Download Known factors affecting children and young people who are deaf

Commissioning highly specialist speech
and language therapy services for children
and young people who are deaf
Table of contents
1. Purpose ............................................................................................................................. 3
2. Incidence and prevalence............................................................................................... 3
3. Any specific population groups covered by the guidance ......................................... 4
4. National policy context and guidance and implications for commissioning in
England ..................................................................................................................................... 4
5. Specific risks facing this population group if communication needs are not met .. 5
6. Role of speech and language therapy in improving outcomes................................. 6
7. Key issues in relation to the care pathway .................................................................. 7
8. Workforce requirements.................................................................................................. 8
Appendix 1: Case study ....................................................................................................... 11
Appendix 1a ........................................................................................................................... 14
Appendix 1b ........................................................................................................................... 15
Appendix 1c............................................................................................................................ 16
References ............................................................................................................................. 18
Page 2 of 19
1. Purpose
The purpose of this document is to support the commissioning of highly specialist
speech and language therapy services for children and young people with severe to
profound deafness and those with moderate hearing loss who are not making
expected levels of progress despite receiving support from mainstream services. The
commissioning of equitable, specialist speech and language therapy for children and
young people who are deaf is problematic, particularly for those with bilateral severe
to profound deafness (>70dB HL BATOD, 2006). This population includes those
eligible for a cochlear implant; those who only hear sounds louder than 90 dB HL at
frequencies of 2 and 4 kHz (NICE, 2009).
The population has a low incidence and deafness is a long term, high need
condition. The low incidence, complexity of need and expertise required from the
speech and language therapist (SLT) presents commissioning challenges for its
provision. This is because the service required is highly specialised and an
integrated commissioning focus is required from Clinical Commissioning Groups
(CCGs). Specialist speech and language therapy should complement and add to the
ongoing support provided by audiological and specialist education services for deaf
children, who also have a specific focus on and undertake ongoing interventions to
promote the language and communication development of deaf children and young
people.
2. Incidence and prevalence
In the UK, there are more than 10 million people, including more than 45,000
children, with a hearing loss (Action Plan on Hearing Loss NHS England 2015,
Hearing Matters 2015, actiononhearingloss.org.uk). The total number of permanently
deaf children aged 0 to 19 years across the UK is at least 48,125. This figure is a 2%
increase from 48,125 in 2014 and an 18% increase since 2011. It is difficult to be
certain about the extent to which this increase is due to changes in demography or
accuracy in reporting (The Consortium for Research in Deaf Education, CRIDE,
2015).
There are 1:1,000 babies born with permanent hearing loss (over 40dBHL) in one or
both ears in the UK increasing to 1:100 babies who have spent 48 hours in intensive
care (www.nhs.uk, accessed 2016). Data from the newborn hearing screen supports
this (Uus and Bamford, 2006); a rate of 1 per 1,000 babies screened. Of these,
approximately 370 children in England are born with permanent severe to profound
deafness each year and more than 900,000 people in the UK are severely or
profoundly deaf (Action on Hearing Loss, 2016). However, hearing loss also
develops throughout childhood, about 1 in every 1,000 children is severely or
profoundly deaf at 3 years old (www.nhs.uk) and for hearing losses over 40dB, the
incidence rises to 1.65:1,000 live births, presenting a possible 2.05:1,000 by 9 years
of age and older (Fortnum, Summerfield, Bamford, 2001).
In terms of the prevalence of severely/profoundly deaf children needing speech and
language therapy input, the Cheshire & Merseyside Speech & Language Therapy
Hearing Impairment Network (the Network) figures average 222 on the caseload
from the 2.8 million total population. If representative, this equates to approximately
4,900 bilaterally severely to profoundly deaf children nationally in need of specialist
SLT intervention. This figure increases with the inclusion of children with moderate to
severe losses.
The CRIDE survey report (2015), estimates that there are 9,700 severely to
profoundly deaf school children in the UK. It also estimates that 10% of deaf children
Page 3 of 19
use sign language in education in some form, either on its own or alongside spoken
language (CRIDE UK wide survey report 2015). Twenty-six percent of the Network
caseload (May 2016 spot analysis) used British Sign Language as a first or second
language. Additionally, Emerson and Robertson (2010) estimate that there are 4,000
deafblind children (0-19) with ‘more severe’ co-occurring hearing and vision
difficulties and up to 23,000 with co-occurring impairments. The ‘more severe’ group
would face significant educational and development issues, requiring input from
multi-agency services that include specialist speech and language therapy services.
3. Any specific population groups covered by the guidance
This guidance covers children and young people, primarily with bilateral severe to
profound deafness (>71dB). However, the guidance is not designed to exclude the
number of deaf children with communication needs, but with a lower degree of
hearing loss, who would benefit from the expertise of the specialist SLT.
The typical population includes those who are bilaterally, severely/profoundly deaf
and who have implantable devices such as cochlear implant/s or other amplification,
using speech or sign. It includes those who use British Sign Language as a first or
preferred language, or sign as a support system and may not have English as a first
language, which presents additional complexities for their specialist speech and
language therapy provision. It may also include those who have specialised
audiological disorders such as auditory neuropathy spectrum disorder and those with
additional and complex needs.
4. National policy context and guidance and implications
for commissioning in England
For deaf children and young people in England, NHS England is driving the
development of population-based integrated hearing networks, combining health,
education, social care, and voluntary agencies in line with the ‘Five Year Forward
View’. The aim is to ‘manage networks of care not just organisations’. This is an
emerging national population system/community of care approach for children and
young people with hearing loss working across service providers and commissioners
for areas with an annual birth rate between 15-30K. These networks are envisaged
across the whole of England and include an integrated network with an auditable
standardised process of system specification. Specialist speech and language
therapy is an essential part of this national specification.
The integrated networks are informed by the following documents:
•
•
•
•
•
•
•
NHSP Quality Assurance (2006 – 2013)
Integrated Care: Our Shared Commitment (May 2013). This is a framework
that outlines ways to improve health and social care integration.
Best practices in family-centred early intervention for children who are deaf
or hard of hearing: an international consensus statement (October 2013)
Atlas of Variation in Diagnostic Services (November 2013); Reducing
unwarranted variation to increase value and improve quality. This highlights
variation in the provision of healthcare services.
NICE technology appraisal for cochlear implantation (January 2009)
Children and Families Act (2014)
Action Plan on Hearing Loss (NHS England, March 2015)
Page 4 of 19
5. Specific risks facing this population group if
communication needs are not met
Deaf children and young people have the potential for high level speech, language
and communication but can present with speech and language communication
needs (SLCN) due to the effects of auditory deprivation from their development in
the womb onwards. Acquired deafness in the early years presents equally important
challenges to ensure age appropriate language development occurs and that
communication needs are supported appropriately. Deafness and SLCN are linked.
If speech and language therapy for deafness is not commissioned appropriately, the
language development and communication needs of this population may not be met,
potentially compromising their educational, social, economic and mental health
outcomes for life.
Such risks for children with SLCN include costs to both society and to the individual.
There is more likelihood of unintelligible speech and delayed language development
(spoken and sign language), leading to poor educational attainments (since age
appropriate language skills are fundamental to the acquisition of literacy). There are
increased risks of experiences of bullying, challenges to mental health, emotional
and behaviour difficulties, later social exclusion, abuse and poorer employment
prospects, and in some cases a descent into criminality (RNID, Opportunity Blocked,
2007; Bercow Report, 2008; Children’s Communication Coalition, 2010).
Known factors affecting children and young people who are deaf:








90% of deaf children are born to hearing parents with little or no experience
of deafness or knowledge of how to communicate with a deaf person
(Moores, 2001, NDCS.org.uk).
21% of deaf children have an additional special educational need (CRIDE
report on 2015 survey).
More than 40% of deaf children are estimated to have mental health
difficulties in childhood/early adulthood compared with an average of about
25% for the general population (Hindley et al, 1994; Hindley, 2000,
www.actiononhearingloss.org.uk)
Deaf children with permanent hearing loss have been twice as likely to
experience abuse as hearing children (Deaf Children at Risk: NDCS briefing
paper, 2010).
Between 15% and 26% of deaf children in England have a statement of
special educational needs or an Education, Health and Care plan (CRIDE,
2015).
Data from the Department for Education (England) in 2015 shows that nearly
three quarters of deaf children (72%) started school having failed to achieve
a good level of development in the early years’ foundation stage assessment.
Similarly, data shows that only 41% of deaf children in England have left
secondary school having achieved the government’s expected national
GCSE benchmarks. This compares with 64% of children with no identified
special educational need.
Hearing loss can impact on the development of language in children, reduce
chances of employment, restrict aspirations and life chances, increase the
risk of mental health problems and interfere with peoples’ ability to care for
their own and their families’ long term health conditions. This can lead to low
achievement, low self-esteem, isolation, loneliness and depression (Shield,
2006).
Page 5 of 19


Pre lingually deaf people are more likely to be diagnosed with a mood,
anxiety, personality or developmental disorder (Black and Glickman, 2006).
In the Netherlands, De Graaf and Bijl (2002) found indication of mental
distress amongst 28% post-lingually deaf men and 43% amongst postlingually deaf women, compared with 22% and 27% in the general
population.
6. Role of speech and language therapy in improving
outcomes
The deaf population is heterogeneous in aetiology and presentation, with
multifactorial influences on expected outcomes for an individual child. The
documented research evidence for speech and language therapy intervention for this
population reflects this complexity with the existence of many small, pre and post
intervention research studies indicating positive outcomes as the result of
intervention. The expertise of the specialist SLT is in choosing and implementing
appropriate intervention for an individual child taking into account their profile and
implementing therapy in the context of the wider multi-agency team.
The role of the specialist SLT for deaf children is as part of this multidisciplinary
team: to optimise the child’s speech, language and communication abilities to their
maximum potential including social and educational outcomes. The role supports the
identification of the many factors contributing to a differential diagnosis and delivers
care with a range of people in the child’s environment supporting access to a biopsychosocial model of care. It is a holistic model improving communication in the
context of the family, nursery and school. An example of this is that specialist SLTs
working in the field of deafness may carry out joint assessments of deaf clients'
communication skills, for example, with a Deaf practitioner, for clients who use
British Sign Language.
This care supports children’s health and wellbeing. If the child’s communication
needs are not supported, there is a risk of isolation and bullying.
The effectiveness and efficiency of the specialist SLT provides a return on health
investment by ensuring that care is given by the right person with the right skills.
There are many well-documented variables that can affect the outcomes for deaf
children. These include age of diagnosis, degree of hearing loss, age of
amplification, use of amplification, co-morbidities, and family support and additional
speech and language disorders (systematic literature review, 2016). The therapist
needs to understand normal speech, language and communication development in a
hearing child, understand the known factors that may affect outcomes for the
individual child who is deaf, have the knowledge of different conditions in order to
support or make a differential diagnosis and then design an individual programme
alongside other members of the team to maximise the child’s potential for effective
communication in the context of their own environment.
Evidence of prevalence of these risk factors among children identified as needing
speech and language intervention is provided from a spot analysis by the Network in
May 2016 (further information in Appendix 1). These figures are likely to reflect
statistics from other specialist speech and language therapy services. The size of the
Network provides a critical mass to support the evidence in this low incidence
condition.
In May 2016, with a population base of 2.8 million, there were 215 severely to
profoundly deaf children on the caseloads of the network specialist SLTs in the
Page 6 of 19
Network. Of these, 21% were diagnosed later than the Newborn Hearing screen.
Fifteen percent were referred to speech and language therapy later than 5-6 months
old, 19% were amplified later than three months old. Seventeen percent had a
specific language impairment (SLI), 33% had additional and complex needs, 14% did
not wear amplification consistently, 22% did not have good family support and 17%
had a home language that was not English. These are all factors known to affect
outcomes and requiring individualised specialised care for the child from the
specialist SLT.
Network discharge information provides evidence of specialist speech and language
therapy intervention outcomes. Discharges occur when the child’s needs have been
met and the child achieves ‘age appropriate speech, language and communication
skills or skills in line with the child’s other skills’, or ‘the child’s further needs are more
appropriately met by other members of the wider multidisciplinary team’ or the child
‘moved area’. When the network first began there were few discharges. By 2010/11,
this had increased to 18% of the caseloads who were discharged on this basis and
32% by 2015/16. Special Educational Needs tribunal decisions have supported
network decisions to cease intervention due to met need without exception. This is
as important as appropriate continued intervention for efficiency and effectiveness
for the service and also for the children to achieve optimal outcomes.
7. Key issues in relation to the care pathway
Currently, speech and language support for deaf children and young people is
commissioned through different pathways such as health, education, sensory
support services, individual schools or a combination of these services. Furthermore,
there is little consistency as to whether the provision is generic or of a specialist
nature. However, the specialist SLT is able to provide an expert contribution to the
differential diagnosis between deafness and other conditions such as autism
spectrum disorder, auditory neuropathy spectrum disorder, and auditory processing
disorder. Part of the role is to ensure that the hearing technology provided is
enabling the child or young person to sufficiently hear speech intelligibly and
functionally, compared to their audiological assessments. The specialist SLT will be
able to recognise the need to liaise with the audiological physician where there is a
mismatch with the child, young person or adult’s actual functional hearing to enable
optimum communication development, taking into account the diagnosis and/or
family communication preference. This may include supplementing spoken
communication with visual support, such as, for example, through sign or Cued
Speech.
Without this highly specialist speech and language therapy intervention, language
outcomes for deaf children who may be optimally amplified, but unable to access
speech effectively, will be suboptimal.
An integrated care pathway for this population would help achieve quality and
consistency. It should also have input from parents, service users, administrative
staff, audiological scientists and audiologists, Teachers of the Deaf, Deaf
practitioners, auditory implant team personnel, social care provision, mental health
services and link to voluntary/charitable organisations.
Key contributors to the care pathway include:
•
•
Newborn hearing screen
Multiagency Children’s Hearing Services Working Groups (CHSWGS)
including Local Health Service, Local Specialist Education Service, Local
Page 7 of 19
•
Social Care Services, Support Group and Voluntary/charitable organisations,
Deaf CAMHS
Regional integrated hearing networks driven by the Department of Health
Key elements of the integrated specialist care pathway include:




Referral: expectation of receipt of referral as soon as identification of
deafness is made to maximise the benefits of early intervention and optimise
outcomes. A suggested response to referral is within 13 weeks from the date
of referral. At this stage, referral is on the basis of the condition of severe or
profound deafness and not on symptoms. The aim is to provide a
preventative service with intervention beginning before language and
communication difficulties have become established. This may be separate
from the existing speech and language therapy care pathways but will need
to interlink, e.g. for those who are deaf with additional complex needs.
Furthermore, referrals for those deaf children with a moderate loss but who
are not achieving the anticipated progress can be integrated into the
pathway.
Assessment: to include differential diagnosis, and ensuring inter-agency
communication.
Intervention: setting goals, review of progress and outcomes.
Accountability: ensuring productivity, supervision, discharge and complaints
processes are in place.
8. Workforce requirements
Given the high needs and low incidence of this population group, the skills and
expertise required are best provided by a specialist SLT.
The specialist SLT is required to have additional post qualification training, skills and
experience to deal competently with the severe to profoundly deaf client group as
described below.
The additional attributes required from an SLT who specialises in supporting deaf
children and young people include:
Knowledge
Ongoing continued
professional development
evidenced by attendance at
and learning from short,
specialist postgraduate
courses/ independent
learning activities to maintain
and develop own specialist
knowledge and expertise in
deafness. For example in
phonology assessment,
working with deaf people,
specific conditions
associated with deafness
such as auditory neuropathy,
amplification devices.
Essential training in the area
of audiology.
Skills
Non-verbal communication
(including use of sign to
equivalent of Signature level
2).
Practical management of
hearing aids/cochlear
implants.
Experience
A minimum of five
years post graduate
experience working
as an SLT, at least
three of which should
be working with deaf
clients.
Practical logistics of
conducting speech and
language assessments with
deaf children and making
necessary adaptations for
hearing children.
Use of family-centred
intervention techniques,
including making necessary
adaptations to those
Page 8 of 19
Detailed knowledge of the
different types of hearing
loss, aetiology and possible
implications for individuals.
Detailed knowledge of
audiological tests available
and understanding of the
findings and implications for
the individual.
An understanding of how
hearing technology works
and the effects of
environmental noise on
hearing/listening.
Detailed knowledge of
acoustic phonetics to inform
intervention and
management decisions.
designed for hearing
children.
Differential diagnosis
between deafness and
specific language
impairment, autistic
spectrum disorder, auditory
neuropathy
Adaptation of speech and
language expectations and
objectives in the context of
the type and degree of
hearing loss.
Advanced transcription of
atypical speech patterns,
including on segmental
features.
Knowledge of spoken
language (English or
language of the home), Sign
(British Sign Language), Sign
Supported English and
bilingualism.
Knowledge of augmentative
communication systems such
as Cued Speech, Sign
Supported English, Signed
English.
Knowledge of communication
strategies that support
communication between deaf
and hearing people.
Knowledge of typical
developmental patterns for
deaf children (as well as
knowledge of patterns for
hearing children).
Knowledge of D/deaf culture.
Ability to sign to equivalent of
Signature level 2.
Knowledge of current
research evidence for this
population and its application
for service improvement.
Page 9 of 19
If a specialist speech and language therapy service is in place, specialist advice and
training can be provided for generalist SLTs, parents and families, schools, further
education colleges, nursing or residential homes. This includes support to deaf
children and young people who are in specialist schools that meet needs that are
additional to deafness. Some deaf children and young people have severe
communication needs but may have a moderate or severe hearing loss and the
expertise of a specialist SLT may be needed for these deaf children and young
people. In order for this to work efficiently and effectively, this tier of specialist
resource needs to be in place in the first instance with referral to an integrated
specialist provision.
Specialists are not easy to recruit or retain. To minimise these difficulties, a local
training provision within the services is recommended with access to ongoing
specialist training and peer support. Appendix 1 contains a case study illustrating a
network approach to service provision, which is representative of an integrated
model of specialist practice and includes a pathway example.
Page 10 of 19
Appendix 1: Case study
What could good practice look like? How can speech and language therapy be
commissioned for this population: a description of the award winning
Cheshire & Merseyside Speech & Language Therapy Hearing impairment
network, a current successful commissioning model.
Speech and language therapy services for deaf children and young people in
Cheshire and Merseyside have been successfully provided on a regional footprint for
13 years: a regional network hosted by Liverpool NHS Community Trust, and
commissioned by the regional CCGs. It was runner up in the NHS Network Awards
2005 as a network fit for purpose and shortlisted for the Health Service Journal
Awards 2014, winner of Liverpool Community Health Trust creativity and innovation
award and leader of the year award 2014. It is currently shortlisted for the trust
creativity and innovation award 2016.
The specialist speech and language therapy network is a consultant-led service
provided as part of the service models in each NHS Trust in Cheshire and
Merseyside, supported by local health, education and social care provision.
The Cheshire & Merseyside Speech & Language Therapy Hearing Impairment
Network is the regional, specialist, community provider for speech and language
therapy for deaf paediatric, adolescent and adult clients in Cheshire and Merseyside.
The mixed urban/rural population covered is 2.8 million with an average total of 222
clients on the caseload in 2015/16.
The model provides some of the most accurate long term national speech and
language therapy intervention statistics for a mixed urban/rural population. Caseload
expectations are 40 clients per full time specialist.
The model for a 2.8 million population.
It includes 1 regional consultant SLT, 1 regional advanced clinician to cover for
absences (fully employed covering long term absences for 13 years), 5 specialist
SLTs (equivalent), 0.5 wte admin post
The network was established in 2002/3, as a result of an evidence based needs
assessment carried out by the North West Specialised Commissioning Team
(NWSCT). Initially, the intention was to improve the cost effectiveness of cochlear
implants by providing local specialist speech and language therapy rehabilitation and
equity of access where there was previously inequity of access to specialist local
speech and language therapy. This remit was then extended to incorporate
rehabilitation for all severely/profoundly deaf people in the region who need speech
and language therapy.
a) Reducing inequalities, reducing barriers, access
There is access to the service for all people who are severe to profoundly deaf who
live or have a GP in the area.
Each network specialist SLT is based in and employed by their local NHS trust and
has a flexible job description allowing them to work across the NHS Trust boundaries
in Cheshire and Merseyside to meet changing needs.
The flexibility across trust boundaries results in a service valued by patients with
equity of access and provision. Families moving out of the area have reported
provision in other areas to be more patchy and more like the provision in Cheshire
and Merseyside before the network was established (see Appendix 1a).
Page 11 of 19
All network specialist SLTs are required to have achieved, or are supported in
working towards British Sign Language level 2 sign or above and use interpreters for
British Sign Language and other languages where needed.
b) Quality and performance indicators: Improving service user and carer
experience and improving productivity
There are three levels of intervention used in the network (outlined in the Appendix
1c), that are applied according to need and are reviewed after an episode of care.
c) Outcomes
The network designed a simple outcomes model using ‘Liberating the NHS:
transparency in outcomes - a framework for the NHS 2012’ (now updated as NHS
Outcomes Framework 2016 to 2017), highlighting domain 2 (enhancing quality of
care for people with long term conditions) and domain 4 (ensuring that people have a
positive experience of care).
Most participating network trusts were using frameworks such as ‘Care Aims’ to
inform the clinical decision-making processes underpinning the delivery of better
outcomes for their service users. The network outcomes model was designed to
work with and complement the principles and variations of all these existing models,
using communication effectiveness targets to improve quality of life for the client and
family.
Parents expressed a preference to be included in discussions about identifying the
desired, or ultimate, outcomes for the child or young person. The SLT assesses the
child/young person’s speech, language and communication as normal and decides
which of these skills need to be targeted and the appropriate interventions required
to achieve the desired outcome(s). To monitor the attainment of communication
effectiveness targets, progress against the target is recorded as achieved or not
achieved with a simple ‘yes’ or ‘no’. The percent of the total gives commissioners
percentage number of targets achieved. The data is collected as a network and can
be viewed from different perspectives.
In 2014, the Royal College of Speech and Language Therapists (RCSLT) carried out
an appraisal of more than 60 outcome measures and frameworks against 11 criteria
compiled by RCSLT members. These key criteria included the ability of the outcome
measure to be used across a range of client groups, compatibility with existing tools,
accessibility and ease of use. The RCSLT Board of Trustees considered the findings
and the measure identified as the ‘best fit’ against these agreed criteria is Therapy
Outcome Measures (TOMs) (Enderby and John, 2015). The RCSLT is developing a
national database to collect and collate TOMs data from speech and language
therapy services across the UK. It is not expected that TOMs will be used as a
standalone outcome measure, but will be used alongside other measures and
frameworks.
d) Finance
There is an agreement between NHS Liverpool Community Health Trust and
Cheshire and Merseyside CCGs for full service costs: salary, travel, specialist
resources, training to develop and maintain skills in hearing impairment.
e) Activity
Activity in terms of adults and children contacts and referral to treatment times are
reported to CCGs monthly.
Page 12 of 19
Calculating the speech and language therapy resource needed for the severely to
profoundly deaf population if a network model is used (based on the Cheshire &
Merseyside Speech & Language Therapy Hearing Impairment Network figures for
2015/16 to date).
Area
Population
Current
caseload
Caseload
per f/t
SLT
No. of
specialist
SLTs
needed
Additional
staff
included
Expected
contacts
per
annum
Cheshire
and
Merseyside
2.8 million
222
40
5.5wte
Consultant
lead 1.0
wte
Specialist
SLT cover
f/t
Admin 0.5
4224
Page 13 of 19
Appendix 1a
Number of specialist speech and language therapy sessions provided across
Cheshire and Merseyside pre network in 2002
Page 14 of 19
Appendix 1b
Cheshire &
Merseyside Hearing
Impairment Network
Therapy Care
Pathway
Referral received
Contact other agencies for
information if required
Referral accepted
Initial contact within 13 weeks from date of referral
(possibly with ToD) at mutually agreed time and place
Decision about
intervention made
and discussed with
parents
Transfer to other
SLT service
Report written to family and
relevant professionals
Sign post to
other services
Discharge with
information on
how to re-refer
Targets / programme to
home / HSS / school
Indirect intervention, eg
training parents/setting
staff development
Review of speech
and language
development
Direct
intervention with
child
Page 15 of 19
Appendix 1c
Levels of network intervention
The network SLTs assess a child or adult’s communication needs and identify where
there is a risk that communication is not or may not develop optimally. Appropriate
intervention is then implemented at Level 1, 2 or 3.
Level 1 - Advice/ information is given and the child discharged from network
therapy.
Example: Intervention for babies and young children as sign and/or speech are
developing is usually provided through play activities but not necessarily always by
the network SLT. If this support is already provided, eg by the Teacher of the Deaf,
network SLT input may not be necessary and the child may be discharged. The
network SLT may re-open the case following re-referral and assessment, for
instance if a gap was widening rather than closing between actual speech, language
and communication (SLC) development and normal SLC development.
Level 2 - Intervention is delivered via others who support the child/adult in their
environment, usually on a more frequent basis with guidance from the network SLT.
Example: For a school child the network SLT may set a functional target and subgoals with the supporting team, train the team if appropriate, write a programme for
others to follow and monitor progress after an agreed time. At this stage, a formal or
informal assessment will be carried out and a new level of intervention - 1, 2 or 3 agreed with a new time frame for achievement of a functional communication target.
Level 3 - The child/client needs direct, one-to-one intervention with the network SLT.
Example: For a child or adult who needs to develop a new communication skill, the
network SLT will set a functional target and sub-goal, provide one-to-one intervention
for an agreed period of time, and monitor progress after a specified time. At this
stage, a formal or informal assessment will be carried out and a new level of
intervention - 1, 2 or 3 - agreed with a new time frame for achievement of the
functional communication target.
Supporting Evidence 1
A manager’s view is given by a former SLT service manager who wrote at the time,
"SLTs acquire a wide range of transferrable skills during their training. They are
equipped to manage all client groups, but require specialist support to develop their
skills in each area and to give clients the best service. This applies to all client
groups, especially to those which require post-graduate training in addition to
experience and support, eg dysphagia and hearing impairment. The provision of
speech and language therapy without specialist support in a particular area presents
risks to the patient and an ineffective service both clinically and financially.
SLTs have much to offer clients with HI, but are not in a position to differentially
diagnose which HI clients will benefit from their input or how to help complex
clients. HI is an area which requires additional specialist knowledge and skills
in assessment, diagnosis and management. These skills are acquired through
Page 16 of 19
extensive post-graduate training and experience. It is my view that every speech and
language therapy department requires a specialist in HI, whose role is to train and
support SLTs to manage less complex HI clients as well as to personally manage
more complex clients. This ensures a safe and effective service for the client and a
cost-effective service for the commissioner."
Supporting Historical Evidence 2: Written by the Mersey Deanery
We are writing as a group of Community Paediatricians in Audiology in Mersey
Deanery. Most of us have been in post since the early 1990s or before, and
remember the very difficult and unsatisfactory times that our deaf children
experienced because of an absence of Specialist SLTs for the hearing impaired. The
children received the continuing support of the Advisory Teachers of the Deaf, but
these very committed professionals did not have the training, nor the resources to
offer speech and language therapy. The SLTs in our individual districts had not
received specialist training for deaf children, and so most would not take these
children onto their caseload. Thus there was no specialist speech and language
therapy provision for our deaf children. In individual cases where the services of
such a professional was paramount, we were obliged to buy in these services on an
individual basis. Our professional group of paediatricians felt that the situation was
most unsatisfactory.
We were approached as a Mersey Deanery Group in the 1990s by the Cheshire &
Merseyside Specialised Commissioning Team to ask how we could improve the
services for our children, who were receiving cochlear implants. With one voice, we
indicated the need for Specialist SLTs for the hearing impaired, working locally in our
own districts. We were most fortunate in that the Permanent Hearing Impaired
Network for Cheshire and Merseyside was set up and we have been receiving the
input of the Specialist SLTs for the hearing impaired from 2003. These skilled
professionals have been supporting our children who have significant sensorineural
hearing losses, many of whom have subsequently received cochlear implants. They
also liaise closely with the Manchester Paediatric Cochlear Implant Centre*, and
share the information with the multidisciplinary team including Paediatrician in
Audiology, Advisory Teacher of the Deaf, and Social Worker for the Deaf.
*Now known as the Manchester Auditory Implant Centre
This is a pilot version of this guidance and as such is open to comment and
subsequent change.
Page 17 of 19
References
Action on Hearing Loss, Hearing Matters (2015), actiononhearingloss.org.uk
Bercow Report (2008), Department for Children, Families and Schools, London:
DCFS 2008
Black PA, Glickman NS. Demographics, psychiatric diagnoses, and other
characteristics of North American Deaf and hard of hearing inpatients. J Deaf Stud
Deaf Educ 2006; 11(3):303-321.
British Association of Teachers of the Deaf Batod (2006) ‘Audiometric Descriptors’
Information Sheet, BATOD Magazine, updated December 2006, www.batod.co.uk
(2006)
Children’s Communication Coalition (2010), Engaging for their futures and our
society: improving the life chances of children with speech, language and
communication needs, www.rcslt.org
CRIDE Consortium for Research in Deaf Education. Report on 2015 survey on
educational provision for deaf children in England (accessed: batod.org.uk)
Davis AC, Parving A. Towards appropriate epidemiological data on childhood
hearing disability: a comparative European study of birth cohorts. J Audiol Med 1993;
3:35-47.
Davis A, Wood S, Webb H, Rowe S. Risk Factors for Hearing Disorders:
Epidemiologic Evidence of Change over Time in the UK. J American Academy
Audiology 1995; 6:365-370.
Davis A, et al. Acceptability, benefit and costs of early screening for hearing
disability: a study of potential screening tests and models. Health Technology
Assessment 2007; Vol II: 42.
De Graaf R, Bijl RV. Determinants of mental distress in adults with a severe auditory
impairment: differences between prelingual and postlingual deafness.
Psychosomatic Medicine 2002; 64:61-70.
Department for Education (DfE), 2015, [on-line], Available at:
GCSEs: https://www.gov.uk/government/statistics/revised-gcse-and-equivalentresults-in-england-2014-to-2015
EYFS: https://www.gov.uk/government/statistics/early-years-foundation-stageprofile-results-2014-to-2015
Emerson E, Robertson J. The estimated prevalence of visual impairment among
people with learning disabilities in the UK Improving Health and Lives. Learning
Disabilities Observatory, Department of Health, 2010.
Fortnum H, Davis A. Epidemiology of Permanent Childhood Hearing Impairment in
the Trent Region, 1985-1993. British Journal of Audiology 1997; 31 (6).
Fortnum HM, Summerfield Q, Bamford J. Prevalence of permanent childhood
hearing impairment in the United Kingdom and implications for universal neonatal
hearing screening: questionnaire based ascertainment study. BMJ 2001; Sep 8: 323
(7312):536.
Gravenstede L, Clements. Specific language impairment and deaf children. RCSLT
Bulletin, 2015.
Page 18 of 19
Hall J, Smith S, Popelka G. Newborn Hearing Screening with Combined Otoacoustic
Emmissions and Auditory Brainstem Responses. Journal American Academy
Audiology 2004; 15: 414-425.
Hindley P. Hill PD, McGuigan S, Kitson N. Psychiatric disorder in deaf and hearing
impaired children and young people: A prevalence study. Journal of Psychiatry and
Psychology 1994; 35, 917–934.
Hindley P. (2000) Child and adolescent psychiatry. In: Mental Health and Deafness,
eds Hindley P, Kitson N, chapter 3. London: Whurr Publishers.
Hindley P. Mental health problems in deaf children. Current Paediatrics 2005; 15,
114-119.
Integrated Care: Our Shared Commitment (13th May 2013) Department of Health,
Health and Social Care Integration. Accessed: www.gov.uk, Jan 2016.
Moeller MP. Early intervention and language development in children who are deaf
and hard of hearing. Paediatrics 2000; 106(3):E43.
Moores D. (1987) Educating the Deaf: psychology, principles and practices. Boston,
MA: Houghton Mifflin.
Moores D. (2001) Educating the deaf: Psychology, principles and practices (5th Ed).
Boston: Houghton Mifflin Company.
National Deaf Childrens’ Society Educational Achievement of Deaf Children in
England in 2009: What government data tells us about performance in GCSEs.
NDCS, London, 2010.
NHS Outcomes Framework 2016 to 2017.
https://www.gov.uk/government/publications/nhs-outcomes-framework-2016-to-2017
NICE technology appraisal guidance cochlear implants for children and adults with
severe to profound deafness (published Jan 2009) nice.org.uk/guidance/ta166.
Policy on Audiology Service Provision in the UK. NDCS, London, 2010.
Queensland Government. (2016) Systematic review of the literature on early
intervention for children with a permanent hearing loss. Volume 1. Centre for Allied
Health Evidence University of South Australia.
RNID. (2006) Opportunity Blocked: The employment experiences of deaf and hard of
hearing people. actiononhearingloss.org.uk
Shield, B. (2006) Evaluation of the social and economic costs of hearing impairment.
A report for hear-it. London South Bank University
Uus K, Bamford B. Effectiveness of Population-Based Newborn Hearing Screening
in England: Ages of Interventions and Profile of Cases. Pediatrics 2006; 117: 5.
Yoshinaga-Itano C, Sedey AL, Coulter DK, Mehl A L. Language of early and lateridentified children with hearing loss. Pediatrics 1998; 102, 1161–1171.
Yoshinaga-Itano C. From screening to early identification and intervention:
Discovering predictors to successful outcomes for children with significant hearing
loss. Journal of Deaf Studies and Deaf Education 2003; 8(1): 11–30.
Page 19 of 19