Linda Hand School of Communication Sciences & Disorders The University of Sydney

1. Child Language and EBP: A Challenge, a stimulus and the potential for changed roles between researchers and clinicians Linda Hand School of Communication Sciences & Disorders The University of Sydney l.hand@fhs.usyd.edu.au

2. The Challenge; to clinicians • The need to understand research better than we do • to fairly critique it • eg. “small sample size” – the easy target that often misses the point • to grasp what “evidence” really means • to look for designs that will answer the questions we have

3. The Challenge; to universities & other researchers • To educate clinicians better in understanding research • To conduct research which relates better to clinical and client needs • to relate to local conditions

4. The particular challenges of Child Language • Realisation of some major issues as to why evidence is problematic • Law (2002) – “no clearly understood definition /common understanding of what language intervention actually is” - • no common definition of what “language” is • theoretical divides not sufficiently discussed, tackled

5. no common usage of frequent terms • eg., ‘early intervention’; ‘reading’; receptive language’ • no common understanding of what “disorder in child language” is • SLI – only half the caseload • N-R tests – ruled out in too many cases; continuum with arbitrary cutoffs • constantly expanding field • failure of the developmental model

6. Some consequences • a research population which may bear little resemblance to a clinical population • research questions or models which may seriously distort the field (eg Glogowska et al, 2000) (Randomised controlled trial of community based speech and language therapy in preschool children. Br Medical Journal 321: 1-5) • a strong bias to quantitative, positivist models of ‘evidence’

7. Beecham (04)- the values inherent in the practice • (positivist, utilitarian discourse – cultural) – rationality, objectivity, empiricism. • In contradiction to moves toward the significance of the subjective life-world, the experience of the person, the client-centered and family-centered themes • eg the reports written by the Connect team (Byng, Cairns & Duchan, 02)

8. Tends to exclude and de-value qualitative research or other methods not embracing these values. • Power back in the hands of the ‘experts’? • the myth of the ‘normative’ and the ‘population’. Individualistic, dynamic nature of communication and of what we do • Power in the hands of the ‘managed care’ ‘value for money’ brigade (Mullen, 2004) • Pay attention to the discourse of EBP

9. The stimulus • Exciting potential • Clinicians to have motivation to understand research • Already seen the difference this makes in students • Further education – eg., continuing education master’s degrees • Researchers have directions to follow for research

10. eg… • As heterogeneity increases, RCT results are less applicable • Evidence from other populations has relevance • Clinically meaningful outcomes are often personal and social judgments Montgomery & Turkstra, 2003 Ylvisaker et al., 2002

11. The problems of missing evidence • Funding bias • Publication bias • e.g., non-significant findings not published • Consumer/researcher mismatch • e.g., lack of studies aimed at improving long-term quality of life outcomes for persons with aphasia Elman R. Aphasiology 2006;20:103-109

12. Stimuli (contd) • Networks develop • to be encouraged to involve both levels • Major reasons to examine in depth the bases on which we are working • Error base? • Developmental base? • Theory base? • Potential to take the field in whole new directions

13. Potential to take material across traditional boundaries; using evidence for assessments and interventions • eg disability -> child language <- • educational interventions • diversity • adult/child?????? • Necessity to explain these to others • (major plank of EBP – to explain the evidence to consumers & other professionals)

14. The potential for changed roles • Different relationship between clinicians and academics – more mutual understanding • research stuff that is actually used • realisations about the nature of research, therefore its limitations • not throwing the baby out with the bathwater • more collaborative research • more direct requests for research

15. Stronger faith in what we do • understanding the strength of theoretical bases, or educational bases etc. • not enough – but it is the essential start • Better grasp of what needs to be done • eg Pring – phased research • faith in appropriate designs; single case designs, matched pairs, wealth of data on relatively few participants versus thin data on many

16. Pring (2004) – clinical outcome research should take place in a series of phases. The RCT too early or with too heterogeneous a group will result in poor outcomes • Systematic reviews often deal with huge variation in methodologies and value of design • fail entirely to deal with qualitative data

17. need specific therapies for well-defined groups • test first in efficacy than effectiveness studies • disseminate results to clinicians • then only then – large-scale trials of effectiveness for therapy provision generally to a client group or have systematic reviews

18. Will EBP change your practice? • Evidence only affects practice if it changes beliefs • Agreement on the evidence, but not on the practice - WHY? • Relative value placed on types of evidence Rubenfield, 2002; Tonelli, 2001

19. It depends on your interpretation of what is a meaningful outcome…a personal and social judgment. • Agreeing on outcomes does not mean we will agree on practice patterns. • to fit in with personal and cultural practice • holistic approaches • the ‘therapeutic task’

20. References Bamford-Lahey Foundation: www.bamford-lahey.org/ebp.html Elliot, E (2004) Evidence-based speech pathology: Barriers and benefits. Advances in Speech–Language Pathology, Vol. 6, No. 2, June 2004, pp. 127 – 130. Beecham R (2004) Power and practice: A critique of evidence based practice for the profession of speech language pathology. Adv in SLP 6. 131-133 Byng S, Cairns D & Duchan J (2002) Values in practice and practicing values JCD 35. 89-106 Gibbard D., Coglan L & MacDonald J. (2003) Cost-effectiveness analysis of current practice and parent intervention for children under 3 years presenting with expressive language delay. Int. J. Lang. Comm. Dis., 39;2. 229–244 Glogowska, Roulstone, Enderby & Peters (2000) Randomised controlled trial of community based speech and language therapy in preschool children. Br Medical Journal 321: 1-5 Greenhalgh P (2001) How to read a paper: The basics of evidence based medicine London:BMJ books. Halpern, D.F. (1997) Critical thinking across the curriculum: A brief edition of thought and knowledge. New Jersey: Lawrence Erlbaum Associates; Chapter 5 Johnson, C. (2006) Getting started in evidence-based practice for childhood speech-language disorders. AmJSLP 15;1 20-35. Law J, Garret Z & Nye C (2004) The efficacy of treatment for children with developmental speech and language delay/disorder: A meta-analysis. JSHLR 47. 924-943 McCauley R. and M. Fey (Eds). Treatment of Language Disorders in Children. NJ; Brookes

21. Meline T (2006) Research in Communication Sciences & Disorders Boston; Pearson Education Meline, T. & Paradiso, T. (2003) Evidence-based practice in schools: Evaluating research and reducing barriers. LSHSS, 34(4), 273. Montgomery E. & Turkstra L (2003) Evidence-based practice: let's be reasonable. Journal of Medical Speech - Language Pathology 11.2 Pain K, Magill-Evans J, Darrah J, Hagler P & Warren S (2004) Effects of profession and facility type on research utilisation by rehabilitation professionals. J Allied Hlth 33;1 3-9. Pring T (2005) Research Methods in Communication Disorders London, Whurr; Reilly, S., Douglas, J. & Oates, J. (Eds.) (2004) Evidence based practice in speech pathology. London: Whurr Publishers. Research & Training Centre on Early Childhood: www.researhtopractice.info Schiavetti N & D Metz (2006) Evaluating Research in Communicative Disorders (5th ed ) Boston; Pearson Education; What works clearinghouse (education interventions) http://w-w-c.org