Small Talk: Identifying communication problems in maltreated children

Abstract

Development of speech and language is rapid in early years, yet if developmental problems in speech and language are not addressed they are likely to continue and impact negatively on a child's overall development and their life trajectory. Children who have experienced abuse and or neglect are particularly vulnerable. The aim of this study was to develop a tool to assist in identifying a child's need for assessment by a speech pathologist so that there could be early identification of problems. A culturally sensitive tool was developed to be completed by the child's carer included questions on language, speech and hearing, voice, fluency, understanding sentences, vocabulary and expression. Sixty-five children aged between 4 and 8 years, who had experienced abuse and/or neglect participated in the study. Fourteen percent were Aboriginal. A speech pathologist undertook an assessment for each child and the results were compared with the information on the Small Talk tool. The Tool was found to be high in sensitivity but low in specificity, requiring further refinement. However, it has the potential to assist non speech pathologists to identify a child's need for speech and language assessment with the findings identifying the Tool as promising practice.

Introduction

Children who experience abuse and neglect are particularly vulnerable to communication difficulties which have further consequences on their overall development (Nathanson & Tzioumi, 2007; Sylvestre & Mérette, 2010). This paper reports on the findings of a research project, Small Talk, which developed and tested a speech and language problem identification tool. The intent was to ascertain if such a tool could be used by non-speech practitioners to identify children, who have experienced abuse and/or neglect, who would benefit from a referral to a speech pathologist and/or audiologist. The purpose for such a referral would be assessment and timely intervention to identify and redress speech, language or hearing difficulties.

Communication is the process by which we share thoughts, feelings and ideas through verbal, gestural and written modes. It incorporates language production (expressive language), speech, hearing plus understanding (receptive language) and the ‘use of language in context’, (pragmatics) which incorporates ways of communicating for functional purposes. Communication also involves being able to relate information coherently (e.g. through a narrative and via a retell or conversation). This is a skill that improves with increasing age and development in vocabulary diversity and sentence complexity (Nelson, Nygren, Walker, & Panoscha, 2006; Law, Boyle, Harris, Harkness, & Nye, 1998).

A child’s primary language is an important element to consider in communication particularly in regards to Indigenous children and those from culturally and linguistically diverse backgrounds.

A number of studies concluded that early detection of speech and language problems, followed by early intervention can offer substantial benefits which may in turn prevent or reduce some of the associated problems (Glascoe, 2000 Broomfield & Dodd, 2011). Consistent with this finding, studies have found that if children are identified as having speech and language problems and do not receive sufficient treatment, their communication problems will continue or worsen (Maeder & Roy, 2000).

In addition to problems directly associated with poor or delayed communication, such difficulties can cause or contribute to other problems, especially in terms of children’s relationships with others, mental health problems, behavioural problems, self-esteem, cognitive development, literacy, and educational attainment (Oberklaid, Wake, Harris, Hesketh, & Wright, 2002; Howard, 2007; Laing, Law, Levin, & Logan 2002; Larney, 2002, Lindsay and Dockrell, 2000, Law et al., 1998, Poe et al., 2004; Spratt et al., 2012; Sylvestre & Mérette, 2010).

A substantial body of research shows that children who have suffered abuse or neglect are at increased risk of having a range of developmental problems including speech and language difficulties (Kaltner & Rissel, 2011; Leslie, Hurlburt, Landsverk, Barth, & Slymen, 2004; Moreno Manso, García-Baamonde Sánchez, & Blázquez Alonso, 2012; Nathanson & Tzioumi, 2007; Spratt et al., 2012; Stahmer, Leslie, Hurlburt, Barth, Webb, Landsverk, & Zhang, 2005; Sylvestre & Mérette, 2010). The prevalence of communication problems for children living in out-of-home care in Australia is above 30% (Nathanson & Tzioumi, 2007) and consistent with international studies (Cross, 1999; McCool & Stevens, 2011).

Studies have shown that children in many protection and care systems are not routinely assessed in terms of their health and development, despite the acknowledgement of their higher risk for health and developmental problems. These studies have particularly focused on children living in some form of out-of-home care (Kaltner & Rissel, 2011; Nathanson & Tzioumi, 2007; Royal Australasian College of Physicians, 2006, Stahmer et al., 2005; Zimmer and Panko, 2006 Zimmer & Panko, 2006).

Language is an inherently cultural phenomenon as well as an individual developmental issue (Dixon, Kot, & Law, 1988). If the person doing a speech and language assessment is from a different language or cultural group than the child, this can affect the interpretation of results.

The available tools for speech and language problems were not considered responsive or sensitive to Australian Aboriginal and Torres Strait Islander children and their needs despite the prevalence of these issues in these communities (Bromfield, Higgins, Osborn, Panozzo, & Richardson, 2005). Many Australian Aboriginal children speak Australian Aboriginal English, which has been described as being on a continuum from approximating Standard Australian English to something close to Creole (Butcher, 2008). Most screening tools for speech and language were devised as attempts at universal screening tools for children in the general population (Law et al., 1998), especially where communication problems were thought to be a primary problem and not secondary to a different problem such as maltreatment. Assessment of children who are bilingual pose particular problems in terms of assessment tools and access to speech pathologists with the knowledge and experience to work with them is limited (Eagar et al., 2005). Furthermore there was no tool found specific to children in out-of-home care and who may not have adults in their lives who know their developmental history.

This current study was based on the premise of the importance of early identification of communication problems given the developmental window for language acquisition is in the early years (Sakai, 2005) and the importance of speech, language and hearing on a child’s preparation and participation in school and learning (Rigby & Chesham, 1982). A number of studies have indicated that speech and language immaturities and some other communication problems self-correct through the process of natural development between the ages of two and three years (Eagar et al., 2005). Thus, the aim of this study was to develop a tool for workers and carers to identify a 4–8 year old child’s need for assessment by a speech pathologist for early problem identification.

Ethics approval was gained from the La Trobe University’s Human Research Ethics Committee (approval no. 09-041). Permission was also received from the Department of Human Services’ Research Coordinating Committee (ref no. CDF/09/1878) and from the research committees of the Victorian Aboriginal Child Care Agency (VACCA), Berry Street and other participating community service organisations (CSOs).

The study sought to identify if those caring for and working with children who had experienced abuse were able to identify if a child required speech and language assessment utilising an instrument The Small Talk Tool which was developed for the study. A secondary aim was to determine if the Small Talk Tool could accurately identify speech and language concerns.

This study was conducted in Victoria, Australia.The research design was a mixed method cohort design using both quantitative and qualitative analysis as it sought to explore the real life situations for at-risk children in relation to their speech, language and hearing needs. The research was exploratory in design.There were five steps in the research process

• Development of the Small Talk Tool

• recruitment of children including engaging and training potential referrers from participating organisations, and gaining consent from the guardians of referred children,

• completion of the Small Talk tool and the Supplementary Background Questionnaire (SBQ) by the workers and carers known to the child,

• speech pathologist assessment of the children referred

• data analysis including integration of findings from the speech pathologist assessment and the Small Talk Tool completed by referrers.

Participants were children who had experienced child abuse and neglect (confirmed by the Government Child Protection agency) and who were between the ages of 4 years and 7 years and 11 months of age, referred from out-of-home care services, family services, therapeutic services, Aboriginal services and child protection in both metropolitan and regional/rural areas. Children were excluded if they had recently been assessed by a speech pathologist, were unable to complete speech pathology assessment, if they had a profound disability or were outside the study’s age range. There was no requirement that the child referred to the Small Talk project had to present with any communication difficulties. There was a purposeful approach to include Aboriginal children as they are over-represented in the protection and care population.

There were 85 children referred to the Small Talk project, 20 children met the exclusion criteria as outlined above. The final sample consisted of 65 children. See Table 1 for demographic details related to the study sample.

The mean age of the children was 6.0 years SD = 1.3; range 4.0-8.0 years. There were no significant age differences between male and female participants with an even distribution between children aged under six years (n = 32) and children aged six to eight years (n = 33). Children were referred from therapeutic services (n = 20); Home Based Care programs (n = 13); Aboriginal Services (n = 5); Community Service organisation (including out of home care, family services and kinship care (n = 26) and Child Protection agency (n = 1). Children’s adverse life experiences were described by referrers using the SBQ as including abandonment or parenting capacity problems (78%); physical harm (28%); emotional harm (67%); developmental harm (72%) and non-specified abuse (22%).

All children with culturally and linguistically diverse heritage were described as having English as their main language. There were no significant differences by age, gender or placement for these children compared to those who did not have a culturally diverse background. There were no significant differences in age, gender or Aboriginal identity based on whether the child was living with parents or in out-of-home care. Although 11 children in this sample were living with a parent, they were considered at-risk children where Child Protection Services had substantiated at least one form of abuse or neglect.

The communication assessment undertaken by the speech pathologist included a hearing screening test, formal assessment of speech and language using standard age appropriate validated assessments:

Goldman Fristoe Test of Articulation: Goldman & Fristoe, 2000. This instrument provides information regarding a child’s articulation ability by sampling spontaneous speech sound production in different positions of words. It has strong internal reliability (0.95), test-retest (0.98) and inter-rater reliability (0.9–0.93).

Clinical Evaluation of Language Fundamentals − Australian Standardised Edition: CELF-4: Semel, Wiig & Secord, 2006. This standardised instrument is used with 5–21 year olds to provide a comprehensive assessment of language skills. It has strong test rest reliability across individual subtests (0.71-0.86) and for composite scores (0.88-0.92); internal consistency ranges form 0.69-0.91 for individual subtests and 0.87-0.95 for composite scores. The inter-rater reliability is between 0.88-0.99.

Australian Preschool Edition: CELF P2: Wiig, Secord, and Semel (2006). This standardised instrument is designed to comprehensively test the language skills of children aged up to six years of age. It has strong internal consistency with 0.77–0.92 for subtests and 0.91-0.94 for composite scores.

TNL: PRO-ED (2004); and Developmental Sentence Scoring: Lee & Canter (1971). This instrument identifies narrative language impairments such as measuring the ability to answer literal and inferential comprehension questions. This is norm referenced for children aged between 5 and 11 years of age and thus was not used with the four year old children in this sample. The internal consistency (0.76–0.88) and the test- retest reliability (0.81-0.85) are such that it is recommended it be used as a complement to a broader suite of assessments, rather than being used on its own.

Language Assessment Remediation and Screening Procedure: LARSP: Crystal (1979); observation of voice/fluency/pragmatic language, sampling and analysis of spontaneous oral language and the speech pathologist’s clinical judgement (Shipley & McAfee, 2004). Phonological awareness, the recognising and manipulating different sounds in words, was also examined. A criterion referenced checklist was used with children to determine adequate use of voice, effective fluency and competent use of language in context and on a functional level.

The Small Talk tool was developed as a problem identification tool to be completed by the referrer with a parent/carer. It included information regarding the indicators of potential or actual speech and language difficulties and hearing problems to facilitate referrals. The areas covered were: changes in language, speech and hearing; child’s voice; fluency; understanding sentences and vocabulary; expression; having conversations; relating or talking about events; nonverbal communication; speech sounds and overall impressions. The Small Talk tool information was not made available to the speech pathologist conducting the assessments but was used to compare with the referrer’s impressions and speech pathologist assessment findings of the speech and language functioning of the children in the study.

The Small Talk project was informed by the literature regarding universal screening but did not aim to develop such a screening tool. This study aimed to provide a means of identifying indicators of speech and language that may be otherwise missed, and is focussed on a specific at-risk population rather than the general population. In particular, the tool aimed to provide a means of supplementing the normal observation and assessment processes within the child protection and care system predicated on the understanding that it is not uncommon for health and development issues to be missed for many of these children (Kaltner & Risell, 2011; Nathanson & Tzioumi, 2007). An assumption underlying this project is that children in the protection and care system who have experienced abuse, neglect and chaos, need additional opportunities to have their developmental needs recognised and met.

The Small Talk Tool was developed for use by practitioners in child protection, out-of-home care, family support and therapeutic services to identify concerns in the domains of speech, language and hearing in children who have suffered maltreatment and to ascertain if further assessment was required. A reference group including speech pathologists, social workers, psychologists and an Aboriginal consultant was established in order to bring knowledge of speech and language, the protection and care system and trauma to the oversight of the project. This group advised on item selection and discussion of validation of the tool. An extensive literature review was undertaken regarding important domains for assessment, and to inform wording of items used in the tool (Jackson et al., 2014). Items were selected to represent essential components of communication, including voice, fluency, hearing, receptive language, expressive language, discourse and narratives, speech sound production, phonological awareness and nonverbal communication.

A draft of the tool was field tested (N = 10) with staff from a foster care program (Berry Street), a therapeutic service for children in the child protection system (Berry Street Take Two program) and an Aboriginal Community Controlled community service organisation (Victorian Aboriginal Child Care Agency, VACCA) to verify the cultural appropriateness of the tool and to shape and refine the tool. A survey about the utility of the tool was completed by staff using it. Feedback highlighted the scarcity of developmental information available regarding the children in out-of-home care. This led to the development of the Supplementary Background Questionnaire (SBQ) which included information about the child’s developmental history and adverse experiences which was given to the speech pathologist prior to their assessment. Unlike the Small Talk tool, the SBQ was designed to directly assist the speech pathologist’s assessment by compensating for the limited information otherwise available. Questions included such topics as: general behaviour in relation to new situations; family, developmental and academic history; culturally specific questions and language experiences.

The Small Talk tool underwent further revision following the pilot and the final version consisted of usage guidelines and 35 items. The areas covered included: changes in language, speech and hearing; child’s voice; fluency; understanding sentences and vocabulary; expression; having conversations; relating or talking about events; nonverbal communication; speech sounds; and overall impressions.

Practitioners in the participating organisations were provided with a briefing about the project and how to make a referral to the project. The project team provided referrers with plain language statements and consent forms to be passed onto the child’s guardian. The referrers were also provided with copies of the SBQ and the Small Talk tool. Completed forms were mailed to the Small Talk project team. The SBQ (but not the Small Talk tool) was provided to the speech pathologist.

Following referral of the child to the study the Small Talk Speech pathologist conducted an assessment with the child over 1–3 sessionsutilising the measures above. The speech pathologist did not see a copy of the Small Talk Tool.

There was one primary speech pathology clinician throughout the data collection period who supervised speech pathology students to undertake some assessments. The speech pathology students also received supervision in relation to trauma-informed work from Take Two. The speech pathologist assessment process took an average of three sessions. At the completion of each assessment the speech pathologist provided a comprehensive report to the referring worker,with suggestions for intervention if recommended, and, where appropriate, to the parent or carer.

Quantitative data analysis was conducted using the Statistical Package for Social Sciences (SPSS) to determine the prevalence of speech and language difficulties in this population. Frequencies and percentages were analysed as well as data being tested for statistically significant differences using chi-square (χ²) analysis for categorical data and t-tests and analysis of variance (ANOVAs) for continuous variables. Pearson’s r correlations were conducted to examine associations between variables (items on the Small Talk tool and the Speech Pathology assessments). Due to the exploratory nature and the small sample size a stepwise (forward) logistic regression was completed to ascertain if there was a correlation between the speech pathology assessment findings and the Small Talk tool.

To examine if a particular mean total score on the Small Talk tool was able to discriminate between children requiring speech and language intervention and those who do not require such intervention, a statistical technique called the Receiver Operating Characteristic curve (ROC curve) was completed. The ROC curve is a plot of the true positive rate against the false positive rate for all the different possible cut-off points for the tool. Cut-off point refers to how many items a worker would need to select as being of concern for the tool to indicate a referral for further assessment is warranted (e.g. 0–14 for the 14-item version of the tool).

Qualitative analysis was undertaken on the comments by the speech pathologist, such as clinical recommendations.