Child Language and EBP: A Challenge, a stimulus and the potential for changed roles between researchers and clinicians Linda Hand School of Communication.

Child Language and EBP: Child Language and EBP: A Challenge, a stimulus A Challenge, a stimulus

and the potential for and the potential for changed roles between changed roles between

researchers and researchers and cliniciansclinicians

Linda HandLinda HandSchool of Communication Sciences & School of Communication Sciences &

DisordersDisordersThe University of SydneyThe University of [email protected]@fhs.usyd.edu.au

The Challenge; to The Challenge; to cliniciansclinicians

The need to understand research The need to understand research better than we dobetter than we do to to fairlyfairly critique it critique it

eg. “small sample size” – the easy eg. “small sample size” – the easy target that often misses the pointtarget that often misses the point

to grasp what “evidence” really to grasp what “evidence” really meansmeans

to look for designs that will to look for designs that will answer the questions we haveanswer the questions we have

The Challenge; to The Challenge; to universities & other universities & other

researchersresearchers To educate clinicians better in To educate clinicians better in

understanding researchunderstanding research To conduct research which To conduct research which

relates better to clinical and relates better to clinical and client needsclient needs

to relate to local conditionsto relate to local conditions

The particular challenges of The particular challenges of Child LanguageChild Language

Realisation of some major issues as Realisation of some major issues as to why evidence is problematicto why evidence is problematic Law (2002) – “no clearly understood Law (2002) – “no clearly understood

definition /common understanding of definition /common understanding of what language intervention actually is” what language intervention actually is” --

no common definition of what no common definition of what “language” is“language” is theoretical divides not sufficiently theoretical divides not sufficiently discussed, tackleddiscussed, tackled

no common usage of frequent termsno common usage of frequent terms eg., ‘early intervention’; ‘reading’; eg., ‘early intervention’; ‘reading’; receptive language’receptive language’

no common understanding of what no common understanding of what “disorder in child language” is“disorder in child language” is SLI – only half the caseloadSLI – only half the caseload N-R tests – ruled out in too many cases; N-R tests – ruled out in too many cases; continuum with arbitrary cutoffscontinuum with arbitrary cutoffs

constantly expanding field constantly expanding field failure of the developmental modelfailure of the developmental model

Some consequencesSome consequences a research population which may a research population which may

bear little resemblance to a bear little resemblance to a clinical populationclinical population

research questions or models research questions or models which may seriously distort the which may seriously distort the field (eg Glogowska et al, 2000) field (eg Glogowska et al, 2000) (Randomised controlled trial of community based speech and (Randomised controlled trial of community based speech and language therapy in preschool children. language therapy in preschool children. Br Medical JournalBr Medical Journal 321: 1-5321: 1-5))

a strong bias to quantitative, a strong bias to quantitative, positivist models of ‘evidence’positivist models of ‘evidence’

Beecham (04)- the values inherent in Beecham (04)- the values inherent in the practice the practice (positivist, utilitarian discourse – (positivist, utilitarian discourse – culturalcultural) – ) –

rationality, objectivity, empiricism.rationality, objectivity, empiricism. In contradiction to moves toward the In contradiction to moves toward the

significance of the subjective life-world, the significance of the subjective life-world, the experience of the person, the client-experience of the person, the client-centered and family-centered themescentered and family-centered themes

eg the reports written by the Ceg the reports written by the Connectonnect team team (Byng, Cairns & Duchan, 02)(Byng, Cairns & Duchan, 02)

Tends to exclude and de-value Tends to exclude and de-value qualitative research or other methods qualitative research or other methods not embracing these values.not embracing these values. Power back in the hands of the ‘experts’?Power back in the hands of the ‘experts’? the myth of the ‘normative’ and the the myth of the ‘normative’ and the

‘population’. Individualistic, dynamic ‘population’. Individualistic, dynamic nature of communication and of what we nature of communication and of what we dodo

Power in the hands of the ‘managed care’ Power in the hands of the ‘managed care’ ‘value for money’ brigade (Mullen, 2004)‘value for money’ brigade (Mullen, 2004)

Pay attention to the discourse of EBPPay attention to the discourse of EBP

The stimulusThe stimulus

Exciting potentialExciting potential Clinicians to have motivation to Clinicians to have motivation to

understand researchunderstand research Already seen the difference this makes Already seen the difference this makes

in studentsin students Further education – eg., continuing Further education – eg., continuing

education master’s degreeseducation master’s degrees Researchers have directions to Researchers have directions to

follow for researchfollow for research

eg…eg… As heterogeneity increases, RCT results As heterogeneity increases, RCT results

are less applicableare less applicable Evidence from other populations has Evidence from other populations has

relevancerelevance Clinically meaningful outcomes are Clinically meaningful outcomes are

often personal and social judgmentsoften personal and social judgmentsMontgomery & Turkstra, 2003Montgomery & Turkstra, 2003

Ylvisaker et al., 2002Ylvisaker et al., 2002

The problems of missing evidenceThe problems of missing evidence Funding biasFunding bias Publication biasPublication bias

e.g., non-significant findings not publishede.g., non-significant findings not published Consumer/researcher mismatchConsumer/researcher mismatch

e.g., lack of studies aimed at improving long-e.g., lack of studies aimed at improving long-term quality of life outcomes for persons term quality of life outcomes for persons with aphasiawith aphasia

Elman R. Elman R. AphasiologyAphasiology 2006;20:103-109 2006;20:103-109

Networks developNetworks develop to be encouraged to involve both levelsto be encouraged to involve both levels

Major reasons to examine in depth Major reasons to examine in depth the bases on which we are workingthe bases on which we are working Error base?Error base? Developmental base?Developmental base? Theory base?Theory base? Potential to take the field in whole new Potential to take the field in whole new

directionsdirections

Stimuli (contd)Stimuli (contd)

Potential to take material across Potential to take material across traditional boundaries; using traditional boundaries; using evidence for assessments and evidence for assessments and interventionsinterventions eg disability -> child language <-eg disability -> child language <- educational interventionseducational interventions diversitydiversity adult/child??????adult/child??????

Necessity to Necessity to explain these to othersexplain these to others (major plank of EBP – to explain the (major plank of EBP – to explain the

evidence to consumers & other evidence to consumers & other professionals)professionals)

The potential for changed The potential for changed rolesroles

Different relationship between Different relationship between clinicians and academics – more clinicians and academics – more mutual understandingmutual understanding research stuff that is actually used research stuff that is actually used realisations about the nature of realisations about the nature of

research, therefore its limitationsresearch, therefore its limitations not throwing the baby out with the not throwing the baby out with the

bathwaterbathwater more collaborative researchmore collaborative research more direct requests for researchmore direct requests for research

Stronger faith in what we doStronger faith in what we do understanding the strength of understanding the strength of

theoretical bases, or educational bases theoretical bases, or educational bases etc.etc. not enough – but it is the essential startnot enough – but it is the essential start

Better grasp of what needs to be Better grasp of what needs to be donedone eg Pring – phased researcheg Pring – phased research faith in appropriate designs; single case faith in appropriate designs; single case

designs, matched pairs, wealth of data designs, matched pairs, wealth of data on relatively few participants versus thin on relatively few participants versus thin data on manydata on many

Pring (2004) – clinical outcome Pring (2004) – clinical outcome research should take place in a series research should take place in a series of phases. The RCT too early or with of phases. The RCT too early or with too heterogeneous a group will result too heterogeneous a group will result in poor outcomesin poor outcomes

Systematic reviews often deal with Systematic reviews often deal with huge variation in methodologies and huge variation in methodologies and value of designvalue of design

fail entirely to deal with qualitative fail entirely to deal with qualitative datadata

need specific therapies for well-need specific therapies for well-defined groupsdefined groups

test first in efficacy than test first in efficacy than effectiveness studieseffectiveness studies

disseminate results to cliniciansdisseminate results to clinicians then only then – large-scale trials then only then – large-scale trials

of effectiveness for therapy of effectiveness for therapy provision generally to a client provision generally to a client group or have systematic reviewsgroup or have systematic reviews

Evidence only affects practice if it Evidence only affects practice if it changes beliefschanges beliefs Agreement on the evidence, but not Agreement on the evidence, but not

on the practice - WHY?on the practice - WHY? Relative value placed on types of Relative value placed on types of

evidence evidence Rubenfield, 2002; Tonelli, Rubenfield, 2002; Tonelli, 20012001

Will EBP change Will EBP change youryour practice?practice?

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 to fit in with personal and cultural practicepractice

holistic approachesholistic approaches the ‘therapeutic task’the ‘therapeutic task’

ReferencesReferencesBamford-Lahey Foundation: www.bamford-lahey.org/ebp.htmlBamford-Lahey Foundation: www.bamford-lahey.org/ebp.htmlElliot, E (2004) Evidence-based speech pathology: Barriers and benefits. Elliot, E (2004) Evidence-based speech pathology: Barriers and benefits.

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