The Independent Review of Early Intervention Delivery
Graham Allen MP is chairing an independent review of how early intervention projects can
improve the lives of our most vulnerable children. We have responded from the BCRP. The
questions and our responses are set out below
About you
This response is from the research team leading the Better Communication Research
Programme (BCRP) funded by the Department for Education (2009-12) as part of the Better
Communication Action Plan, the government’s response to the Bercow Review of services
for children with speech, language and communication needs (SLCN) 1 published in 2008.
The BCRP team is led Professors Geoff Lindsay, University of Warwick; Julie Dockrell,
Institute of Education, University of London; James Law University of Newcastle and Sue
Roulstone University of the West of England.
Who has SLCN?
SLCN refers to a wide range of conditions affecting any aspect of communication from
children with poor speech at one end, to children with specific learning difficulties, those with
more general learning disabilities and on to those with complex needs of which SLCN is a
part. Children with autism also fall within this group because communication is a feature of
their profile.
The BCRP focuses on the child with SLCN and the additional problems experienced by
some of the children including literacy, behaviour and academic performance. We would
argue that the needs of the child with SLCN fall fairly and squarely within the remit of this
review given the impact of poor communication on learning and socio-emotional
development. The BCRP included five specific projects in its first year of which one focuses
on the evidence for best practice both at a research and a practitioner level and a second
will be making recommendations about economic evaluations.
Questions - Early Intervention
1.
What are the likely causes of impairments to children’s social and emotional
capability? And how common are they across the population?
Of the order of 10% of children across the population have some sort of SLCN. This is
higher in early childhood than it is in adolescence and much higher in children from areas of
high social disadvantage. Some forms of SLCN may be hereditary although the precise
mechanisms are complex and underspecified in many cases. They may be acquired in the
sense that they can result from medical conditions such a cleft palate or from trauma such
as road traffic accidents or illness such as meningitis. They may also be exacerbated by and
in extreme cases caused by environmental factors. The key issue is that they co-occur with
other difficulties that children experience and can affect the child’s ability to respond to
interventions and services: for example children with poor language skills are less likely to
respond to reading interventions. The developmental pathways are complex. There are
some children who start at a disadvantage and manage to achieve well and similarly there
are those who become more disadvantaged over time. We know that good parenting and
supportive neighbourhoods can make a huge difference and likewise schools can play a
considerable part in raising children’s aspirations and changing predicted trajectories.
1
Bercow, J. (2008) A review of services for children and young people (0-19) with speech, language
and communication needs.
2.
Do we know how to improve children’s social and emotional capabilities in a
cost-effect way?
At least 58 relatively high quality effectiveness studies have been carried out with regard to
children with SLCN. These have tended to be carried out with younger children and often
show positive responses for speech and expressive language. Six studies have examined
the cost effectiveness of intervention related to SLCN. Both of these sets of studies have
been reviewed as a part of the BCRP (details are available). Findings suggest that the costs
of intervention as currently delivered can be quite low and given the outcomes from many
studies it is likely that many interventions will be cost effective. The strongest message is
that parents play a considerable role in both improving outcomes and reducing costs for
younger children. We are currently examining the relationship between such studies and
what actually goes on in practice.
3.
If we know how to improve children’s capabilities in a cost effective way, why
are we not doing so? What is the split between universal schemes and specific
schemes?
We don’t know that we are not doing so. In fact the demand for such services appears to be
increasing suggesting that consumers, at least, favour intervention. That said, studies which
show that an intervention works are often carried out in relatively favourable conditions – ie.
with enough staff and over a long enough period of time (this shows efficacy). In practice
children often receive fewer services than those available in the intervention studies
(effectiveness). Again we are exploring the issue of dosage in the BCRP but it is by no
means clear that children necessarily need more support services. What they need is the
right services at the right time.
A single universal programme will not necessarily be the most appropriate answer; we need
to understand what are the key mechanisms of effective programmes in order to be able to
replicate effectively in different contexts. A programme of research closely related to the
BCRP has been funded by the National Institute of Health Research to investigate this and
begins in January 2011. More information about this is available from Sue Roulstone.
4.
What are the patterns of income and expenditure for late versus early
intervention in general and are there proven rates of return for specific
schemes?
It is often assumed that early intervention is better than later intervention. It is an appealing
claim and it is certainly the case that early intervention is effective in ameliorating the
potentially negative consequences of a number of adverse factors, whether within-child (e.g.
certain developmental conditions) or environmental. But considerable cognitive changes
occur during adolescence and interventions often aim to address these factors. Also,
whereas there have been studies arising out of the US Headstart programme that have
demonstrated substantial long term outcomes in terms of societal outcomes, these
interventions reflect a model and intensity of early intervention which has never been
available in the UK. We simply do not know that early intervention prevents later difficulties:
true in some cases but in others this is best viewed as amelioration – important in itself –
whereas in other cases the continuing adverse life circumstances of the child may lead to
‘wash out’ of the earlier gains. Indeed the equivocal nature of the evaluation of Sure Start
demonstrates this complexity. We would argue that there is an important role for early
intervention but also that services need to be responsive to the needs of the children
throughout the age range, particularly for those with continuing high level needs.
It is also important to consider the method of identification of those in need of early
intervention. Substantial evidence indicates that this is more problematic than may be
assumed. Briefly, there are highly effective screening procedures for some conditions which
allow early identification to be targeted efficiently. However, as we move away from
conditions with clear biological causes (e.g. profound hearing loss) to less severe
developmental difficulties, the accuracy of screening methods for identifying children is
considerably reduced. This is particularly the case with children with lower levels of language
difficulties. The important message here is that early identification should be conceptualised
as a more elaborate system and not simply a series of screening procedures. Again we can
provide more information.
5.
What lessons can previous experience teach us about what doesn’t work?
What programmes have proved ineffective? What characteristics associated
with previous programmes are ineffective? What other aspects of early
intervention are ineffective?
Professional development provided in inset alone, that is without appropriate development of
skills and mentoring is minimally effective
Evidence based universal pre-school or school provision reduces the need for specialist
services, although there is currently limited evidence of what works in the educational
context. This leaves those children with significant difficulties who require additional
interventions and continuing targeted or specialist interventions. We do not know how little
intervention is needed to have an effect (the ‘dosage’ issue) and clearly further work is
needed on this type of threshold. These issues are important as the less intervention an
individual or family receives the less they are likely to respond but, on the other hand, there
may be diminishing returns - more is not necessarily better beyond a certain amount.
But there is also the question of delivery not just absolute quantity. There is a question
whether intervention is better for children if provided intensively or in small doses less
frequently. There is strong research evidence that distributed practice is more effective than
the same amount in larger and less frequent sessions. This will work more readily in schools
where such a model is feasible but is less easy to deliver in “clinical” contexts where
practitioners see the children, for example, on a weekly basis This speaks to the benefit of
speech and language therapists working with school, staff.
6.
Are there interventions with a robust international evidence base that
have been effectively applied in the UK? We are particularly interested in
evidence which demonstrates both the effectiveness and cost-effectiveness of
interventions. Programmes which can clearly and unambiguously demonstrate
measurable benefits, which have a cashable value, will be particularly helpful.
There are a number of interventions which would appear to have robust evidence but these
have not been replicated either nationally or internationally. We can forward these to the
panel if required
7.
What are the common characteristics and processes which facilitate effective
and cost-effective early intervention policy?
To date our sense is that some of the policies in this field are neither evidence-informed nor
evidence-based – Every child a talker is an exception. It would be helpful if policy makers
were more engaged in the evidence. This consultation may be a step in the right direction.
8.
Are there promising programmes that have yet to be properly evaluated? What
are the future evaluation plans and over what timescale might we expect
results?
There are a number of interventions which look promising and have been piloted but which
have yet to be evaluated for their effectiveness, in sizeable populations, as opposed to their
efficacy under optimal conditions. Some of these are documented on the What Works
Clearing House. For example, there are a number of high quality intervention studies being
out in Melbourne Australia which are likely to have an impact in the future (3-5 years).
Similarly the Nuffield Foundation has funded three trials of relevant interventions which are
currently being written up. As far as we are aware there are no plans to roll these out.
It cannot simply be assumed that an intervention carried out in optimal conditions of a
research trial, which is shown to have high efficacy, will be effective when rolled out on a
large scale, implemented by staff less directly involved in the original trial(s). For example, a
recent meta analysis of the effect of book reading on vocabulary learning highlighted the fact
that the robust findings with experimental studies were simply not replicable in a natural
classroom setting. The trials are essential to provide basic evidence but we also need
studies of the subsequent roll out on a medium to large scale. A good example of this is the
roll out across all English LAs of evidence-based parenting programmes for children at risk
of behavioural problems (The Parenting Early Intervention Programme). This is currently
being evaluated by one of this team (Lindsay) in a separate DfE funded study – interim
findings are positive, indicating that large scale roll out of evidence-based programmes can
produce positive results. Funding to promote translational research or knowledge transfer in
this field could facilitate this important stage in the development of evidence based practice.
9.
What could be done to test and promote these ideas nationally? How should
we best communicate best practice?
While it would be possible for central government to try to regulate current services care
needs to be taken not to assume that there is a simple solution. Intervention of this type
does not work like a pill and is only likely to function effectively in the right policy
environment. As noted in 8, it is necessary i) to run trials of theoretically driven, practical and
acceptable interventions to identify efficacious interventions under optimal conditions; ii) then
to evaluate the large scale roll out of interventions which show efficacy in order to ensure
they are effective when delivered on this large scale, and the conditions under which this
occurs, e.g. the necessary organisational factors at local level.
10.
What could be done to nurture and develop ideas in the field of early
intervention? Is there a role for a central body to test, approve and promote
policy in this field? Are there organisations that have some or all of these
functions already?
Ideas about early intervention across the public, charitable and research contexts have a
long history. Many of these rely heavily on untested assumptions. The key issue is the
proper controlled evaluation of programmes. There is a stronger case for government
funding for the evaluation of such programmes and promulgating good practice rather than
acting as a regulatory authority in this field.
11.
What new models of financing early intervention, or wider social policy, exist?
This does not fall within the remit of the BCRP
12.
What other instruments could be introduced to diversify funding of early
intervention?
This does not fall within the remit of the BCRP
13.
What could be done to nurture and develop these financing ideas?
This does not fall within the remit of the BCRP
14.
What must government do and not do to enable non-government financing to
assist Early Intervention?
This does not fall within the remit of the BCRP