Lockdown and oral language therapy: practical things we can do to make things better for everyone in these tough times

Seven weeks of lockdown in Sydney – and counting – have given us ample time to reflect on our therapy systems and practices. To protect our clients and staff, we’ve had to close our physical clinic temporarily to clients and families. We’ve been operating 100% by telehealth, six days a week. We couldn’t be prouder of our talented team for being so adaptable. We are so grateful to our clients for sticking with us through thick and thin.

Despite all the service-delivery changes, some things have stayed the same. As with many speech pathologists, our waiting lists remain longer than we would like them to be.  

In these difficult times, children with developmental language disorders and other learning disorders are particularly at risk. We are all under pressure to improve our practices so we can:

• help our clients and families to get the most from therapy in the shortest amount of time; 
• help more children on our waitlists; and
• avoid wasting anyone’s time on things that don’t work or aren’t efficient.

Recap: Key elements of providing good quality language therapy 

For years, we’ve read peer-reviewed studies to figure out how to improve language therapy outcomes for clients. We’ve learned a lot about:

• language as a complex system with a social purpose;
• the importance of joint attention and interaction;
• how to deliver the right the amount (or dose) of therapy;
• giving children the right kinds of feedback and rewards;
• the benefits of targeting multiple goals and mixing up language activities;
• the evidence for distributed or spaced practice;
• building retrieval practice and self-explanations into every session; and
• introducing facts about the real world into therapy.

We’ve learned to work with our clients and their families to choose:

• language goals – rather than subskills like auditory processing or working memory – to improve language outcomes;
• functional goals – things that matter most to families, and things that get in the way of the child following their interests and participating in the real world; and
• complex goals that promote system-wide change to language skills, rather than simply following a developmental sequence or targeting isolated goals that don’t have a noticeable effect on language as a system.

We’ve realised that many evidence-based therapy techniques share common elements, including:

• an explicit focus on the skill you are working on;
• clear language models to reduce the noise and to increase the signal of the target for the client;
• repetition and repeated opportunities for learning skills; and
• responsiveness to the child’s attempts.

We’ve come to understand the importance of:

• collaborating with families, educators, health professionals and others to support the whole child; and
• including natural play, conversation, dialogic reading, and storytelling activities into therapy to encourage transfer of language skills to the real world.

You can read more about these elements of therapy and how we think about them in our therapy here. 

So what else can we do to make language therapy more effective? 

As waiting lists for services have increased, and as we’ve pivoted to telehealth, we’ve been looking for other ways to improve the efficiency of our language therapy further. Specifically, we’ve been looking at ways to improve the transfer of language gains in one area of language to other areas of language to give clients and their families more value for their time and money. 

Transfer of learning happens when one set of skills transfers to another set of skills. When looking at the evidence for transfer, it helps to be clear about what kind of transfer you mean:

• Near transfer is transfer between skills that are very similar. For example, if you do working memory training, you can improve your performance on tests that resemble the tasks that have been trained.
• Far transfer is transfer between domains that are rather different, e.g. chess to problem solving, or working memory to language and reading. 

Many researchers think that far transfer is rare, or question whether far transfer is even possible. Different studies of working memory training, music, and video games have found a lack of, or very limited, transfer from one domain to another. This is why we do not recommend working memory training for language disorders. 

Other researchers think that transfer is possible between tasks that are quite different in content if they share the same basic underlying structure, or if the tasks (and the skills underpinning them) are interconnected in the learner’s mind. 

Within the language domain, a group of researchers thinks that transfer can occur when a new word is related to similar words that are already known (e.g. “parched” and “thirsty”); and that learning new words improves the learner’s understanding of words they already know. Vocabulary studies typically show large gains for words that have been taught or trained, but limited gains for words that are not trained. 

In 2019, Dr Melby-Lervåg and colleagues looked at transfer within the domain of language in more detail and concluded that transfer is possible within the domain of language, although direct transfer – as measured by improvement in one specific task to another – is difficult to obtain (see citation below). 

Despite its rather intimidating title, the paper includes some very practical guidance for front line speech pathologists and others working with children with language disorders during lockdown. Here are some of the main things we learned from the paper, followed by some examples of how we are seeking to apply the research recommendations in our practice within the constraints imposed on us by lockdown:

(1) Focus therapy on expressive language goals

A review of the evidence suggests that most of the effects of language interventions are generated through expressive language measures. This means we should focus on complex expressive language skills in functional ways, such as having clients:

• construct sentences;
• retell stories; 
• make up their own stories; and
• finish stories already started.

(2) Smaller groups are better than big ones   

On the whole, small group language interventions are more effective than large group or whole-class interventions. This is probably because children have more opportunities to speak and practice their expressive language in smaller group settings.

(3) Target words should be presented in context

We should not work on new vocabulary in isolation, e.g. by teaching word lists with definitions. Instead, we should introduce and explain new vocabulary in sentences, in stories, as well as in other texts. The ways in which different words can be used in different contexts should also be emphasised.

(4) Therapy should focus on the procedures that are used to complete language tasks, not just the content of each task

We want children to become aware of the procedures they use when solving a task so it is more likely they will use them in other tasks. For example, rote learning the definition of a cactus is less useful to children than learning the process of describing a cactus by features like category, function, location, shape, size, colour and its parts – an approach that can be transferred to nouns, generally. 

(5) We should tell children what they are working on and why it matters

We should prime children with knowledge of what we are working on and why, and be specific about what we are trying to achieve. We should tell children that we are working on their language skills to make them more conscious of how they use language and the language that surrounds them. This may make it more likely that the effects of therapy will transfer out of the clinic and into the child’s “real world”.

Our efforts to date to translate research into practice when delivering therapy by telehealth 

In response to research, we have developed a range of language tools for our clients that are explicit in their goals, and focused on expressive language in context. We’ve also adapted some of our resources to make delivery by telehealth easier for clients. For example, we’ve written:

• a variety of Compound and Complex Sentence builders;
• several picture-based Complex Sentence Makers using a range of subordinating conjunctions;
• Simple, Compound, and Complex sentence writing programs;
• Noun and Verb-Description Programs Using Semantic Feature Analysis to teach children the process of describing and defining objects and verbs;
• contextualised Narrative Language Workouts for Young Primary Schoolers, based on Fables by Aesop;
• a Master Story Builder to help children master and use story grammar and to make up their own stories using scaffolds and story starters; 
• Social Use of Language and Theory of Mind Questions to work on expressive language in familiar contexts;
• Barrier tasks to practice problem solving and expressive language at the sentence level;
• strength-based Verbal Reasoning and Problem Solving Workouts;
• resources to work on expressive language while exploring the world and talking about topics of interest like space, dinosaurs, ants and spiders, Venus flytraps and death cap mushrooms;
• language resources to discuss favourite books like “The Giving Tree”, “We’re Going on a Bear Hunt”, “Room on the Broom”, “Dog Man”, and “The Bad Guys”;
• for older students, a 10-module (100 exercises) Listen then Speak oral language workout oracy program, including complex sentence formulation, verbal reasoning tasks, tasks requiring inferencing and making predictions, and storytelling;
• a 5-module Higher Level Oral Language Skills Program to work, among other things, on high frequency Tier 2 academic words in context; and
• an Exam and Essay Verbs Program to target academic vocabulary in context.

Having used these tools with clients, we are now much more conscious of the need to work on expressive language for social purposes as part of a complex system, and the importance of making sure we collaborate with children and their families through therapy planning and delivery so that we all understand what we are working on, and why.

Bottom line

Effective language therapy can increase children’s participation and success at home, at school, and in life. Regardless of all the other things going on in the world right now, speech pathologists and others working with children with language disorders should keep a close eye on research developments so that we can continue to improve our practices by focusing on therapy tasks that make a positive difference to clients and their families outside the clinic. 

Related articles:

• Language therapy works. But can we make it better?

Principal source: Melby-Lervåg, M., Mjelve Hagen, A., and Lervåg, A. (2020). Disentangling the far transfer of language comprehension gains using latent mediation models, Developmental Science. 23:e12929. See: https://doi.org/10.1111/desc.12929.