shapes, colors, letters, numbers, and words before age 2. Of course I had to laugh because I didn't know what the Einstein Syndrome was but I knew Einstein because I took 4 physic classes in college so I had to google it. And I laughed even more. If your mother have a Bachelor in nursing and your dad is an engineer. Naturally the child genes (dna) would pick some of that potential up. Now I know there's no correlation between children being smart and their parents but I'm pretty sure kids who have parents who went to college do better than kids who have parents who didn't go to college. So the early intervention people told her let's start sessions. So he meets with a "overall evaluator" and a speech "expert". Now when my son is extremely happy or hear a song that he likes he run around in circles on his tippy toes. Moreover he's fixated on picking things up off the floor and putting it in his mouth. So what do they recommend? He needs physical therapy now. Help him to "control himself". Mind you my son only turned two last week. So what's next. I didn't call a psychic but I bet that next they will say he's to hyper and diagnosed him with ADHD. Now ADHD is a "mental disorder" so why don't they do a MRI to show the parents this abnormal brain activity. But ADHD is commonly diagnosed based on referrals from the parent or the doctor. There's no science to it. Purely subjective. The treatment for that is Ritalin which has the same chemical structure as the illegal substance Speed and is a Category 2 drug and is highly addicting. Then what's next Special ed. and you can guess the rest.


    So my son mother sent me this link hoping to change my perspective. Show me a study where they follow the kids of these early intervention programs and see it they are in special ed. drugs/medicine and any behavior issues and then I may reconsider allowing my son to attend early intervention.


    So if your child truly have a physical/mental/emotional disability then by all means try early intervention with a grain of salt. But if these "certified" "experts" "specialist" are telling you based on no visual evidence that your child would benefit than question it. Wouldn't any child benefit from special treatment (intention)? See the issue I believe is that we are so quick to put labels on people such as African American, no daddy, left handed, ghetto, tongue tie when we don't even give our child a chance to blossom into the person they are destined to be. Not everyone in life should be an extrovert social butterfly. I like to be by myself and value my alone time. Does that mean that I have issues and because it was because of a lack of a father in the household? no.

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  10. That's why 1 in every 166 child is diagnosed with autism and then later on when they find out they were wrong they came up with something called Asperger’s syndrome. If that doesn't stick its gonna be ADHD.


    So if the mother of my child took my son to early intervention and they say we don't see anything wrong and later down the line our son have issues. Early Intervention is liable because they misdiagnosed my son. So better to be safe than sorry they will diagnose him with something and let the government pay the bill.


    Did you know that there used to be something called Attention Deficit Disorder (ADD) in the
    Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) but it's not there anymore. Why? because the pharmaceuticals couldn't make a drug that can make you pay attention they can only create a drug to slow down your central nervous system.


    So before you come here trying to denounce what I say please do your research and prove me wrong. Anything I wrote is my personal experience and based on facts.


    If you want to get informed look at the following:


    http://www.youtube.com/watch?v=jlbO7QS_FAY

    ReplyDelete
  11. I fascinated by this topic. I had two late blooming children. One qualified for EI and one missed qualifying. The one who qualified did 1 year of EI and graduated age appropriate in speech. I am glad the program was available and it eased my worries having him in therapy but I do believe his language would of followed the same path if he wasn't in EI but I still don't think it is a waste of resources.

    I know that in general that late talking is correlated with problems related to language in the school years and that early talking is correlated with that being a strength which makes sense. My kids don't seem to follow this pattern. They are now 3 and 5 and there language skills are fine and I can't tell them apart from kids who were really early talkers and really advanced.

    I wonder how you can tell what kids will be just be late bloomers and what kids will have issues down the road and the late talking was a sign of a delay in the area of language that will persist.

    I still worry about my kids that it was a sign but based on where they are now I honestly think they are fine and it wasn't a sign of a problem for them. How do you know what early talkers will just average out and what late talker will actually be advanced down the road.

    The topic kind of fascinates me and I want to know what it means and how to better predict.

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  12. I have had extremely negative experience with Early Intervention services in the UK.
    My son is a late talker who displays some autism-like behaviours. However, he does not lack desire to communicate, has no cognitive delays, is an affectionate and empathetic child who has great imagination and perception of the world around him – which all indicates that he does not have autism. I had approached our local speech therapy services hoping that he would get speech therapy. My son was not offered any speech therapy sessions. Instead, I got numberless reports from various 'professionals' from Early Intervention services, filled with insinuations that my child was autistic. I ended up in a sort of twilight zone where I could not reconcile the image I had of my child and the image suggested by the reports I was getting. On the one hand I knew that my kid was intelligent and loving; on the other hand I thought: 'How come that all these professionals are suggesting otherwise?'
    There was no way I could communicate my idea with the EI people. If I said something that contradicted their 'observations', the only response we would get was a patronising head nodding with the look which said 'poor parent in denial'. I went through a period of major depression (I had never been depressed before) and my whole family suffered as a consequence.
    The moment I managed to regain some peace of mind, I went on to educate myself on the speech therapy methods and started working with my child on my own. Speech therapy isn't a rocket science. Any parent can learn it, provided they have the right literature. My son's language developed rapidly. He went on from no words at the age 2y 6m, to almost 1000 words at the age 3 and now, at the age 3y 6m speaks in 7-8 words sentences in our mother language. He is still lagging behind his peers, though, especially in English, which is his second language.
    have had extremely negative experience with Early Intervention services in the UK.
    My son is a late talker who displays some autism-like behaviours. However, he does not lack desire to communicate, has no cognitive delays, is an affectionate and empathetic child who has great imagination and perception of the world around him – which all indicates that he does not have autism. I had approached our local speech therapy services hoping that he would get speech therapy. My son was not offered any speech therapy sessions. Instead, I got numberless reports from various 'professionals' from Early Intervention services, filled with insinuations that my child was autistic. I ended up in a sort of twilight zone where I could not reconcile the image I had of my child and the image suggested by the reports I was getting. On the one hand I knew that my kid was intelligent and loving; on the other hand I thought: 'How come that all these professionals are suggesting otherwise?'
    There was no way I could communicate my idea with the EI people. If I said something that contradicted their 'observations', the only response we would get was a patronising head nodding with the look which said 'poor parent in denial'. I went through a period of major depression (I had never been depressed before) and my whole family suffered as a consequence.
    The moment I managed to regain some peace of mind, I went on to educate myself on the speech therapy methods and started working with my child on my own. Speech therapy isn't a rocket science. Any parent can learn it, provided they have the right literature. My son's language developed rapidly. He went on from no words at the age 2y 6m, to almost 1000 words at the age 3 and now, at the age 3y 6m speaks in 7-8 words sentences in our mother language. He is still lagging behind his peers, though, especially in English, which is his second language.
    (the rest of the text is in the following post; couldn't post the whole text in one post due to the word limit)

    ReplyDelete
    Replies
    1. We believe that my son's problem is language related and that his delays in social communication skills are the consequence of his language delay, rather than the other way around. However, I realised that if we went along with a formal evaluation process, our son would probably end up with an inaccurate label, due to all those reports from the EI people which had been sent to the paediatrician who was supposed to assess him.
      That is my experience with the Early Intervention. They never did anything helpful for myson. The only thing that they managed to do is to cause unnecessary anxiety and frustration for the parents and to instigate lowered expectations from his nursery teachers. For example, the nursery refused to take part in our potty training efforts (which they normally do) claiming that it was too early and that our son showed no awareness that he was ready. Even though he was fully potty trained at home (when he was 2y 7m), the nursery refused to ditch the nappies. Only after they realised that he was completely dry every time they tried to change him, did they agree to switch to knickers. He never had a single 'accident' after we potty-trained him, which they said was 'amazing', but they never apologised for not wanting to work together with us. This was just one among numerous frustrating episodes we had to deal with due to the inaccurate evaluations of our son's skills by the whole EI team. The problem is that we agreed for information to be shared among all the people who were involved with our son, hoping that it would make it easier to co-ordinate help and support we hoped he would get. What this information sharing caused, instead, is that these people read each other's reports which had informed their opinion of our child before they even saw him and we ended up with a parroting set of evaluations which misrepresented our child's problem and his abilities.
      We never managed to get our son seen by a professional who was willing to look beyond the behavioural check-lists and provide any helpful suggestion in terms of therapies and services which may aid him in his development.

      Delete
    2. I'm glad that your son's condition is resolved. If you have the time could you please pass me some speech therapy references that you refer to so that I can pass it to someone in a similar situation as you are.

      Delete
  13. Addiction Treatment is really about second chances, and it’s a sad and difficult situation when people who need help the most are ineligible.Intervention services are needed to those addicts. Intervention services

    ReplyDelete