#61 Is Your Language Therapy "Evidence Based"?

During the time when numerous anti-oral motor articles were being published and when Evidence-Based Practice (EBP) came into vogue, a comprehensive literature review of language intervention with children was done by Cirrin and Gillam in 2008. 

Although the article is almost 12 years old, I bet you’ve never heard of it--or the results. 

I’ll warn you, while most of us that do language therapy in the schools pride ourselves that what we do is effective (and I believe what we do is effective), that positive sentiment is not reflected in the literature.  Or at least it wasn’t prior to 2008. 

Following is a brief overview of the details of what they searched and how, the results, and their conclusions.  The article itself is 28 pages long. 

The Article 

Authors:  Frank M. Cirrin and Ronald B. Gillam

Title:  Language Intervention Practices for School-Aged Children with Spoken Language Disorders:  A Systematic Review

Year Published:  2008

Objective:  “To assess the effectiveness of language intervention practices for school-age students with spoken language disorders.” 

What They Searched and How 

The authors searched a range of electronic databases to retrieve peer-reviewed English-language articles published since 1985.  To be included in the research review:  

• The students had to be school-aged (K-12) with language disorders as a primary disorder; students with secondary language and communication problems (autism, for example) were excluded. 

• The study had to be one of the following design types: Randomized clinical trials (RCTs), meta-analysis of RCTs, and systematic reviews of RCTs (referred to as Level 1 evidence); nonrandomized comparison studies; or multiple-baseline single-subject design studies (referred to as Level 2 evidence).  

Studies were grouped according to specific areas of language:  Syntax and morphology, semantics/vocabulary, phonological awareness/metalinguistics, language processing, and pragmatics/discourse. 

The Results 

Initially, they located 593 published reports, but only 21 studies met all four of their selection criteria.  Eleven of the studies limited participants to children in kindergarten and first grade.  The results were tenuous, at best.  Because I wanted to be accurate, I cited quotes from the article: 

• “Our search yielded only 3 Level 2 studies of interventions designed to treat aspects of syntax and morphology in school aged children.” 

• “Our search yielded 6 studies of interventions designed to treat aspects of semantics, vocabulary, concepts, and word finding in school-age children. All 6 studies were Level 2 nonrandomized comparison studies.” 

• “Our search yielded only 2 studies of interventions designed to treat aspects of pragmatics, conversation, discourse, and narratives that met our criteria.” 

• “No studies were located that examined the efficacy of language intervention with students with language disorders in middle grades or in high school. This is a major gap in the language intervention evidence base and is especially problematic for SLPs in school settings.” 

They identified several other gaps: 

• “Only two of the 21 studies examined the maintenance of treatment effects. The lack of research on whether various language interventions produce lasting positive effects in school-age children is a major gap. Proof…is especially critical as SLPs face increasing mandates to demonstrate their effectiveness.” 

• “Another major gap in language intervention outcome research for school-age children is in the area of narrative treatment strategies. Given the theoretical and practical importance of student’s narrative skills to literacy, it is surprising that we found no Level 1 or 2 studies that investigated the effects of narrative-based interventions with school-age students.” 

• “The lack of evidence that relates to the use of curriculum-relevant materials and general education standards in language intervention, and on the effects that language therapy has on students’ progress in the general education curriculum (reading, writing, math), is especially problematic for SLPs who work in schools.” 

• “Another major gap in the evidence is that no studies were found that examined the amount and frequency of intervention required to make significant progress on language targets for the child in schools.” 

Their Conclusions 

Cirrin and Gillam concluded, “The fact that only 21 studies [out of 593] met our criteria means that there is relatively little evidence supporting the language intervention practices that are currently being used with school-age children with language disorders.” 

They also stated, “In general, the quantity and quality of research for informing EBP optimally in schools must be enhanced.  Specifically, resources are needed for studies on effective language intervention practices for school-age children (i.e. in grades K-12).” 

To their credit, they did not suggest SLPs to stop doing language therapy because it’s not supported in the research.  As a therapist, I greatly appreciate that.  

A Few Thoughts 

Over the last few years, I’ve read many research reviews, and the research evidence for much of what SLPs do—with children and adults and within a variety of disorders—is minimal, at best.  It’s lacking not just in language therapy, and not just in oral motor therapy, but in other areas, including service delivery.  And almost every article says:  We need more targeted and professional research studies.  Perhaps the “targeted” piece is the answer.  I hope so; we’ll see. 

If it makes you feel any better, we’re certainly not the only field struggling with EBP.  The medical community is under the evidence-based microscope, big time. 

In a 2017 study of medical doctors and their application of EBP in their treatment, in a section called, “What are the findings?” the authors state “In a primary care-oriented medical reference, 18% of recommendations were based on consistent, high-quality patient-oriented evidence, while approximately half (51%) were based on expert opinion, usual care or disease-oriented evidence.”  Wow. 

Then in the section, How Might it Impact Clinical Practice in the Foreseeable Future? (same article) they recommend, “Primary care physicians should be aware that only a minority of recommendations are based on high-quality patient-oriented evidence.  This highlights the need for regular literature surveillance by primary care physicians to identify stronger evidence as it is developed.  More research is needed in the primary care setting that evaluates the impact of interventions on patient-oriented health outcomes. 

Oh, boy. 

Bottom-line:  I do believe, in part, because of the abstract and complex nature of “communication,” plus the variability of working with human beings, especially kids, from week-to-week, it is difficult to “prove” in scientific research that has stringent criteria and restrictions (such as, “eliminate as many variables as possible”), that what SLPs do in real-world therapy is effective.  It doesn’t mean we should try.  But, obviously, it’s challenging. 

And finally, in an article by Steinberg and Luce (2005), they caution those in health-related fields, “The absence of evidence regarding the effectiveness of an intervention does not mean that the intervention is not effective.”  Good thing.  

Now go do your high-quality language therapy and give a kid a hug. 

Next week, a literature review on oral motor. 

Have a good one—and stay warm, 

Char 

 

Cirrin, F.M., Gillam, R.B.  (2008).  Language intervention practices for school-age children with spoken language disorders:  A systematic review.  Lang, Sp and Hear Serv in the Schools, 39,S110-S137. 

Ebell, M.H., Sokol, R., Lee, A., Simons, C., Early, J.  (2017).  How good is the evidence to support primary care practice?  BMJ Journals, Vol. 22, Issue 3, 13 pages. 

Steinberg, E.P. and Luce, B.R. (2005).  Evidence based?  Caveat emptor!  Health Affairs, Vol 24 (1),80-92.