Child Language Teaching and Therapy 21,3 (2005); pp.

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Developing childrens conversational skills in mainstream schools: An evaluation of group therapy

J. Godfrey Bromley Primary Care Trust, Bromley, Kent, UK and T. Pring and M. Gascoigne Department of Language and Communication Science, City University

Abstract
Children from two mainstream schools who had poor communication skills were selected to take part in this study. Following formal and informal assessments of their language and pragmatic skills, they were randomly assigned to treatment and no treatment groups. Treatment consisted of attending eight weekly sessions of a social skills training group. Assessments carried out four to six months after training showed that treated children had improved their pragmatic knowledge signicantly more than untreated children. However, caution is required in generalizing these results to other children. The children in this study had a variety of difculties and it appeared that those whose communication skills were primarily the result of underlying language problems made the least progress. Further research is warranted with more homogeneous groups of children to establish which children gain the most from this approach.

Introduction
For a variety of reasons, many children in mainstream schools nd it difcult to conduct social interactions and hold conversations. Their difculties are not well understood and Koegel (2000) has stressed the need for further research
Address for correspondence: Jana Godfrey, The Willows Clinic, Red Hill, Chislehurst, Kent, BR7 6DA, UK. E-mail: jana.godfrey@nhs.net
# 2005 Edward Arnold (Publishers) Ltd 10.1191=0265659005ct291oa

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in the area. He points out that their problems may have long term consequences. They may lead to poor social and emotional development, peer rejection and reduced opportunities for learning. In the longer term failures in relationships and career development may result. These children are often referred to as having difculties with social communication or as having pragmatic difculties. They have a poor understanding of the rules that govern social interaction. This gives the impression that they are a homogeneous group. They are not. Conversation is a complex skill that can be impaired in a variety of ways. Social communication problems may be found in children with specic language impairment (SLI), in children with Autistic Spectrum Disorder (ASD) and in children with behavioural problems, dysuency and voice problems. McTear (1991) recognized this heterogeneity by distinguishing ve groups of children. Children with SLI have problems that stem from an underlying linguistic disability. They have poor syntactic skills and limited knowledge of word meanings leading to poor comprehension and word nding problems. Other children have more purely pragmatic difculties. They have a poor understanding of conversational rules. They are weak at initiating, turn taking and responding to requests for clarication. These difculties impair their conversational skills despite adequate linguistic knowledge. In a further subgroup, use of language is impaired by cognitive decits. Decient world knowledge will affect a childs ability to make sense of events and to make predictions, inferences and apply what has been learned to new situations. Other children have what McTear calls sociocognitive deciencies. They are unable to recognize the social attributes of a listener or to make inferences about their actions, intentions and beliefs (i.e., infer mental states). This can lead to a breakdown in conveying or understanding a message or to a misperception of communicative intent. Children with a diagnosis of ASD are typically decient in these areas. Finally, there are children with affective and emotional difculties who often exhibit socially inept behaviour such as withdrawal or inappropriate overfriendliness. Not all children t comfortably within these groups; some fall between them or exhibit characteristics of more than one group. As a result, some clinicians may be unhappy at this (or any other) classication of children with poor conversational skills. Nevertheless we have adopted McTears categories as a useful way of describing the children in this study and of illustrating the variability of their underlying problems. The heterogeneity of children with social communication problems has hindered research on therapy for their problems and clinicians may be in doubt about the appropriate treatment for individual children in their care. It is likely that the optimal approach differs for different types of children. The present study is a preliminary

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investigation of the effects of therapy on conversational skills. Children were included because their social communication was poor. Only subsequently and for descriptive purposes was an attempt made to assign them to different categories. Walker et al. (1994) have divided treatments for social communication problems into two types: behavioural, skill-based approaches and metacognitive problem solving approaches. These differ in their emphasis and the procedures used but are not mutually exclusive and clinicians often combine elements of both in their treatment. The behaviourist approach seeks to change behaviour through shaping and reinforcement. It has the advantage that behaviours are easily taught and that progress within the therapy setting may be quickly apparent. The approach strongly emphasizes success and praise and so builds condence. Therapists are often reluctant to rely on this approach alone, however, because of concerns that skills learned within therapy do not generalize to other situations. The metacognitive approach aims to make the child consciously aware of the rules governing social interaction. Walker et al. (1994) believe that the metacognitive approach is good at developing problem solving strategies but weak on effecting specic changes in social skills. In contrast, the behavioural approach is best for teaching specic social skills but has little impact on cognitive problem-solving strategies. Andersen-Wood and Smith (1997) say that little is known about the comparative effectiveness of the two approaches thus justifying the eclectic nature of the therapy offered by many clinicians. Models of the delivery of therapy also differ. Both indirect and direct methods are used. Examples of indirect methods are training, naturalistic intervention and peer mediated approaches (e.g., peer prompting). Direct methods include one to one therapy sessions and social skills groups. The present study used a social skills group and combined the behaviourist and metacognitive approaches. Social skills training is a two-part process in which children are taught to discriminate important features of their own and others social behaviour and then to apply the newly learned skills in naturally occurring situations (Walker et al., 1994). It involves the child acquiring conscious knowledge of skills such as making eye contact and incorporates role-play as a means of practise. Groups, therefore, involve peers both as a context for intervention and as an essential ingredient in accomplishing the goals of intervention (Gallagher, 1991). In the present research there were opportunities for children to interact informally, providing contexts in which children might practice new skills. Previous small-scale investigations have reported on the use of social skills and group training on a variety of children with social communication problems. Sedman (1998) worked with children with emotional and behavioural problems who were at risk of exclusion from school. Manz (2000) used a group approach to therapy to develop interactive and pragmatic skills in

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children with a range of disabilities. The group operated within the school and school staff monitored the childrens progress. Steel (1995) gave social skills training to children with semantic pragmatic disorders, assessing their progress with observational checklists and parent questionnaires. The latter studies reported promising outcomes, although the lack of controls prevents any denitive verdict on the effect of the treatment. The present study is also small in scale; however, the inclusion of an untreated group of children provides a stronger test of the effects of the treatment.

Method
Design Children with social communication difculties were randomly assigned to treatment and control (no treatment) groups. A person who was unacquainted with any of the children carried out the allocation of the children to groups. Children in the control group received the training course after the completion of this study. The children were assessed before and from four to six months after the treatment. The Test of Pragmatic Language (TOPL, Phelps-Terasaki and PhelpsGunn, 1992) was used to assess their pragmatic skills. The Oral Directions and Formulated Sentences subtests of the CELFR (Clinical Evaluation of Language Fundamentals Revised; Semel et al., 1994) were used to assess their language. It was expected that the treated group would show greater improvement on the TOPL but that no difference would be seen on the CELF-R subtests. Assessments before and after treatment were carried out blind by therapists who did not know which children were allocated to which group. Prior to therapy, the children participated in a one-off language group. This was videoed and therapists not otherwise involved in the research viewed and rated their nonverbal skills, nonverbal responses, listening skills and basic conversation skills. The Basic Social Skills Assessment Chart Score Sheet (Spence, 1995) was used. It was not intended to use this to assess the progress of the children during the study and it was not conducted again after therapy. Rather, it was used to inform therapy by discovering particular areas of weakness in individual children. It was also used to ensure that the children selected were appropriate for the training. Measures The TOPL is a formal assessment of the effectiveness and appropriateness of a childs pragmatic skills. Children are asked to indicate an appropriate picture

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to correspond to items read by an examiner. Different areas of pragmatic ability are examined. The test is standardized and scores were converted to standard scores for analysis. The CELF Oral Directions subtest assesses comprehension, recall and execution of oral commands. The Formulated Sentences subtest requires children to form sentences of increasing complexity. These were chosen as measures of receptive and expressive language respectively. Standard scores were used in the analysis.

Participants Twenty-four children took part in the study. The children attended one of two mainstream junior schools. The Key Stage 2 children had been identied by the schools as having difculties in the curriculum area of speaking and listening, specically in their ability to have conversations with their peers. Thirteen of the children were already known to the speech and language therapy service and were known to be suitable for the study. The video assessment of the childrens social skills was used to show that the remainder of the children had been appropriately referred. One child, assigned to the treated group, changed schools during the study and practical difculties made it impossible to complete the after therapy assessments. The treated group contained four girls and eight boys (mean age 9.7, range 7.711.6). The untreated group contained two girls and 10 boys (mean age 9.8, range 7.610.10). The children were grouped according to McTears (1991) categorization of subtypes of conversational disability. Assignment to the rst four subgroups was based upon the assessments and to the fth on parental and teacher report. The results are in Table 1. The number of children in each subgroup is approximately the same in the treated and control groups. None of the children in the study were classied as having cognitive decits.
Table 1 Distribution of children by subtype across the treatment and control groups

Type of conversational disability Problems due to linguistic impairment Problems involving conversational rules Cognitive decits affecting use of language Sociocognitive deciencies Affective and emotional difculties

Treatment group 5 3 0 3 1

Control group 4 2 0 5 1

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Treatment Treated children attended one of two groups, which took place in rooms in their own schools. They attended eight weekly sessions in which they were taught how to listen attentively, begin and end conversations, ask questions in order to maintain and repair conversations and the importance of nonverbal communication. Individual targets, based on the assessment results and data from the videos of the children were also targeted. The group was run by the rst author, who is a speech and language therapist, with learning support assistants who worked in the school. They monitored the childrens progress making notes on each child after each session. This gave information about the childrens progress within the group and educational staff added to this by providing examples of the childrens use of their skills in school. Activities within the sessions included games, brainstorming and role play. Ideas for games were taken from resources (Rustin and Kuhr, 1989; Pax Christi, 1994) and papers describing social skills-type interventions (e.g., Lamb et al., 1997). Role-play was used to give children the opportunity to practise engaging a partner in conversation in a style appropriate to the context. Conversation practice in pairs, triplets or the whole group was also a part of each session. Topics were suggested by the therapist but were sometimes modied according to the childrens wishes. The adults in the group monitored conversation between children in order to give children feedback. Theory of mind tasks taken from Happ (1994) were used to encourage conversations e about characters thoughts and feelings in the light of their nonliteral utterances (e.g., white lies, irony). After each session, practising a skill and=or homework in the form of worksheets from Semel and Wiig (1992) and Kelly (1996) was given to each child and returned the following week. Ideas for practising=observing pragmatic skills outside of the group were taken from Andersen-Wood and Smith (1997). These exercises had a dual role. They encouraged practice outside of the training group and allowed for greater involvement by parents. The sixth session was videoed and viewed by the children the following week. Pupils were asked to set a target for themselves based on their own observations. In the nal session, the pupils were encouraged to say how they had improved and what, if any, skill they would continue to work on.

Results
Table 2 gives the means of the assessments for the treated and control groups. The scores are standard scores. For the TOPL the population mean is 100 and for the CELF subtests it is 10. Analysis of variance (ANOVA) was

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Table 2 Mean standard scores on the assessments for each group

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Control group Pretreatment TOPL CELF oral directions CELF formulated sentences Mean SD Mean SD Mean SD 88.75 13.09 8.66 2.31 6.33 3.17 Posttreatment 87.58 10.65 9.08 3.45 7.33 2.67

Treated group Pretreatment 88.72 9.10 8.09 3.14 6.63 2.73 Posttreatment 96.63 10.95 9.09 3.20 7.72 3.03

used to analyse the results. ANOVA was used because the interaction of groups by time provides the most direct test of whether the groups differ in their improvement over time and because the data met the necessary assumptions for use of a parametric test. A two factor mixed ANOVA was used to analyse the TOPL pre- and post-treatment scores. Group was a between subject variable and a time within subject variable. There was no main effect of group or time but their interaction was signicant (F (1, 21) 5.50, P < 0.05). This reects the stronger improvement seen in the treated group. A mean improvement of half a standard deviation on the test is seen in this group. Simple main effects analysis carried out on the two-way interaction showed that the change in the treated group was signicant, (F (1, 21) 7.99, P < 0.01). No change was seen in the untreated group (F < 1). A three-factor mixed ANOVA was carried out on the pre- and post-treatment scores of the two subtests of the CELF-R. Group was a between subject variable and time and subtest were within subject variables. The main effects of time (F(1, 21) 4.81, P < 0.05) and subtest (F(1, 21) 7.21, P < 0.05) were signicant. These results show that children in both groups improved and that scores on the oral directions subtest were higher than those on the formulated sentences subtest. No interactions were signicant in the analysis. Critically, there was no group by time interaction (F < 1) indicating that there was no difference in the improvement made by the two groups on these assessments. Improvement on the TOPL among the treated children was quite variable (range: 7 to 22 points). Although the numbers of children in each of McTears subcategories is too small to draw any denite conclusions, it is worth recording that the four children with language impairment had improved very little (mean 0.75 points).

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Discussion
The results are broadly in line with the expectation outlined in the introduction. The treated group improved signicantly more than the control group on the TOPL suggesting that the social skills training course was successful. It should be recalled that the post-therapy assessment was conducted between four and six months after the pre-treatment assessment so the improvement in the treated group is maintained for some time after the completion of the training. The social skills training was not expected to affect the childrens language ability. Two subtests of the CELF were used to assess this. Against expectations, improvement was seen on these measures. Though not substantial, it was signicant. However, the change was similar in both the treated and the untreated groups. This suggests that it was a general effect of increasing age and exposure to language (for most children a six-month interval had elapsed between assessments) and not a result of the social skills training. The results suggest, therefore, that the training directly inuences the childrens pragmatic skills as assessed by the TOPL. As McTear (1991) suggests, a variety of children have poor pragmatic skills and problems with social interactions. Four of the ve groups described by McTear were represented in this study. These groups have a common surface difculty with communication caused by different underlying linguistic, cognitive or emotional problems. The present training programme targeted communication. Although efforts were made to treat particular social skill problems observed in individual children, no attempt was made to vary the treatment systematically to cater for the different groups of children. It is likely that attempts to do so may further increase the benets to the children and this issue should be investigated in future research. Indeed, there are suggestions in the present ndings that some children responded to the treatment better than others. Children in the language impairment group made very modest gains while those with sociocognitive problems particularly and those with poor knowledge of conversational rules improved substantially (only one treated child had an affective=emotional problem). The numbers involved are far too small to be condent that this result will apply to other children. Nevertheless, this outcome is not an implausible one. Children with language impairment may not be able to improve their conversational skills until their underlying language difculties are more directly addressed. If this possibility is conrmed by further research, clinicians may wish to be more selective in their choice of children for inclusion in social skills training groups. For the present, the nding that many children can benet from the

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group approach is a welcome one. Group therapy is attractive because it allows children to receive more attention at less cost in clinical time than other approaches. It also provides a context for practising skills and for children to appreciate their and others problems and the progress made. Groups are likely to include a heterogeneous selection of children, however, and limit the extent to which children can receive individually tailored therapy programmes. Group training also offers a number of less obvious benets. Its use in main school settings can lead to increased opportunities for collaborative working between therapists and teachers. There are barriers to such collaboration (McCartney, 1999), but there are also benets for the children from coordinated therapeutic and educational support (Wright, 1992). Few barriers were encountered in this research. Joint working was helpful to the therapist and the educational staff. The therapist gained access to information about the childrens transfer of skills practiced in the group to contexts within the school and support assistants valued the support they were given and reported gaining a better understanding of the childrens difculties. A further advantage of a collaborative approach is that children with communication problems within mainstream schools may be more readily identied by educational staff and are more likely to be referred to the speech and language therapy service. Within this project, some of the children put forward for inclusion by the school had language and=or pragmatic difculties (veried by subsequent assessments) but were previously unknown to the service. The use of the TOPL in this research deserves comment. As a standardized test of pragmatics it can both measure childrens improvement across time and compare them with the population of other children. It is a reliable test, which provides quantitative data for analysis. It is primarily a test of knowledge not performance, however. As such critics may doubt the clinical signicance of improvements seen during therapy. Although not included in this study, an analysis of conversational behaviour may be useful. Adams and Bishop (1989) have developed a procedure to examine features such as exchange structure, turn taking and conversational repair. Previous studies (Steel, 1995; Manz, 2000) have used questionnaires and observation to assess childrens performance in real life situations. Such measures are less reliable and more subjective than standardized assessments. Nevertheless, it is likely that future research will want to use both types of measures. The ndings of this research support the provision of intervention in a mainstream school setting to children who have difculty acquiring speaking and listening skills as a result of pragmatic language impairment. It is likely that speech and language therapists will need to initiate and support such provision. However, it should be possible for schools to become less

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dependent on therapy input as educational staff became more familiar with the needs of the children and the running of the groups. Lennox and Watkins (1998) report on a collaborative scheme in a primary mainstream school where language groups were jointly planned and run by teachers and therapists with therapy input gradually reduced. A further advantage of the involvement of teaching staff is that they may more easily monitor and encourage the transfer of learnt skills to the school environment.

References
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