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Review
. 2018 Oct 15;10(10):CD012089.
doi: 10.1002/14651858.CD012089.pub2.

Parent-mediated interventions for promoting communication and language development in young children with Down syndrome

Ciara O'Toole  1 , Alice S-Y Lee, Fiona E Gibbon, Anne K van Bysterveldt, Nicola J Hart
Affiliations
Review

Parent-mediated interventions for promoting communication and language development in young children with Down syndrome

Ciara O'Toole et al. Cochrane Database Syst Rev. .

Abstract

Background: Communication and language development are areas of particular weakness for young children with Down syndrome. Caregivers' interaction with children influences language development, so many early interventions involve training parents how best to respond to their children and provide appropriate language stimulation. Thus, these interventions are mediated through parents, who in turn are trained and coached in the implementation of interventions by clinicians. As the interventions involve a considerable commitment from clinicians and families, we undertook this review to synthesise the evidence of their effectiveness.

Objectives: To assess the effects of parent-mediated interventions for improving communication and language development in young children with Down syndrome. Other outcomes are parental behaviour and responsivity, parental stress and satisfaction, and children's non-verbal means of communicating, socialisation and behaviour.

Search methods: In January 2018 we searched CENTRAL, MEDLINE, Embase and 14 other databases. We also searched three trials registers, checked the reference lists of relevant reports identified by the electronic searches, searched the websites of professional organizations, and contacted their staff and other researchers working in the field to identify other relevant published, unpublished and ongoing studies.

Selection criteria: We included randomised controlled trials (RCTs) and quasi-RCTs that compared parent-mediated interventions designed to improve communication and language versus teaching/treatment as usual (TAU) or no treatment or delayed (wait-listed) treatment, in children with Down syndrome aged between birth and six years. We included studies delivering the parent-mediated intervention in conjunction with a clinician-mediated intervention, as long as the intervention group was the only group to receive the former and both groups received the latter.

Data collection and analysis: We used standard Cochrane methodological procedures for data collection and analysis.

Main results: We included three studies involving 45 children aged between 29 months and six years with Down syndrome. Two studies compared parent-mediated interventions versus TAU; the third compared a parent-mediated plus clinician-mediated intervention versus a clinician-mediated intervention alone. Treatment duration varied from 12 weeks to six months. One study provided nine group sessions and four individualised home-based sessions over a 13-week period. Another study provided weekly, individual clinic-based or home-based sessions lasting 1.5 to 2 hours, over a six-month period. The third study provided one 2- to 3-hour group session followed by bi-weekly, individual clinic-based sessions plus once-weekly home-based sessions for 12 weeks. Because of the different study designs and outcome measures used, we were unable to conduct a meta-analysis.We judged all three studies to be at high risk of bias in relation to blinding of participants (not possible due to the nature of the intervention) and blinding of outcome assessors, and at an unclear risk of bias for allocation concealment. We judged one study to be at unclear risk of selection bias, as authors did not report the methods used to generate the random sequence; at high risk of reporting bias, as they did not report on one assessed outcome; and at high risk of detection bias, as the control group had a cointervention and only parents in the intervention group were made aware of the target words for their children. The sample sizes of each included study were very small, meaning that they are unlikely to be representative of the target population.The findings from the three included studies were inconsistent. Two studies found no differences in expressive or receptive language abilities between the groups, whether measured by direct assessment or parent reports. However, they did find that children in the intervention group could use more targeted vocabulary items or utterances with language targets in certain contexts postintervention, compared to those in the control group; this was not maintained 12 months later. The third study found gains for the intervention group on total-language measures immediately postintervention.One study did not find any differences in parental stress scores between the groups at any time point up to 12 months postintervention. All three studies noted differences in most measures of how the parents talked to and interacted with their children postintervention, and in one study most strategies were maintained in the intervention group at 12 months postintervention. No study reported evidence of language attrition following the intervention in either group, while one study found positive outcomes on children's socialisation skills in the intervention group. One study looked at adherence to the treatment through attendance data, finding that mothers in the intervention group attended seven out of nine group sessions and were present for four home visits. No study measured parental use of the strategies outside of the intervention sessions.A grant from the Hospital for Sick Children Foundation (Toronto, Ontario, Canada) funded one study. Another received partial funding from the National Institute of Child Health and Human Development and the Department of Education in the USA. The remaining study did not specify any funding sources.In light of the serious limitations in methodology, and the small number of studies included, we considered the overall quality of the evidence, as assessed by GRADE, to be very low. This means that we have very little confidence in the results, and further research is very likely to have an important impact on our confidence in the estimate of treatment effect.

Authors' conclusions: There is currently insufficient evidence to determine the effects of parent-mediated interventions for improving the language and communication of children with Down syndrome. We found only three small studies of very low quality. This review highlights the need for well-designed studies, including RCTs, to evaluate the effectiveness of parent-mediated interventions. Trials should use valid, reliable and similar measures of language development, and they should include measures of secondary outcomes more distal to the intervention, such as family well-being. Treatment fidelity, in particular parental dosage of the intervention outside of prescribed sessions, also needs to be documented.

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Conflict of interest statement

Ciara O'Toole (COT) received a Health Research Board Cochrane Fellowship Grant to assist in completing this work. The fellowship was received in January 2015, lasted for two years and paid for teaching cover, training support and related travel expenses. COT's institution received a grant from Foras Na Gaeilge for a project looking at early language acquisition of Irish. COT receives royalties as Co‐Author of the Language Development and Language Impairment: A Problem‐Based Introduction, which she confirms does not cover the interventions being investigated in this review.

Alice Lee (AL) is currently a Principal Investigator on a research project (2016 to 2018) funded by the Health Research Board, Ireland. AL was involved as a Co‐Investigator on a research project (2010 to 2012) funded by the National Institutes of Health, USA. AL received support through the programme, ERASMUS Staff Mobility – training for higher education institution staff at enterprises and at higher education institutions, European Commission, in 2012, for research‐related activities. None of these financial activities are related to the present systematic review.

Fiona Gibbon (FG) was paid an honorarium from the University of Hong Kong in 2013 for her advice on a research strategy for a Research Assessment Exercise, and received a fee from Newcastle University in 2014 for being an external participant on an Internal Subject Review. FG's institution received funding from the Health Research Board for a Health Research Award in 2012 to 2015 and 2016 to 2018. FG receives royalties as Co‐Editor of the Handbook of Phonetic Sciences, which she confirms does not cover the interventions being investigated in this review. FG has shares in various companies, which she confirms do not have a real or potential vested interest in the findings of this review.

Anne van Bysterveldt (AvB) received fees for clinical supervision of a staff member from Christchurch District Health Board. AvB holds an unpaid adjunct position at the Champion Centre, a multi‐disciplinary early intervention centre for preschool children with complex developmental disabilities. AvB's current position at the University of Canterbury involves the development and delivery of courses in the field of speech and language therapy.

Nicola J Hart (NH) is a national Speech and Language Advisor for Down Syndrome Ireland, a charity that provides training, support and advocacy for people with Down syndrome and their families. NH leads a small multidisciplinary team of advisors who provide information and advice about issues that arise across the lifespan, from early intervention to old age, in people with Down syndrome.

Figures

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1
Study flow diagram.
2
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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
See this image and copyright information in PMC

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