Communication interventions and their impact on behaviour in the young child: A systematic review

Abstract

Speech, language and communication needs (SLCN) and social, emotional and behaviour difficulties (SEBD) commonly overlap, yet we know relatively little about the mechanism linking the two, specifically to what extent it is possible to reduce behaviour difficulties by targeted communication skills. The EPPI Centre systematic review methodology was applied to the intervention literature related to primary school aged children with both SLCN and SEBD. Studies were graded for study quality. Nineteen studies including 148 children met the inclusion criteria. Heterogeneity was high in terms of symptoms, methodology, interventions and outcomes. All studies reported positive effects of intervention on both communication and behavioural outcomes although the majority were graded as being of relatively low quality. Despite study limitations the findings suggest that this is a promising direction of enquiry. There remain many gaps in the evidence, for example study quality needs to improve, comparative work is rare and it is difficult to use these interventions to reflect on the type of systemic classroom models of service delivery recommended for many of these children. The results have implications for both clinical practice and further research.

Keywords

behaviour child communication intervention systematic review

I Introduction

Social, emotional and behavioural difficulties (SEBD) are widely recognized to be of major concern to policy makers and practitioners both in their own right and in terms of the potential impact they can have on school achievement and health more generally (Adi et al., 2007; NIHCE, 2008). One feature of the profile of many children with SEBD, which has been somewhat underexplored in recent years, is the tendency of these children to have relatively poor communication skills. This association has been highlighted in literature reviews and both empirical and observational studies (Cohen et al., 1993; Gallagher, 1999; Botting and Conti-Ramsden, 2000; Benner et al., 2002; Bradshaw and Tipping, 2010) and has tended to be sustained across time (Law et al., 2009).

Yet to say that the two categories co-occur is not the same as saying that they are either necessarily linked or that when they are that they are causally related. Most studies point to the fact that the relationship is multifaceted, with social disadvantage, gender and IQ contributing extensively to the model. Nevertheless a variety of possible explanations for this overlap have been postulated (Stevenson, 1996), for example that language delay precedes the onset of SEBD, poor communication causing behaviour difficulties in the first instance or, more likely, exacerbating difficulties in the primary school classroom and the home. This may then be further attenuated with reading difficulties in the early school years (Tomblin et al., 2000). An alternative explanation is that neuro-developmental delays underlie both conditions rather than them being causally related, with the focus at any given time reflecting societal, family and school expectations. In such a scenario the child might be first identified because of language delay at two years, but their behaviour is only identified as a difficulty as expectations of behaviour rise. Latterly the focus may shift from early communication to classroom behaviour and the capacity of the child to interact with peers. Poor use of language and limited social skills – and the mismatch between the two – then makes the formation of relationships with peers and teachers difficult, further reducing the capacity for peer negotiation and effective interaction (Botting and Conti-Ramsden, 2000). More specific mechanisms can be postulated, such as the link between early phonological awareness and expressive language feeding through to poor communication skills, or that there is a link between executive function and behaviour which is moderated by communication; this is a potential relationship highlighted for children with attention deficit hyperactivity disorder (Barkley, 1997; Baird et al., 2000). But such cognitive ‘within-child’ explanations do not necessarily take into account the possible role played by adverse environmental influences, child abuse and neglect at one end of the spectrum, a restricted communication environment and limited opportunity for experience at the other. Finally, of course, it may be that there is no single mechanism that accounts for this association in all children, but rather a series of different relationships that vary between individuals and change over time in the context of different environmental experiences. While such speculation may be conceptually sensible, the only way of really unpicking causal mechanisms is to explore the relationship between the two through intervention, thus demonstrating, for example, that interventions designed to promote phonological processing skills or increase meta-linguistic skills reduce poor behaviour. This type of enquiry remains at a pre-theoretical level within the Medical Research Council (MRC) framework for complex interventions to tap into ‘likely process of change by drawing on existing evidence and theory’ (Craig et al., 2008). This can be achieved through modelling or preliminary experimental work. In this article we explore the latter route by adopting a systematic review methodology to examine the relationship between interventions targeting communication skills, and behaviour and communication outcomes.

Positive outcomes for interventions focusing on speech, language and communication skills have been identified in both narrative reviews (Goldstein and Hockenburger, 1991; Mclean and Woods Cripe, 1997) and systematic reviews (Law et al., 1998; Law et al., 2003; Cirrin and Gillam, 2008; Boyle et al., 2010). With the exception of one practitioner review that attempted to extrapolate the findings in terms of mental health (Law and Garrett, 2004) these reviews focus exclusively on speech, language and communication outcomes, effectively filtering out detail on co-morbidity such as SEBD. Similarly there have been literature reviews that have addressed the efficacy of interventions for children with SEBD. For example, a review of social skills training for children with specific learning disabilities, mental retardation, emotional disturbance, and Attention Deficit Hyperactivity Disorders (Gresham et al., 2001) concluded that these interventions were relatively ineffective in producing relevant, long-term social skills that may be transferred across various social settings for students with specific learning disability. To date there have been only two systematic reviews of the effectiveness of interventions for SEBD in mainstream education, both published by The Evidence for Policy and Practice Information and Co-ordinating (EPPI) Centre at the Institute of Education in London (http://eppi.ioe.ac.uk/cms; Evans et al., 2003; Harden et al., 2003). While the evidence base was limited, the first of these two reviews found a variety of approaches to be effective in reducing disruptive behaviour in primary aged boys and girls. Again the review did not find social skills interventions implemented by regular classroom teachers to be effective in reducing the incidence of childhood emotional problems (Evans et al., 2003). One of the best-developed interventions for emotional and behavioural difficulties is Cognitive Behavioural Therapy (CBT) but we were unable to find a single study that included an analysis of the communication skills of those included in such studies. Similarly, a narrative review of CBT interventions documented the benefits of this approach to children with anxiety, autism and Asperger syndrome but did not include studies that looked at communication difficulties nor consider the extent to which a child’s communication skills may influence the successful implementation of CBT (Graham, 2005).

II Methods

The systematic review methodology adopted was that developed by the EPPI Centre. The EPPI approach to this process is characterized by a stringent and replicable data collection and extraction procedure but with a flexible approach to both inclusion criteria and analysis, reflecting the requirement of the specific review question. Studies were included if:

they included children with primary communication difficulties and related behavioural problems;

they included both communication and/or behavioural outcomes;

the intervention was behavioural in nature rather than pharmaceutical;

they included children who spoke English as a first language;

they included children between the ages of 5 and 11 years;

they reported empirical data; and

they were completed and published in English between 1985 and 2004.

A series of online databases – Medline, Eric, Psychinfo, Cinahl, Language and Linguistics Behavior Abstracts (LLBA) and Web of Science – sources of grey literature and bibliographies of topical textbooks were searched.

The abstract of each study was examined by two of the authors (Plunkett and Law) and, where relevant, agreement reached over inclusion. They were then ‘key worded’, and the categorization was checked by members of the Nuffield Speech and Language Review Group. A full copy of the report for the study is available on the EPPI Centre website (Law, Plunkett and the Nuffield Speech and Language Review Group, 2009).

1 Assessing quality of studies and weight of evidence for the review question

Reports identified as meeting the inclusion criteria were analysed in depth using the EPPI-Centre’s detailed data-extraction software, EPPI Reviewer. Three components were identified to help in making explicit the process of apportioning different weights to the findings and conclusions of different studies. The weight of evidence judgements (WoE) are based on:

the soundness of studies (internal methodological coherence), based upon the study only;

the appropriateness of the research design and analysis used for answering the review question;

the relevance of the study topic focus (from the sample, measure, scenario, or other indicator of the focus of the study) to the review question; and

an overall weight taking into account (A), (B) and (C).

These weights were then summed and an overall quality judgement made. If A + B + C was between 3 and 5 then the quality was considered Low, if between 6 and 7 it was Medium and if between 8 and 9 it would be considered High.

2 Reporting

The results are reported in narrative fashion rather than meta-analysed. This approach was taken for a number of reasons. There was too much variability in the intervention. The outcomes used and the types of difficulties included in the review and the fact that the majority of the studies employed some form of experimental single-participant design, which can be difficult to combine in a meaningful fashion.

3 Findings

Of the 4,447 studies identified at the scoping stage of the review, 34 involved some level of researcher manipulation, and of these 19 with a total of 148 children met the criteria for the review. Of the 71 children for whom gender data were reported, 63 (89%) were male and the age covered by the study ranged from 3 to 13 years. Of the included studies none included randomized allocation to groups, one was a group comparison, six had pre-test/post-test designs, six employed multiple baseline across participants, two ABA (applied behaviour analysis) withdrawal/reversal, and four were described as ‘small n’. Fourteen had sample sizes less than 10 participants. The remainder had between 11 and 50 participants. Following Law et al. (1998) these were separated out into two main intervention ‘types’, namely didactic and hybrid intervention styles. Didactic interventions involve the use of behaviour modification techniques of the type commonly associated with applied behaviour analysis to train specific behaviours such as initiation, joint attention, etc. These interventions tended to be context specific and highly contingent and tended to be employed with children with more severe developmental difficulties. Hybrid interventions, by contrast, use a wider range of techniques to achieve the desired outcomes, for example paying more attention to context and the child’s capacity to reflect on their actions or their communication skills. A wide range of specific interventions were identified including: Picture Exchange Communication System (PECS) training (1), pivotal response training (2), peer interventions (4), behavioural interventions (2), functional communication training (2), classroom wide intervention (1), social stories (2) and speech and language interventions (5). Eight of the studies were carried out in mainstream schools, 6 in clinics, 4 in the home and 7 in ‘other’ environments, usually special schools. In terms of the types of intervention there were 11 didactic interventions (9 measuring speech/language outcomes and 10 measuring behaviour outcomes) and 8 hybrid interventions (6 measuring outcomes in speech/language outcomes and 8 measuring behaviour outcomes). In terms of the weight of evidence attributed to the included studies, all the didactic interventions were weighted as low evidence, 6 of the 8 studies in the hybrid group were weighted as low evidence, and 2 were weighted as medium evidence. The key characteristics in numbers, gender, etc. of the children included in the remaining 19 studies are summarized in Table 1, and the outcomes and broad conclusions of the authors of the individual studies are provided in Table 2.

Table 1

Characteristics of included studies

Number	First author	Date¹	Age	n	Gender (male:female)	Design²	WOE³
Didactic interventions:
1	Beilinson	2003	5;6–6;3	3	2:1	ABA	L
2	Carter	2001	5;4–7;0	3	2:1	ABA R	L
3	Charlop-Christy	2002	3:8–12;0	3	3:0	MBAS	L
4	Garrison-Harrell	1997	6;7–7;2	3	2:1	SSD	L
5	Keen	2001	4;5–7;7	4	3:1	MBAB	L
6	Nientemp	1992	12–13;4	3	2:1	ABA W	L
7	Pierce	1995	10	2	2:0	MBAP	L
8	Pierce	UM	7–8	2	2:0	MBAP	L
9	Sigafoos	1996	8	2	2:0	MBAP	L
10	Thorp	1995	5;4–9:9	2	2:0	MBAS	L
11	Zercher	2001	6;3	2	2:0	MBAS	L
Hybrid interventions:
12	Cooper	UM	kindergarten	43	NS⁴	PTPT	L
13	Heneker,	2005	5–11	11	NS	PTPT	L
14	Hyter	2001	8;6–12;11	6	6:0	PTPT	L
15	Ivey	2004	5:1–7:5	3	3:0	SSD	L
16	Law	2002	9–11	20	NS	QE	M
17	Pasiali	2004	7–9	3	2:1	ABA	L
18	Smith	2004	3–5	20	NS	QE	M
19	Stringer	2006	11;8–13;2	12	12:0	PTPT	L

Notes: ¹ UM = Unpublished Manuscript; ² Design: MBAP = multiple baseline across participants; MBAB = multiple behaviours across behaviours; QE = quasi experimental study; PTPT = pretest posttest; ABA R = ABA reversal; ABA W = ABA withdrawal; ³ Weight of evidence: L = Low; M = medium; H = High; ⁴ NS = Not Specified

Table 2

Outcome and results of included studies

Number	First author	Outcome SLCN	Outcome SEBD	Intervention and Findings
	Didactic interventions:
1	Beilinson	On line coding of specific behaviours: General and specific statements to peer, initiation.	On line coding of specific behaviours: Wait and hover, play, disruption.	Authors concluded that intervention provides a way to teach peer-group entry skills to children with social communication deficits or language impairments. Treatment produced small changes in social interaction among peers in a relatively short time with intensive training. This is an effective strategy when implemented by speech-language pathologist and teachers.
2	Carter	Specific behaviours: grammatical morphemes	Specific behaviours: Disruptive behaviour, initiating play, maintaining play/turn taking	The author concluded that the intervention is a practical and effective intervention to increase language and social play skills and decrease disruptive behaviour in language intervention for children with autism.
3	Charlop-Christy	Number of trials to criterion and the length of time to reach criterion; Specific behaviours: responses during spontaneous and imitative speech.	Specific behaviours: Co-operative play, Joint attention, Requesting, initiation, eye contact, tantrums, grabbing, out of seat, disruptions.	Authors concluded that these primary findings provide the first empirically controlled evidence on the efficacy of PECs for promoting the emergence of speech, with collateral gains in social-communicative behaviour and decreases in problem behaviour in children with autism.
4	Garrison-Harrell	Use of augmentative communication system with specific behaviours: initiation, response or interaction activity.	Specific behaviour: Social interaction duration.	Authors concluded that peer networks including communication systems are a functional, effective intervention for students with autism in public school settings, particularly for communicative behaviour and peer acceptance (social relationships).
5	Keen	Video observation of specific behaviours set for individual children: Specific behaviours: greeting, and requesting.	Observation of use of intervention procedures by teachers (opportunities, acknowledge, prompt and react); Specific behaviours: Turn taking and Choice making	Authors concluded that this intervention was effective in replacing pre-linguistic behaviours.
6	Nientemp	Specific behaviour: verbal responses given within 5 seconds of the peer/teacher. initiated greeting; echolalic responses, prompted correct verbal responses.	Specific behaviour: error responses.	Authors conclude that introducing constant time delay procedure was successful in teaching students socially valid interaction responses to teacher-initiated and non-handicapped peer-initiated social greetings. Authors conclude that this study showed that independent appropriate social interaction responses increased and echolalic responding decreased for all participants following the constant time delay technique.
7	Pierce	Specific behaviours based on 10 minute play session: Maintaining interaction, initiating conservation, initiates play.	Specific behaviours: non-engagement, on looking, object engagement, supported joint attention plus the Walker McConnel Scale of Social competence.	Authors conclude that using typical peer training in an appropriate social environment with minimal supervision was effective in teaching complex social behaviours such as initiations, enhancing joint attention behaviours, with evidence of response generalisation, and increasing language skills.
8	Pierce	10 min video tape scored for social behaviours: maintaining engagement, initiating conversation.	Walker-McConnell Scale of Social Competence: 10 min video tape scored for specific behaviour: Initiates play, non-verbal initiation.	Authors conclude that it is possible to extend their earlier work by assessing the effectiveness of multiple peer-implemented PRT for increasing social behaviour of children with autism in the mainstream, with generalisation across untrained peers, novel settings and toys.
9	Sigafoos	Specific behaviour: “correct requesting”.	Specific behaviour: “challenging behaviour”.	Authors conclude that, while these results are limited in generalisation, they imply that it is possible for fairly sophisticated behavioural techniques to be applied in a classroom setting by the teacher with some success with children with restricted abilities.
10	Thorp	Peabody Picture Vocabulary Scale, Expressive One Word Picture Vocabulary test; Specific Behaviours: Spontaneous speech, inappropriate speech, other speech.	Specific behaviour: time spent in positive social engagement.	Authors conclude that it is possible to increase socio-dramatic play using socio-dramatic play training using Pivotal Response Training. The also conclude that this approach may be an effective treatment package for increasing play, language and social skills in children with autism with the appropriate developmental prerequisites. Generalisation of these skills to novel situations indicate that play training may be an efficient way to improve multiple behaviours across a variety of settings.
11	Zercher	Specific behaviour: An intelligible utterance directed towards a peer.	Specific behaviours: symbolic play – objects treated in a non-literal manner, joint attention response to others directing behaviours.	Authors concluded that this type of intervention can be adapted for non-school settings. Typically developing peers can be trained to guide an autistic child without direct guidance from an adult. Intervention is capable of producing high levels of peer interaction consisting of shared attention, talk and pretend play. However, the intervention was less successful in improving joint attention.
	Hybrid interventions:
12	Cooper	Test of child’s abilities to identify and label emotions expressively and receptively.	Child completed: social interaction survey, group reflection log assessing co-operative learning activities and teacher observation checklist to document progress in social skills.	The authors conclude that the intervention strategies positively impacted upon all three classrooms. This was evident in student’s desire for co-operatively working, and co-operative behaviour during activities that were not co-operatively structured. The authors also state that the four elements of the intervention that led to success were the small number of social skills targeted, students were led step by step through the conflict resolution strategies, the co-operative groups that the students worked in and the reflection period that allowed the student’s to consider their learning.
13	Heneker	The Clinical Evaluation of Language Fundamentals, The Test of Word Knowledge, The Social Use of Language Skills rating chart, South Tyneside Assessment of Phonology.	Formal and informal report from teaching staff.	The author concluded that the findings of this study provided evidence that speech and language therapy is required in order to diagnose the communication difficulties of pupils with BESD and to provide intervention to reduce the impact of communication difficulties within this group of children.
14	Hyter	The Test of Language Development and the Test of Pragmatic Language	The Behaviour Evaluation Scale.	The authors conclude that the classroom-based pragmatic language intervention may have positively influenced the ability of all participants to describe objects to a naive listener to provide sequenced directions. Furthermore, it is argued that this study provides preliminary evidence of the efficacy of classroom-based intervention for the certain aspects of the pragmatic language skills in children with emotional-behavioural difficulties and language disorders.
15	Ivey	Five different skills in four different contexts – Setting change, purchase, novel toy and novel event - language outcomes – vocabulary and making a request	Five different skills in four different contexts – Setting change, purchase, novel toy and novel event – behaviour outcomes remaining on task, continuing activity and following rules	Authors concluded that the use of social stories with children with ASD is effective for preparation of a novel event. However, within the five target behaviours the intervention had the least success with attention. The authors propose that this skill should be addressed directly with focused intervention techniques as opposed to indirectly with social stories. The authors also state that this method of social stories may be generalised to other novel events.
16	Law	SAOLA School Age Oral Language assessment and video observation of social communication skills.	The Strengths and Difficulties Questionnaire; The “What I think about myself” questionnaire for self esteem.	The authors concluded that the intervention was successful at improving the language and social communication skills of children with emotional and behavioural problems. The study also provides evidence of the benefits of close collaboration between teachers, learning support assistants and speech and language therapists for the generalisation of skills gained in therapy to the classroom.
17	Pasiali	Individualised targets – observational data i.e. aberrant vocalisation.	Individualised targets – observational data i.e. responding to a physical task, reducing specific activities.	The author concluded that although there was some evidence for the effectiveness of the intervention (in reality there was a decrease in the frequency of inappropriate behaviours), future research is needed to decipher if the effect is due to the music or the social story embedded in the therapeutic song.
18	Smith	WPPSI raw scores BAS Naming vocabulary; MLU; Scale of Pragmatic Communication Skills.	Specific behaviours: Social involvement, five cognitive game levels.	Aimed to improve expressive and pragmatic language and social behaviour. Authors concluded that the intervention successfully improved game participation and language development. Therefore interventions that utilise the children’s existing skills can be used to improve their understanding of language within the social context. Enabling them to apprehend the rules of social exchange and turn taking helped them to cope with play situations at home and in educational settings.
19	Stringer	Clinical evaluation of language fundamental – four subscales concepts and directions, word classes, formulated sentences, listening to paragraphs; test of word knowledge subscales expressive vocabulary and receptive vocabulary.	Strengths and Difficulties Questionnaire.	The author concluded that adolescents with language difficulties and behaviour difficulties can continue to benefit from appropriately targeted and structured speech and language intervention in a group setting. Significant improvements in expressive and receptive language can be achieved with some seven hours’ input.

In terms of outcomes the studies fall into two groups: those that record individual behaviours using observation and video recordings, and those that use specific assessments or tests. The two approaches split according to category of intervention and level of difficulty of the children concerned. In general, the less severe the children’s difficulties, the more likely assessment procedures rather than observation will be used. It is interesting that the observations and more formal assessments merge to some extent because the behaviours are often ‘pragmatic’ in nature.

a Didactic interventions

Positive findings results were reported for many of the didactic interventions, which tended to focus on autistic children (n = 8). Specifically, one study found the PECS training to be successful in improving spontaneous speech, imitative speech and expressive language as measured by mean length of utterance in autistic children. Improvements in social communicative behaviour and a reduction in problem behaviour were also reported (Charlop-Christy et al., 2002). Two studies reported peer interventions to be effective for autistic children in teaching functional communication and improving language (increased number of verbal utterances). This type of intervention also improved social interactions (duration and frequency), peer acceptance, joint attention, symbolic play (Garrison-Harrell et al., 1997; Zercher et al., 2001). The two functional communication interventions increased appropriate requesting, improved functional behaviours and reduced challenging and pre-linguistic behaviours in children with autism (Sigafoos and Meikle, 1996; Keen et al., 2001). The behavioural technique of constant time delay improved social responses and reduced echolalic speech in autistic children (Nientemp and Cole, 1992). Intervention to teach peer group entry was effective in teaching high risk peer group entry behaviours and increasing co-operative play in children with autism (Beilinson and Olswang, 2003). The two variations of pivotal response training (PRT) both improved spontaneous language and reduced inappropriate language. In terms of behavioural outcomes, these studies reported improvements in social behaviour, play behaviour and a reduction in disruptive behaviour (Thorp et al., 1995; Carter, 2001). Peer implemented PRT was found to improve expressive language, social interactions and peer/teacher preferred behaviour in autistic children (Pierce and Schreibman, 1995, 1997).

b Hybrid Interventions

A similar pattern of positive outcomes was reported for hybrid interventions. ‘Social stories’ intervention improved participatory behaviour in children with a diagnosis of ‘pervasive developmental disorder not otherwise specified’ (PDD–NOS; Ivey et al., 2004). Prescriptive therapeutic songs intervention, a variation of social stories, was effective in reducing disruptive behaviour in autistic children (Pasiali, 2004). Pragmatic language intervention was effective in improving social involvement in children with communication difficulties and autistic children (Smith et al., 2004). Behavioural improvements were reported in children with language difficulties and SEBD (Hyter et al., 2001). Speech and language therapy improved language, vocabulary, social skills and classroom behaviour in children with SEBD (Law and Sivyer, 2003; Heneker, 2005; Stringer, 2006). A classroom wide co-operative skills program also improved expressive language, receptive language and social skills in kindergarten children with language and behaviour difficulties (Cooper et al., 2000).

III Discussion

The findings suggest that a variety of communication promoting interventions may be useful in improving behaviours irrespective of the type and severity of the child’s behavioural profile when behaviour difficulties and communication co-occur. We see variety of different intervention techniques, methodologies and types of outcomes being used for those with more and less severe presentations. More formal ABA or didactic techniques are used with those with PDD–NOS and autism spectrum disorders, while more naturalistic educational interventions were for those with less severe behaviour and communication difficulties. This is probably to be expected given both the professional orientation of those carrying out the studies and the nature of the children’s difficulties. The fact that there is a paucity of high quality studies in the field is indicative of the lack of clarity about the mechanism linking communication and behaviour. We have not been able to go further to say that a given intervention works better than others with a particular group of children. Indeed, it is almost certainly true to say that the complex needs manifested by many of these children call for the type of individualized management reflected in the types of intervention designs adopted.

1 Limitations of the review

Any conclusions drawn from the review are necessarily preliminary. Probably the single greatest challenge to the interpretation of these data is the heterogeneous nature of both the children included in the studies and the measures used to assess both their communication and their behaviour. This, of course, reflects the experience of the classroom teacher, but outcomes may differ for different subgroups, for example those with language learning difficulties but without other developmental delays, or those with autism spectrum disorder or PDD –NOS. Our impression is that the type of difficulty certainly affects the intervention techniques and outcomes adopted but not necessarily the result. Although the EPPI review process is robust in the identification and reporting of relevant studies, reviews can only pick up completed studies that are in the public domain. Study samples were mostly very small, demonstrating the preliminary nature of the much of the investigation. The fact that all the studies reported positive outcomes is heartening but, of course, the potential for selection bias is an inherent challenge to the interpretation of poorly controlled studies. Similarly, no studies reported significant follow-up suggesting that it is impossible to establish whether effects were sustained. Inevitably this affects the conclusions that can be drawn in terms of service delivery. This is particularly true when seeking to identify recommendations that would be relevant for public mental health in so far as it could be extrapolated to the wider population of children with such difficulties (Law and Elliott, 2009). It is important to stress that evidence limitations characterize the early stages in most evidence based enquiry. A substantial proportion of such reviews in the Cochrane and Campbell Collaboration databases (see http://www.cochrane.org and http://www.campbellcollaboration.org) include a handful of studies. Reviews have the effect of flagging up an intervention domain. Researchers and clinicians then improve on data quality as the domain develops.

2 Implications for research

The results of this review point in a number of directions in terms of future research with this particular group of children, i.e. those with both communication and behavioural difficulties. The first direction concerns the level of detail provided about both the types of intervention and assessment employed in intervention studies. Even taking into account the very special needs of some of these children, the interventions need to be clearly articulated and ultimately replicable. For this the interventions need to be made manual. This was not the case in the majority of studies included in this review, although it could be argued that specific techniques such as pivotal response training was sufficiently clearly articulated to be replicable. It would also be helpful to know whether the changes reported go beyond individual behaviours to meaningful changes on well-recognized measures, which would allow comparison across studies. For example, the ‘strengths and difficulties questionnaire’ (Goodman, 1997, 2001) and the ‘communicative development index’ (Fenson et al, 2006; Law and Roy, 2008) have become the measures of choice for assessing behaviour and expressive language respectively in young children but these have only rarely been used in this literature. The studies do indicate that the development of reciprocity is achievable, and that this makes a difference to the behaviour of many children, but there is no single accepted measure of such behaviours. Of course, the measurement issue is complicated further by the respective contributions of both age and development, i.e. what might be expected of a 3-year-old is unlikely to be relevant for a 13-year-old. Finally, it is clear that – in the research literature at least – such interventions are more commonly directed towards boys than girls, and it may well be the case that different interventions should be recommended for the two genders.

Although the weight of evidence attached to each of these studies is relatively low, it is important to consider the findings in the light of the recent re-development of the UK’s MRC’s guidance on complex intervention (Craig et al., 2008). What we are seeing in this review is the very early conceptual development in the area concerned. N of 1 studies, while traditionally weighted as being of low evidence on evidence hierarchies are very useful both for the level of detail about the interventions provided and for unpicking some of the more intricate relationships between input and output. They are commonly used in the earliest stages of the development of domain of concern and lead on to more sophisticated intervention designs. Most of the intervention research currently being conducted in this area is at the pre-theoretical stage (Craig et al., 2008). While authors have suggested possible mechanisms (Stevenson, 1996) we do not know whether the mechanisms differ according to individual circumstances or whether there is one group of children, for example whose underlying problems are affective and related to anxiety and another group for whom the underlying difficulty is linguistic and who subsequently development behaviour difficulties. That said, there has been some suggestion that the communication of children with attention deficit hyperactivity disorder (ADHD) may have specific features that may affect potential interventions. With this knowledge, specific interventions could be developed with an underlying theoretical rationale, which would have the potential to feed into a more robust evidence base. However, these are mainly social/pragmatic intervention, with only a few targeting linguistic development. From Stevenson’s (1996) model and Benner et al’s (2002) review it is possible to hypothesize that an intervention targeting underlying phonological processing would impact on both language and literacy and therefore behaviour (Tomblin et al., 2000). There is a need for further development work with single-participant experimental designs probably using multiple baselines to increase the confidence that it is communication rather than other factors that mitigates the child’s behaviour. It would also be useful to see larger scale studies with behaviour as the primary outcome but, perhaps, including communication as a moderator of a behavioural outcome or as a key component of a more systemic intervention. Does the level and type of the child’s communication influence the extent to which they are able to make use of the intervention concerned? The role played by interventions focusing on pragmatic skills would also appear to be a useful line of enquiry, with the level of detail in the programme specification going beyond traditional social skills training. Once this developmental work is complete and it is possible to be clear about what are the most promising interventions for a given age range and profile, it should be perfectly feasible to describe a randomized controlled study that either compares the impact of different language interventions on behaviour outcomes or that compares the effect on the group of children with both language and behavioural difficulties language, and behavioural interventions with both behavioural and language outcomes. The former would test the assumption that there are specific aspects of communication that affect behaviour and can thus be intervened with the influence the causal mechanism; and the latter would test whether these children respond more favourably to linguistic rather than behavioural interventions or vice versa.

3 Implications for policy and practice

The needs of children with both SLCN and SEBD are relatively high up the political agenda at present, albeit for different reasons. There is a public narrative in the UK about different approaches to managing the behaviour of young children in the public sphere. Of particular significance has been the concern expressed by the children’s commissioner in England about the dangers of labelling children as having SEBD if they have developmental difficulties of one sort or another. Effectively this represents a tension between different strands of a debate that have yet to be reconciled. This review adds support to the general discussion of whether it is appropriate to identify children as having SEBD when they are not able to understand what is said to them nor express their needs effectively. Indeed, there is a good case for identifying children with combined difficulties for distinct management. In turn this is likely to have a bearing on the management of children within the classroom context. There is a move towards greater focus on classroom wide activities to promote behaviour (Adi et al., 2007) and, while these have shown some positive results, the ability to engage children in such a process and specifically to promote their meta-cognitive skills relies on an appropriate understanding of the child’s communication skills. Children with SLCN – and especially those whose difficulties have implications for the child’s mental health and for their subsequent engagement with mental health and prison services – have been identified as of central importance in the UK (Bercow, 2008; Lindsay et al., 2008).

IV Conclusions

The potential overlap between SLCN and SEBD needs to be widely recognized by practitioners, and the implications for practice of this overlap explored more fully. Joint assessment is key but this is not simply relevant to case identification. It raises questions for practitioners from the health sector providing assessment and diagnosis, namely speech and language therapists, clinical psychologists and psychiatrists etc., on the one hand, and teachers and teaching assistants supporting these children in class, on the other hand. The context is key to the way in which services for these children are delivered, and collaboration across disciplines and professional groups is the only way that good quality services are likely to be achieved. This review acts as a preliminary step to consolidating and developing the evidence base in this area.

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