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James Law,1 Liz Todd, Jill Clark, Maria Mroz, Julie Carr
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First published 2013
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Cover photo: Clare and her six-month-old son, Kai, at their home in Slough.
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Executive summaryviii
2 Do children living in poverty in the UK suffer
disproportionately from early language delay? 7
3 How does early years language delay affect
school readiness and later life chances?10
4 What policy changes could help to solve the
problem of early years language delay?12
5 What practice changes could help to solve the
problem of early years language delay?17
6 Next steps24
Between birth and the age of two years,
babies and toddlers develop their
communication skills. Not only do these skills
allow children to start speaking their first
words and making simple sentences, they also
equip them with the ability to express feelings
and understand the world around them. Early
language skills underpin subsequent reading
and writing skills; therefore, children’s early
language development has a significant impact
on future school performance. Without
language and communication skills, children
are unlikely to reach their full potential.
Early language development is rooted in the
interactions children have with their parents, childcare
providers and peers. These early social exchanges
both foster developing language skills and provide a
vital foundation for children’s school readiness and
academic achievement. However, studies indicate
that poverty can seriously hamper parents’ ability to
adequately respond to their child’s early language needs
and provide a home learning environment which is best
suited to enhancing language and communication skills
in the early years. The aforementioned link between
children’s early language development and subsequent
school performance highlights the serious impact
which poverty is having on children’s ability to thrive in
childhood and later life.
In 2012 Save the Children’s UK Programme
Innovation Impact and Learning team recognised the
need for further investigation into this important
area of childhood development and began to carry
out internal desk-based research. This scoping work
revealed a significant need in terms of children living
in poverty lagging behind their peers in language skills,
including developing vocabularies at a slower rate,
having less phonemic awareness and lower reading
ability. However, much of the research was outdated
and used small sample sizes.
The most significant studies were also not UK-based.
A decision was therefore made to commission an
external report which would provide up-to-date
information on the prevalence of language delay in
the UK, and examine the strength of the relationship
between a child’s family income and their ability to
develop early language skills. After receiving a number
of expressions of interest, our internal procurement
process identified Professor James Law and colleagues
from the School of Education, Communication and
Language Sciences, Newcastle University as the best
suited for carrying out this work.
The report highlights the significance of communication
for fostering life chances in early childhood. It also
demonstrates the key role that is played by everyone
in the child’s environment, showing that what
families do is far more significant for a child’s early
development than who they are. The report makes
recommendations for the need to scale up and roll out
interventions that have been shown to work and to
test their value across whole populations and over an
appropriate length of time.
Save the Children UK has an opportunity to work
in this space and add real value by developing and
robustly evaluating an intervention which aims to
support low-income families to give their children
the best start in life through the development of
appropriate language and communication skills that
will set them up for school and ensure they have the
same chance of achieving their potential as their more
well-off peers.
The decision to tackle this issue is timely, given
the growing recognition of the need to focus on
early years (Frank Field’s Independent Review on
Poverty and Life Chances, which recommends
intervening early; Graham Allen’s Early Intervention
Foundation; the Department for Education’s Early
Intervention Grant and free early education places for
disadvantaged children).
Save the Children will use this report as evidence
for the need to develop a programme, based on
evidence and existing effective practice, which works
to ensure that children living in poverty have an
appropriate home learning environment, offering
them the opportunity to develop the language and
communication skills which will equip them to arrive
at school ready to learn and achieve and break the
cycle of poverty for good.
Momentum is also building for a focus on children’s
early language and communication skills. In 2008
the government published the Bercow Report into
services for children with speech, language and
communication needs, and in 2012 Ofsted revised
its framework for the Early Years Foundation
Stage (EYFS). This placed strong emphasis on
communication and language as one of three prime
areas considered to be crucial for igniting children’s
curiosity and enthusiasm for learning, and for building
their capacity to learn, form relationships and thrive.
Communication and language is described in the
EYFS framework as “giving children opportunities to
experience a rich language environment, to develop
their confidence and skills in expressing themselves
and to speak and listen in a range of situations”.2
Gemma Bull
Head of Innovation, Impact and Learning
Emily Rayner
Development Officer
Educational psychologist (EP)
Language impairment
Professional with responsibility for monitoring
children’s progress in school and for developing
school achievement
A term used to describe children with pronounced
and persistent language learning difficulties
Language disorder
Executive function
An umbrella term for cognitive processes that
regulate other cognitive processes, eg, planning,
working memory, attention, etc
A term used to suggest that a child’s language is
developing differently from that of typically developing
Early Years Foundation Stage – term used in England
for the assessment of children at school entry
Government acronym for ‘Not in education,
employment or training’
Non-specific language impairment
Expressive language
Vocabulary, grammar and morphology (small changes
to words, ie, plural ‘s’)
Term used to describe language learning difficulties in
conjunction with other developmental difficulties
Environmental factors
All external influences on the child’s language
development, ie, factors which are not genetic,
including the child’s experiences of language from
parents, wider family and education
The extent to which a skill or characteristic is
inherited from the child’s parents
Index of Multiple Deprivation (IMD)
A composite measure of relative socio-economic
deprivation used in the UK
Intelligence Quotient (IQ)
Tested indication of a child’s overall intelligence –
often separated into verbal and non-verbal IQ
Language delay
Expressive and receptive language skills significantly
below expectations
The way in which the context determines meaning
Receptive language
Comprehension of spoken and/or written language
Meaning as conveyed through language
Scottish Index of Multiple Deprivation – scale of
deprivation used in Scotland
Socio-Economic Indexes for Areas – scale of
deprivation used in Australia
Special Educational Need
Special Educational Need and Disability
Generic term used to describe characteristics of
a child’s social environment – commonly refers to
parental employment or educational status
Sure Start Local Programmes – interpretation of Sure
Start at local level
Socio-economic Status (SES)
Specific language impairment
Term used to describe language learning difficulties
without any other developmental or learning
Speech, Language and Communication Needs –
generic term used in England to describe the full
range of communication difficulties in children.
Language delay would fall within this category
The meaningful combination of words to represent
complex ideas
Talk of the Town – an integrated community
intervention designed to promote language
development in schools
UK social research agency that “helps the government,
private sector and third sector plan and care
for society”
Speech and Language Therapist – professional with
specific expertise in identifying and ‘treating’ children
with language learning difficulties, including language
Executive summary
In the early years, children whose language
skills develop more slowly are often
described as having a ‘language delay’. While
many of these children catch up with their
peers, those who do not can experience
difficulties in school – for example, in learning
to read or in contributing effectively in the
classroom. There are signs that such early
difficulties may be associated with lower adult
literacy, a poorer record of employment and
even mental health difficulties.
A variety of factors affect the extent to which
children’s early language and communication skills
develop. Recent research has shown that both
genetic and environmental factors have a role to
play, environmental influences playing a stronger part
in the early years – this is especially true of verbal
comprehension, or the child’s ability to understand
what is said to them. Genetic factors play an
increasing role as the children reach middle childhood.
In terms of environmental factors, there is strong
evidence that the degree to which the child is spoken
to and the way in which they are spoken to makes a
difference, but there are various other related factors
that contribute, including the type of positive language
learning experiences to which the child is exposed.
Children who are under-stimulated are more likely to
have language delay, although by the same token they
may be more likely to respond well to nursery or
early-years input. It is important to acknowledge that
while language delay may be the only difficulty that a
child experiences, in practice many such children have
other difficulties as well.
When we look at studies of whole populations, we
see a clear ‘social gradient’ for language, with children
from the most disadvantaged groups having lower
language skills than those in the least disadvantaged
groups. Importantly, it is not just that the lowest
group performs poorly in comparison with the others;
there is a gradual decrease in performance across
social groups. Neither is it simply a case of all children
in the lowest groups performing poorly – many are
doing well. It is rather that the average for the group
is lower. Similarly, the numbers of children that one
would expect to have scores falling below average at
school entry are higher in the more disadvantaged
groups. The precise figures vary according to the
measures used and the populations sampled. If we
look at the longer-term impact of language delay, all
studies appear to tell the same story – namely, that
those from the most disadvantaged backgrounds are
the least likely to catch up.
We know a lot about what can be done for these
children and interventions range from broad-based
programmes intended to stimulate language, along
with a wide range of other skills, to programmes
carried out with individual children or groups of
children which are specifically intended to stimulate
language development. Although such programmes
have been developed and evaluated, they are not
necessarily widely available. They can be expensive
to implement and rely heavily on local focus and
commitment. Nevertheless, there is evidence for
positive economic benefits from such interventions
through into adulthood.
There have been a number of convergent initiatives in
recent years suggesting an increasing policy interest
in early development in general and in language delay
in particular. As a result of the recent initiatives
following the Bercow Report into services for
children with speech, language and communication
needs, the Communication Trust, an umbrella group
of national charities, has been set up to promote
the importance of language development, to provide
relevant materials for practitioners and parents, and
to lobby for better services for children with language
delays and other children with speech and language
needs. Also in response to this report the Better
Communication Research Programme published
We can agree on four general principles with
regard to early child development which have been
developed by the US National Scientific Council on
the Developing Child.
General principles
Principle 1: Each of us is the product of an ongoing
interaction between the influence of
our personal life experiences and the
contribution of our unique genetic
endowment, within the culture in which
we live.
Principle 2: Human relationships are the ‘active
ingredients’ of environmental impact on
young children.
The key understanding in this report is that all policy
should be developed from the research evidence,
that it should emphasise the whole child, their family
and their community, and that there should be an
emphasis on emotional wellbeing in addition to
early cognitive skills. At one level such principles are
non-contentious, but how they play out in a policy
context depends on the nature of that context. It is
relevant that similar messages are being developed
in the UK, where we have seen a series of reports
over recent years emphasising the need to address
early cognitive differences in the context of the
family. To these messages we would add a series of
supplementary principles that specifically relate to
language development.
Executive summary
a series of research reports in December 2012 to
help underpin the future development of services
for these children. Campaigns to encourage a focus
on communication skills have been organised by the
Communication Trust (the Hello campaign) and the
Royal College of Speech and Language Therapists (the
Giving Voice campaign). The All-Party Parliamentary
Group on Speech and Language Difficulties will
also be reporting on the links between speech,
language and communication needs (SLCN) and
social disadvantage in spring 2013. The Healthy Child
Programme in England and comparable initiatives
in Northern Ireland, Scotland and Wales include
reference to the identification of early language delays.
There have been a number of initiatives to raise the
profile of oral language development in the early years
and primary school curriculum. While there has been
pressure on education services in recent years, the
government has introduced the Pupil Premium, which
is specifically designed for the needs of children from
disadvantaged families. Such initiatives are welcome,
but sustainable changes to attitudes and practice are
the key measures of success.
Language-specific principles
Principle 5: Communication is key to the fostering
of life chances in early childhood.
Everyone in the child’s environment
has a role to play in fostering the child’s
communication skills. This starts at birth
and includes immediate and extended
family, and potentially a wide range of
professionals, health visitors, speech
and language therapists, early educators,
teachers, psychologists, etc.
Principle 6: The importance of early communication
skills and their implications for the child’s
social and educational development
across the early years and beyond need
to be understood by all parents.
Principle 7: All professionals need to be aware of
how to identify early language delays and
confident about what they can do to
enhance language skills.
Principle 3: The development of intelligence,
language, emotions and social skills is
highly inter-related.
Principle 8: We need to scale up and roll out
interventions that have been shown to
work, and test their value across whole
populations and over an appropriate
length of time.
Principle 4: Early childhood interventions can shift
the odds towards more favourable
outcomes, but programmes that work
are rarely simple, inexpensive, or easy
to implement.
Principle 9: We need to sustain the pressure on
policy-makers to improve services
for the child who is language-delayed,
especially in the very early years
(ie, before three years).
• After 40 years of research, a great deal is known
about what needs to be done for children who
experience early language delays.
• Much of what can be done to promote children’s
early skills is not exclusive to language, but a focus
on language, given its importance to modern
society in terms of school achievement and
employability, is important for any intervention
• There is a need to make sure that all professionals
are aware of what is needed and that their input
is monitored through the most appropriate
means available.
• Parents, teachers and specialists need to be actively
involved in subsequent developments.
• The picture is muddied by the fact that many
children who are late talkers go on to have
reasonable language skills. We need to know
more about the developmental pathways that
children follow and what it is about some children
that makes them more resilient than others.
Nevertheless, it is clear that there is a risk of
later difficulties, for which society needs to take
a responsibility.
• In the current economic climate, services will
only develop if they are underpinned by a strong
evidence base. Any steps to develop interventions
need to be supported by effectiveness research
built into the design of the intervention, not bolted
on after the intervention has been started, as is
too often the case in government policy.
• It is relevant to develop interventions at any age,
but given the genetic evidence and the evidence
about the role of specific environmental features
that make a difference to language development
in the first three years of life, there is a strong
case for developing and robustly evaluating
interventions targeting early language before the
age of three years.
• One of the features of such an intervention
should be the involvement of different agencies
and professional groups with an interest in these
children. There is a potentially strong role for the
charitable sector to take a lead in catalysing this
type of activity.
• The evidence base is developing, especially in light
of the recent Better Communication Research
Programme. The priority is more and better
evaluation of promising interventions that can
be delivered in a sustainable manner.
• There is much to be learned from the Sure
Start experience in terms of both the specificity
of the interventions and the way in which the
interventions were evaluated.
• While clinic- and school-based interventions
are important, the role of the family and
neighbourhood are central to developing
interventions for young children.
1 background
What is ‘language delay’?
Our capacity to communicate is one of the most
important features of our lives, and it is in young
children that we are most aware of it. We watch with
amazement as two-year-olds start to master their
language skills and we marvel at their capacity to let
people know what they mean, to share a joke, etc. To
some extent this process appears to be biologically
driven, and it has even been called an instinct (1), yet
anyone who has watched their child mimic those
around them, copying words, phrases and intonation,
will know that the context in which they start
speaking is very important. Children acquire language
under widely differing circumstances, and a number
of factors have been shown to be associated with
language development. It is widely reported in the
literature that the child’s environment is associated
with language development, but this is not the whole
story, as heredity and other factors also play a part.
Experience tells us that most children learn to
express themselves in the first two or three years of
life without too much effort, yet some do not, and in
the early years at least these children are commonly
said to have a language delay or be language-delayed.3
This means that their language skills are developing
significantly more slowly than those of other children
of the same age. Children who have language delay are
slower than other children to start to use words, and
are then slower to put simple sentences together by
the age of two or three. This has a knock-on effect
on their ability to express themselves more generally,
and they are likely to have difficulty responding
to questions or telling stories. While the language
development of most other children develops very
quickly over the first three or four years of life, the
language skills of children with language delays may
continue to lag behind and can affect early reading
skills, classroom performance and the ability to
make friends.
Language delay is commonly distinguished from
speech delay and other communication difficulties
which can occur without affecting language. It can
occur in isolation but is commonly associated with
other conditions. Thus, the language of children who
have a hearing loss or a learning disability is often
described as delayed, especially when they are very
young. The term is not normally used to describe
the English language skills of children whose first
language is not English, unless it is clear that their
skills in their family language are also delayed. The
use of the word ‘delay’ suggests that the sequence
of the child’s language development is following the
normal pattern, and it is sometimes contrasted with
language ‘disorder’, where the pattern of development
is said to be unevenly disrupted. Similarly, a distinction
is commonly drawn between language delay and
‘specific language impairment’, where a child’s
language is slow to emerge but there are no other
associated difficulties. In practice, these distinctions
are not always easy to make, and there are no clear
criteria for the level at which a child is considered
to be delayed rather than within the normal range of
language development. Practitioners commonly talk
about children falling below a certain threshold – for
example, below -1 standard deviation of the mean for
a given test or below -1.5 or -2 standard deviations,
suggesting that the children are in the bottom 16%,
7% or 3% of the population. But other researchers
have sought to describe what children are not
able to do at a specific age and given a particular
developmental milestone (2).
The term ‘language delay’ tends to be used to refer
to relatively young children, perhaps up to the end of
the ‘early years’ period. It is much less common
to hear it being used to describe, for example, a
12-year-old. Although there is plenty of evidence that
for some children difficulties persist, the assumption
is sometimes made that by this stage their language
will have caught up and be indistinguishable from
that of their peers. We use the World Health
Organisation (3) definition of early years, which
covers the range from “pre-natal development up to
eight years of age”. Although designed to capture the
point at which children generally enter the education
system, earlier in some countries, later in others,
it has the advantage of including access to national
assessments in the UK system, where children
start school relatively early. Language delay is thus a
description that may be applied to many children in
the first few years of life. As such it can be of concern
to parents, practitioners and more recently policymakers. In this report we look at the literature related
to language delay and ask four key questions:
• Do children living in poverty in the UK suffer
disproportionately from early language delay?
• How does early language delay affect school
readiness and later life chances?
• What policy changes could help to solve the
problem of early language delay?
• What practice changes could help to solve the
problem of early language delay?
In addressing these questions we focus on literature
that has been published in the past ten years or so,
although much of this is built upon earlier work. We
begin with a discussion of the importance of language
delay in 2013 and what we know about what causes it.
Why is language delay
Language delay is important in its own right because
it affects the child’s experiences at home and at
school. It is important because it raises anxiety among
parents and teachers when it is first identified, but
increasingly it is becoming important because of
what it may tell us about the child’s future potential.
In recent years it has been proposed that children
with delayed language development may also be
experiencing delays in the development of symbolic
thought, delays which may have consequences later
on in school and for future employability. And this
is occurring in the changing context of the modern
workforce, where the nature of employment has
fundamentally changed over recent years. As Hart and
Risley (4), two of the most outstanding researchers in
the field, have said, language is key to the development
of symbolic thought. They also state, “The economic
importance of intellectual, symbolic and problem
solving work has increased (over recent years) and
that of blue and white collar work has decreased.”
The more sophisticated, the better educated and the
more automated or digitalised the society becomes,
the greater this shift from blue-collar manual
employment towards white-collar ‘communicationfocused’ jobs, something which creates particular
challenges for the less advantaged, particularly in
times of economic downturn. This makes it difficult
for a young person lacking in communication skills to
break into and progress within the job market:
The shepherds, seamstresses, plowmen, and spinners
of the past did not require optimal communication
skills to be productive members of their society, as they
primarily depended on their manual abilities. Today a
fine high-school athlete – a great “physical specimen” –
who has no job and suffers from poor communication
skills is not unemployed, but, for the most part,
unemployable. On the other hand, a paraplegic in a
wheel chair with good communication skills can earn
a good living and add to the wealth of the society. For
now and into the 21st century, the paraplegic is more
“fit” than the athlete with communication deficits.
(Ruben (5), p 243)
Acknowledgement of the significance of
communication competence is also reflected in the
recently released Industry Skills Council of Australia
report No More Excuses (6), in which Australian
Federal Member of Parliament John Dawkins states,
“There is undeniable evidence to demonstrate
that poor communication skills adversely affect
productivity in the workplace and productivity suffers,
as does our global competitiveness.” (p. 3)
Early child development and the factors that influence
it have also been linked to subsequent health status:
Socio-economic gradients in health across the life
course begin as socio-economic gradients in early
child development. Thus, the social environment is a
fundamental determinant of early child development
and, in turn, is a determinant of health, well-being and
learning skills across the balance of the life course.
(p 627) (7)
Clearly, child development goes beyond language
development, but the child’s capacity to use language
effectively is a key feature of that development.
The antecedents of
language delay
It is sometimes assumed that all children have the
same intact language potential, but recent evidence
from the field of genetics (and specifically twin studies)
has suggested that the playing field is not as level
as has been suggested. In early childhood, shared
environmental factors account for most of the variance
in early language, and as children move into middle
childhood and adolescence the genetic factors play an
families. Yet this finding has not gone unquestioned.
Other researchers have suggested that there may be
significant interaction effects for verbal ability with
family chaos, instructive parent–child communication
and informal parent–child communication, and have
concluded that there was greater group heritability in
high-risk environments and that this relationship was
particularly true in the most disadvantaged groups (17).
Genetic influences can emerge over the course
of a child’s development, and this relationship can
differ for children from different socio-economic
backgrounds (13). One of the key issues is whether
heredity plays a greater role in children from families
with lower or higher socio-economic status (SES).
Here the interpretation of the data differs. Some
studies have suggested that heredity is stronger for
less disadvantaged children, at least as far as IQ (14),
vocabulary (15) and reading (16) are concerned.
Children who live in higher SES families have stronger
genetic influences on cognitive ability (language and
developmental intelligence) than those from more
disadvantaged families (lower SES). At two years of
age, genes accounted for 50% of variation in high-SES
families, compared to 5% in children from low-SES
Although the role played by genetics is clearly
important, that played by the environment has
received more attention. In the most commonly
cited study describing the relationship between how
parents speak to their children and the level of their
children’s subsequent language development, Hart
and Risley (4) recorded in detail and on a monthly
basis the way that 42 parents from different social
groups in the USA talked to their children between
10 and 36 months of age, and studied the relationship
between the amount of input that such children
receive and their language development at three years.
The cumulative language experience, measured in
terms of the number of words heard, of children from
three groups (professional, working-class and ‘welfare’
families) is summarised in the figure below.
increasingly dominant role (8–10). The effect of genetic
factors remains relatively constant thereafter. Genetic
and shared environmental influences contribute to
low expressive language ability in particular (11). As
increasingly severe cases of expressive vocabulary
delay were identified, the heritability of low expressive
vocabulary and the influence of shared environmental
factors increased (12).
Figure 1: Amount of language (in words spoken to children from different
social groups (Hart and Risley 1995) (4))
Estimated cumulative words addressed to child (millions)
0 12243648
Age of child (months)
The number of words directed towards a child over a
given year ranged from 11 million in the ‘professional’
families to 3 million in a ‘welfare’ family. This pattern
was reflected in parenting style and in the amount
of encouraging feedback that the children had
experienced, and also in the non-verbal IQ and tested
vocabulary scores that they achieved.
Hart and Risley concluded:
The social distinctions between professional and
working class have increased. In our small sample of
American families we saw virtually all the professional
families preparing their children for symbolic problem
solving from the very beginning of their child’s lives.
We saw them devoting time and effort to giving their
children experience with the language diversity and
symbolic emphasis needed for manipulating symbols;
we saw them using responsive and gentle guidance
to encourage problem solving; we saw them proving
frequent affirmative feedback to build the confidence
and motivation required for sustained independent
effort. We saw how strongly related the amount of such
experience was to the accomplishments of children
from working-class families. But we saw only one third
of the working-class families and none of the welfare
families similarly preparing their children.
(p 204)
Numerous studies have supported Hart and Risley’s
broad conclusions about the way that parents talk
to children and the potential impact that this can
have on language. Depending on the criteria used,
SES identifies attributes of the home environment,
such as reading frequency and cultural activities (18),
and it is the home environment which is associated
with early language acquisition (19, 20). Low parental
educational level is a risk factor for speech and
language impairment (21–23), as mothers with a low
level of education tend to talk to their children in
fewer utterances and with poorer vocabulary than
mothers who have higher education (24), although it
should be recognised that this is not always found to
be a significant factor (25), and there always remains
the question of whether the parent’s low educational
attainment may be related to their own language and
cognitive skills.
Other specific aspects of the child’s early environment
which have attracted attention are television
watching, childcare arrangements, what are known
as ‘neighbourhood effects’, and schooling. The
effects of watching television depend upon what
is watched, with positive relationships noted if the
chosen programme is appropriate to the age of the
child (26). There is evidence that children who are
heavy television users have lower language scores,
yet children’s entertainment television can provide
opportunities for verbal interaction and talk (27). The
issue is about how children watch television rather
than the length of time for which they are exposed
to it. While the emphasis is often placed on the
television itself, it is more important to focus on the
child’s wider communication environment. Children’s
environments also vary according to childcare
arrangements and where the child spends their time
during the day. A review of social context support and
language development (26) reports that the amount of
language directed at children in the childcare setting
is a positive predictor of their language development
at 15, 24 and 36 months (using standardised tests
and maternal reports), although childcare experience
only accounts for 1.3–3.6% of the variance. Broadly
speaking, the impact of integrated childcare and
education is beneficial for children, especially those
from multi-risk families (28).
As we have seen, social interactions with others
provide a framework through which young
children learn forms and features of language (26).
Children whose social experience provides more
communicative opportunities and richer input build
their vocabularies at a faster rate than children with
less communicative experience and less rich input,
indicating that the language acquisition mechanism
makes use of the communication experience and
language data. But such interactions are not solely
the responsibility of the parent. Peers can provide
opportunities to engage in joint planning, negotiating
conflicts and telling stories and may be an important
source of input for language acquisition, although
not sufficient alone, as children must get input from
expert speakers in fairly substantial amounts (26).
Language experiences at school can differ from those
at home, and there may be a discontinuity between
these environments for children from disadvantaged
backgrounds (26). Being in school is associated with
more rapid language development than not being in
school, and it has been noted that children’s language
skills progress more rapidly during the school terms
than over the summer holiday (26). Research suggests
that training in language practices for early-years
teachers can have a positive effect on the vocabulary
of the children in their class, and the amount and
quality of language input has effects on children’s
language development (26).
Neighbourhood influences
Although the emphasis in most of the above studies
is on the parent–child relationship and its implications
for language development, it is also important to
consider the impact of the wider social environment
or neighbourhood in which the child grows up. The
neighbourhood, village or local community will vary in
its cohesion and the extent to which values concerning
children and the way that they should be cared for are
shared. Although such factors have not been explicitly
examined in relation to language delay, it has been
suggested that family characteristics “buffered the
neighbourhood effect of school-readiness more for
toddlers than for older children” (p 631 (7)). The range
of contributing factors, and the degree to which they
may be associated with outcomes in young people,
depends on what exactly is measured and reported.
Children in minority, poorer and less educated families
in at-risk neighbourhoods spend fewer days per week
engaged in activities such as reading, singing and being
taken on family outings (33).
Neighbourhood factors probably become stronger
direct influences on child development around the
time of transition to school (34). In all age groups
investigated, the quality of the home environment is
positively associated with test scores on Peabody
Picture Vocabulary Test (PPVT) (4–5 years: r2 = 0.42,
6–9 years: r2 = 0.53, 10+ years: r2 = 0.43 (34),
compared with 0.29, 0.44, 0.27 respectively, when only
neighbourhood deprivation and age were taken into
account in the model). Family effects generally
overshadow neighbourhood effects in the early years,
and the difference depends on how disadvantage is
measured. Recent research supports these findings
where the child- and family-level characteristics
account for more variance than the neighbourhood
level (33) in the early years. Nonetheless,
neighbourhood factors (safety, cohesion and
crowding) may influence family practices – for
example, children may not be allowed to play in the
neighbourhood park if the area is not deemed to be
safe by the parents, which then reduces the number
of experiences the child is exposed to (7). So the
neighbourhood effects on language development may
be indirect in critical early stages of development.
Various other factors are also likely to be associated
with early delays. For example, a family history of
language delay has been shown to be an important
predictor (21, 22, 25). First-born children experience
an early social and language environment which
is different from that experienced by later-born
children, with greater possibilities for communicative
interaction with an adult (26). Birth order has been
shown to be a risk factor for vocabulary delay in
two-year-old children (22, 25, 29). Results of recent
research with children under two years of age have
suggested that biological trajectories are the primary
drivers of early communication and vocabulary
development (25), and social and environmental
factors have a minimal effect (explaining less than
7% of the variance (30). However, it can be argued
that the environment has an important role to play,
as there are associations between a child’s earliest
experiences and their preparedness for school (19). It
is also important to add that early language delay has
been identified as a feature of the profiles of children
who have been abused, and especially those who have
been neglected in the very early years (31, 32).
Potential mechanisms
Given the number of factors associated with early
language delay, it is worth pausing to reflect on
the mechanisms which result in slow language
development (35). It is one thing to say that such
factors are associated with early delays, but another
to determine the precise nature of such a relationship,
especially for the individual child. Hart and Risley (4)
suggest that early parent–child interaction makes
a difference in relation to how much or how the
parent talks to the child. It may be that reduced
input has a disproportionate effect on the lowest SES
groups – “child-directed talk not only enables faster
learning of new vocabulary – it also sharpens the
processing skills used in real-time interpretation of
familiar words in unfamiliar contexts, with cascading
advantages for subsequent learning” (p 91) (36) – and
this may make them less likely to respond effectively
to intervention. There may be differential effects on
specific aspects of language development: for example,
vocabulary development and semantic development
more generally may be much more sensitive to
environmental input than syntax or what might be
considered to be the heritable and developmentally
driven aspects of language development. There is also
the question of whether there is an underpinning
difficulty with executive function (memory, attention,
etc) which disproportionately affects low-SES children.
Similarly, care has to be taken not to over-interpret
the evidence. For example, if we return to television
watching, there does appear to be evidence that
the more children watch television, the more likely
they are to have poor language skills, but television
watching is not an activity separate from other factors
such as parenting, and the child may be driving some
of these relationships. Likewise, we can assume that
low parental input is related to child performance,
but some children are simply less responsive to
parents, and this may create a reciprocal rather than a
unidirectional relationship. Exploring this relationship,
Gutman and Feinstein (37) concluded that, although
the role played by children in this process was
identifiable, it was much less strong than that from
parent to child, although this idea of bi-directionality
may be more clearly defined in the relationship
between parental input and child behaviour than it is
for language development (38).
One of a number of outstanding questions is whether
composite measures of SES, such as the Index of
Multiple Deprivation (IMD) (39), really account
for the softer social characteristics (parent-child
interaction, enriched social experiences, etc), and is it
sufficient to use such measures to establish whether
the child is at social risk. In a recent phase of the
Avon Longitudinal Study of Parents and Children
(ALSPAC), Roulstone and colleagues asked just this
question, looking at a variety of predictors of language
delay at two years and then school readiness at five
years (40). There was a strong association between
a child’s social background and their readiness
for school as measured by their scores on school
entry assessments covering language, reading, maths
and writing. Children from more disadvantaged
backgrounds perform more poorly than those
from more privileged backgrounds. Children’s
understanding and use of vocabulary and their use
of two- or three-word sentences at two years is
very strongly associated with their performance on
entering primary school. They then looked at features
of the child ‘communication environment’ such as the
number of books available to the child, the frequency
of visits to the library, parents teaching a range of
activities and the number of toys available, which
are all important predictors of the child’s expressive
vocabulary at two years, and found that they all
predicted language performance at this age. The
amount of time television was on in the home was
also a predictor: as this time exposed to TV increased,
so the child’s score at school entry decreased. When
they looked at the relationship between these factors
and language development at two and five years,
they found that these specific environmental factors
were more significant than a composite measure of
disadvantage at two years, and while these features
of the child’s communication environment remained
significant predictors at five years, the effect of a
composite measure had become stronger. At two
years the communication environment was especially
important irrespective of the social background of the
child, a finding that is potentially very important for
early intervention.
In summary, twin studies tell us that, like other aspects
of cognition, language development is more a function
of environmental factors in the very early years, but
that heritability becomes increasingly important with
age. There is clearly a wider range of other factors
that have been shown to be associated with different
rates of language development, the most significant
of which is probably parent–child interaction. But
it is important that any of the models that have
been developed only account for a relatively small
proportion of the variance in the child’s language
skills in any given study, which means that there
must be a number of other factors which have yet
to be accounted for. Care also needs to be taken in
interpreting the direction of the evidence. Limited
parental input may be important, but it may reflect
communication difficulties in the parent as much
as a lack of understanding of how best to promote
language development. There is clearly a great deal
more that we need to find out about how children
come to be language-delayed.
Summaries of prevalence data regarding
the number of children with language delay
have been notoriously difficult to interpret,
because they are so sensitive to the age at
which the question is asked, the way that the
need is identified, and who says whether the
child has a need or not.
The figure that has been most widely cited
throughout the 1990s and the first decade of the
21st century is Tomblin’s (41) 7.4% for children with
specific language impairment, based on a carefully
constructed way of measuring the level of children’s
difficulty across a whole population. Other recent
studies are reported in Appendix 2. With two
exceptions, the most recent studies have not sought
to identify the level of need in the more socially
disadvantaged populations. Locke and colleagues
reported up to 50% in a population of children in
nursery in very disadvantaged areas of Sheffield at
four years of age, all of whom were in the lowest
IMD quintile, a figure which dropped to 30% by five
years (42). Law and colleagues reported similarly
high figures for a population in a school in Edinburgh
where all the children’s postcodes fell within the
lowest quintile (43).
Although taken together these studies give a sense
of the range of prevalence estimates, we are still
left with uncertainty as to the extent to which it is
a phenomenon that affects all but the most socially
disadvantaged equally, or whether there is a social
gradient, ie, those that are most disadvantaged have
scores lower than the next group up, and so on. To
establish this we need to look at large populations
of children at the same age, using the same measure
of language development for all. Fortunately, there
are now a number of representative cohorts which
allow us to do just this. In Figures 2–4 below we see
this relationship in three cohorts in the UK, Scotland
and Victoria, Australia, at five years of age. The first
is the Millennium Cohort Study4 in the UK, using the
Naming Vocabulary Scale of the British Ability Scales;
the second uses the same measure in the Growing Up
in Scotland study,5 which, as the name suggests, relates
only to the population of Scotland. The third is the
Early Language in Victoria Study (ELVS)6 in Melbourne,
Australia, using the core score from the Preschool
Vocabulary Scale. The data were all collected between
2005 and 2010. The measure of social disadvantage
varies across studies. The IMD and the SIMD (Scottish
Index of Multiple Deprivation) differ from one
another and from the SEIFA (Socio-Economic Indexes
for Areas), but the elements within each scale are
similar. In each case the five quintiles for disadvantage
are presented across the bottom of the graph, with
the lowest quintile (the most disadvantaged) on the
left. On the vertical axis of the graph we have the
language level on the measure concerned. The grey
line represents the average score for the test. The
box-and-whisker plots show the median (the line
in the middle of the box), and interquartile range
plus the overall range for each of the social groups.
The pattern of results broadly remains the same.
Three conclusions may be drawn from these data.
The distribution of language scores for each social
group is very wide, and to all extents and purposes
they overlap. This means that many children in the
most disadvantaged groups have perfectly acceptable
language skills. That said, we see a clear social
gradient in each graph: the median for each group
declines with social quintile. These differences tend
to be statistically significant, but the sample sizes are
large. The difference at least for the MCS and ELVS
cohorts appears to be more pronounced at the more
disadvantaged end of the distribution.
BAS naming vocabulary at 5 years (T-score)
Figure 2: Data from England – the Millennium Cohort Study (MCS)7
Lowest IMD quintile
Highest IMD quintile
Figure 3: Data from Scotland – the Growing Up in Scotland Study8
1 – most deprived
5 – least deprived
excludes outside values
Figure 4: Data from Australia – the Early Language in Victoria Study (ELVS)9
ELVS 5YO CELF-P2 Core Score
Although the figures differ, we see a relatively
consistent pattern, especially in the lowest quintile,
where the rates are higher than anticipated (18–23%).
It is interesting to compare the much higher figures
reported above. It is possible that the Sheffield and
Edinburgh populations included relatively extreme
groups within the lowest quintile.
In summary, the answer to this question is that
while there is a clear social gradient to the children’s
language scores, there is considerable overlap in each
quintile. In terms of the proportion of children with
difficulties, the figure is disproportionately elevated in
the lowest social group, although it is not as high as
two recent estimates have suggested.
Table 1: Prevalence of language delay (%) at five years with a threshold
of -1 standard deviation below the mean
Quintile 1
Quintile 2
Quintile 3
Quintile 4
Quintile 5
Millennium Cohort Study
Growing up in Scotland
Early Language in Victoria Study
Finally, in Table 1 we ask to what extent the
prevalence rates vary across social groups. Recall that
these are not referred populations, and we establish
whether a child is or is not described as languagedelayed by their performance on the relevant language
test at five years. Here we use the same threshold in
the three studies – namely, one standard deviation
below the mean for the test. This corresponds to a
prevalence of 16.6% in a ‘normal’ population.
We have seen how early environmental
factors can affect early language development,
but it is also important to see whether
early language delays affect other aspects of
development. One of the most important of
these is ‘school readiness’. School readiness
includes the readiness of the individual child,
the school’s readiness for children, and
the ability of the family and community to
support optimal early child development.
An individual’s school readiness is determined largely
by the environment in which they live and grow (44).
Some children experience marked increases and
decreases in ability in comparison with their peers
in the pre-school years, and it is hard to identify
who will go on to have language impairment (45).
Facilitating smooth transition between home and
school, including cultural sensitivity, and striving
for continuity between early care and education
programmes and later schooling can help ensure a
child’s readiness for school (44). We also need to
be careful to acknowledge that language skills are a
key element in most measures of school readiness
(32), which inevitably increases the likelihood that
early language skills and school readiness will be
related. Nonetheless, there is evidence that language
competence is critical scaffolding for readiness to
learn (46), as well-developed communication and
word skills are fundamental to a good start in the
early years at school (47).
It is well established that learning to read builds
upon oral language skills. Language and phonological
skills are the foundations of literacy development
(48). Children with poor comprehension are often
characterised as having a hidden difficulty because
they decode well and, on the surface, are fluent
readers. It is only when they are asked questions
about what they have read that their difficulties are
revealed (48). This emphasises the importance of
language as a precursor to subsequent literacy and
academic achievement. It is important to foster the
development of oral language skills as a foundation
for literacy development (48).
Adult outcomes
While the links with school readiness and early
literacy are probably unsurprising, one of the key
determinants of the importance of language delay
to society is the long-term sequelae. If children do
genuinely ‘grow out of it’, we might question the value
of providing services. A number of such studies have
attempted to do this, and they broadly fall into two
types: those that have followed up a group of children
who had been in receipt of services because they
had been identified as having developmental language
impairment, and those that have examined a large
cohort of children across time, irrespective of their
service use, but whose early performance was known.
Fortunately, two other large-scale representative
studies following children identified with early delays
have reported adult outcomes for their populations.
The first of these is the Ottawa-Carleton study
in Canada, which has been reported at 5, 12, 19
and, most recently, at 25 years (49). In this case the
children were identified as ‘cases’ if their language
or speech scores fell more than one standard
deviation below the norm for the test. In the most
recent follow-up study, 112 young people’s outcomes
(with this history of speech and language difficulty)
were analysed against a comparable group from
the original sample who did not. The young people
differed significantly on all objective measurements
of communication behaviour. In each case those with
The second study comes from the 1970 British
Cohort Study (BCS70), one of Britain’s richest
research resources, for the study of 17,196 persons
living in Great Britain who were born in one week in
1970, of whom two groups were identified as having
delayed vocabulary development at five years of
age (38). Children in one of the groups also had
other general difficulties. These were compared with
children whose vocabulary was within the expected
range at school entry on three domains at 34 years –
namely, literacy, mental health and employment. Adult
literacy difficulties were predicted by the five-year-old
child being in the group with more general difficulties
(odds ratio (OR) 4.35) and the group with difficulties
specific to language (OR 1.59) after controlling for
demographic and other variables. Adult mental health
difficulties were associated with the child being in the
group with specific language difficulties in all but the
final model, whereas being in the group with the more
general difficulties continued to be strongly associated
with adult mental health, irrespective of what else
was included in the analysis (OR 2.9). Being in either
of the delayed vocabulary development groups was
significantly associated with low employment.
Language delay and the
criminal justice system
One rather special case which has attracted recent
attention is the young offender and prison populations.
According to the Royal College of Speech and
Language Therapists, it is estimated that more than
70% of young people in the justice system have a
communication disability; other research shows that
around 60% of young people in contact with youth
justice services in Scotland have SLCN (50, 51). These
needs have the potential to influence every aspect of
offenders’ experiences of the justice system, making it
more difficult for the individuals concerned to access
rehabilitation services and respond to those services
when they are available and, thus, to break the ‘cycle’.
It has also been reported that 50% of the UK prison
population has literacy difficulties, compared with
17% of the general population, and 35% of offenders
have only basic-level speaking and listening skills (52).
Vulnerable young people with communication
problems may be unable to express themselves
effectively, resulting in disruptive and aggressive
behaviour (53). The high number of young offenders
with speech and language difficulties (54) has serious
implications for the way justice is done and for their
rehabilitation (55). This is particularly important given
that most offending behaviour programmes – such as
Thinking Skills programmes – are structured in such a
way that participation requires high levels of literacy
and oracy (56). There is not much evidence of
interventions taking place within prisons to address
this (57), but research has been cited which found
that offenders gaining oral communication skills
qualifications were 50% less likely to re-offend in the
year after release than the national average.
Children and young people with speech and language
difficulties are particularly at risk of poor outcomes
which are multiple (58). Research indicates that an
inability to interact with others and to access the
curriculum can, in some cases, lead to behavioural
problems in children and young people with SLCN
(59, 60). Children with primary language difficulties
are at higher risk of developing behavioural, emotional
and social difficulties (61). This increases the risk of
their exclusion from school and, in the most extreme
cases, can lead to young people entering the criminal
justice system. Leaving education at the age of 16 and
acquiring ‘not in education, employment or training’
(NEET) status has been linked to later criminal
activity, early parenthood, long-term unemployment,
and substance misuse (62).
In summary, the answer to this question is that
even when a variety of associated social and other
developmental factors is taken into consideration,
language delay at five years is associated with poorer
adult outcomes not just in literacy, which might be
predicted, but also in broader social outcomes such
as mental health and employment. This does not
mean that all children with early language delays are
necessarily likely to have persistent difficulties. But it
does suggest that the risk is much higher for those
who are more socially disadvantaged and if their
language difficulties are reflected in other skills. In
other words, the impact is greater if the difficulties
are not confined to language.
early language difficulties were different from both the
typically developing comparison group and the early
speech delayed group, suggesting that the outcomes
for those with language difficulties are much more
pronounced than for those with early speech
difficulties. The types of occupations differed markedly
across the groups, with the comparison group most
commonly going into sales and retail, and those with
early speech and language difficulties going into trades
and construction.
A number of policy documents have
highlighted the critical role played by child
development in the early years. With the
exception of the Bercow (58) report, these
do not focus specifically on communication
or early language delay, but language is
commonly considered to be a key feature
of these early developmental skills.
The Marmot Review (64), probably the single most
important document on the relationship between
social inequalities and health, highlighted the key role
played by the transition to school and the potential
problems that can arise when children do not have
the pre-requisite skills or ‘school readiness’ to make
this transition satisfactorily. It also observed that
early school difficulties are associated with a variety
of negative outcomes. Those from disadvantaged
backgrounds often struggle with the move to a
more formal approach to learning, and even the best
primary schools find it difficult to cope with an intake
of children who lack ‘school readiness’. The review
proposed the introduction of an indicator of readiness
for school to capture early-years development, on
the basis of information collected at age five from
the Early Years Foundation Stage (EYFS). As we have
seen, school readiness must include communication
skills if children are to have the best possible learning
experience. The role that language delay can play in
accentuating social exclusion was also picked up in a
policy document produced by the charity I CAN (63).
The Centre for Social Justice report Early Intervention:
Good parents, great kids, better citizens emphasises the
importance of the first three years of life (64). The
authors suggest that there are ‘sensitive windows’ in
child development when specific learning takes place,
and if it doesn’t those skills may never fully develop.
The report suggests that the solution was an all-party
approach to tackle the causes underlying social
deprivation, including teenage pregnancy, anti-social
behaviour, low educational attainment, drug and
alcohol abuse and poor parenting. The authors
highlight the importance of early intervention, which
they argue is cheaper, and more effective, than what
they consider the current and more expensive option
of intervention introduced once a child has started
to fail. Their long-term plan for early intervention is
designed to break the intergenerational cycle of
underachievement evident in many inner- and outercity estates by helping all 0–18-year-olds become
good parents, and to optimise impact on the 0–3 age
group, which is where the authors believe positive
nurturing has its greatest impact. The authors
recommend early intervention should start with a
pre-natal package and move on to a post-natal family
nurse partnership. They also recommend use of Sure
Start children’s centres to promote parents’ ability to
play and communicate with their children and aid the
development of language and readiness to learn.
Primary school follow-on programmes should offer
support for parents and focus on the development of
language, literacy, numeracy and social competencies.
Finally, like Marmot, they also recommend ‘school
ready’ assessments and programmes that support
the young people and their parents through to
secondary school.
The Allen Reports (65, 66) took this one stage
further, emphasising the need for early intervention
to promote social and emotional development
and thus significantly improve mental and physical
health, educational attainment and employment
opportunities, and the importance of working
The Field Report (68) also encouraged a focus on
the early years: “We have found overwhelming
evidence that children’s life chances are most heavily
predicated on their development in the first five
years of life” (p 5). It established a set of life chance
indicators to measure how successful the UK is in
making life outcomes more equal for all children.
It identified that language and communication
development at age three is number one in these
indicators. The report also suggested that schools
should teach parenting and life skills throughout
the whole of their children’s school life, in order to
encourage good parenting of future generations and
to help break the poverty cycle.
Given the emphasis placed by the earlier reports on
school readiness, it is important that the approach
to measuring school readiness has also been under
review. The Tickell report (69) reviews the EYFS and
sets out recommendations for improvement to the
framework. The updated EYFS was published in March
2012, for implementation in September 2012, and it
made a number of improvements, including simplifying
the statutory assessment of children’s development at
age five, reducing the number of early learning goals,
and having a stronger emphasis on the three prime
areas which are most essential for children’s healthy
development. These three areas are: communication
and language, physical development, and personal,
social and emotional development.
The current government recognises the need to
address issues associated with social disadvantage, and,
to this end, it has introduced the Pupil Premium (70)
as a mechanism for directing funding to schools with
high levels of social need. The Pupil Premium is part
of an overarching government strategy to improve
support for children, young people and families,
focusing on the most disadvantaged. It takes the form
of additional funding allocated to schools on the basis
of the numbers of children entitled to free school
meals (FSM) and of children who have been looked
after continuously for more than six months. The
expectation is that this additional funding will be used
to support actions which improve the outcomes and
life chances of pupils experiencing disadvantage.
The funding is approximately £600 per pupil in
2012–13, and an increased sum in 2014–15. Schools
are free to decide how they spend the additional
funding, but they are expected to report to parents
and to Ofsted on how they have used the Pupil
Premium. New measures have been included in
performance tables to capture the achievement of
disadvantaged pupils. Ofsted will put questions to
head-teachers in separate meetings concerning the
amount of the school’s Pupil Premium, what it has
been spent on and the impact that this has had.
There is little current information on the use of Pupil
Premium. The expectation is that it will be mostly
directed to educational support for pupils in literacy
and numeracy. However, there is one mention in
the recent Ofsted report on Pupil Premium (71)
of a small amount of funding used to support EYFS
language development (p 29). A consortium led
by TNS BMRB with Newcastle and Manchester
Universities is conducting an independent evaluation
on behalf of the Department for Education and is
due to report in the spring of 2013. Since individual
schools are in very different situations in terms of
the composition of their pupil population, they are
likely to make very different decisions. Moreover,
schools will need to determine their use of Pupil
Premium within the context of their existing forms
of provision for tackling educational disadvantage and
the often complex funding streams through which
that provision is supported. It seems likely, therefore,
that very different patterns of use for the Premium
will emerge in different places.
together effectively to reap the benefits of early
identification (65). The reports highlighted the need
for interventions to help break the intergenerational
cycle of deprivation and listed interventions
considered to give the best value for money in
tackling the problem. One of the gaps in this work is
its failure to identify the role played by communication
or the interventions available to meet this need.
Although the Allen report looks at intervention
in early childhood, it missed the opportunity to
identify cost-effective ways of improving life chances,
increasing social mobility and reducing crime by
enhancing communication skills (67). The second of
Allen’s reports sets out how the government will pay
for the programmes and recommendations made,
such as setting up Early Intervention Foundations to
provide advice and support to local commissioners
on evidence, and building a strong evidence base on
what works in early intervention in the UK (66). He
recommends that some of the investment should
come from outside the public and charitable sectors,
in order to ensure financial sustainability. As far
as we are aware, the question of funding for such
programmes has yet to be resolved.
Policy and health
Although many of the policy-related documents cited
above are education-related, the fact is that many
language-delayed children are initially identified and
managed through the health system. In particular,
they fall within the child health surveillance agenda
through which children are identified by public health
professionals, specifically health visitors, and are often
referred on to speech and language therapists, the
majority of whom work within the National Health
Service (NHS) in the UK. With the prevalence rates
described above and the overwhelming picture
that early development and support are critical for
subsequent attainment, it is tempting to suggest that
the solution is to put in place a systematic programme
of population screening to identify children who
can then be treated or at least provided with the
necessary support to redress the balance in relation
to their peers.
Until the late 1980s this was the preferred option
in the UK, where health visitors screened children’s
development at various points. An evidence-based
report, Health for All Children (72), which became
known as the Hall report, questioned the accuracy
of many of these procedures. This was found to be
true for language delay (73), not so much because
no screens existed (there were 78), but because our
limited understanding of the ‘natural history’ made it
difficult to predict which children would be likely to
have persistent problems (and would thus be most in
need of support). The Hall report (supported in the
international literature (74)) recommended health
surveillance and latterly health promotion as methods
of engaging with parents, but without formally
screening children. This position remained in place
through the 1990s as a specific screening procedure
dropped away.
This has changed somewhat in recent years – the
Healthy Child Programme (HCP) (75), as it is now
called, has made specific suggestions for assessments
that health visitors might wish to use (76), and there
are similar recommendations in the USA (77). In
addition, in the UK we now have (since autumn
2012) a measure to be carried out between 24 and
36 months by those working in early years settings,
as recommended by the Tickell report (69). This is
not a screening procedure as such, but the intention
is to use it to identify children for whom additional
attention, if not additional resources, is needed within
that setting.
The HCP is the NHS’s framework for provision in
the foundation years. It is the early intervention and
prevention public health programme and provides
an invaluable opportunity to identify children at risk
of poor outcomes, in order to provide them with
additional support. It aims to build the HCP team
across general practice and Sure Start children’s
centres, with an increased focus on vulnerable
children and families. Every child has a health and
development review at various stages in their
development, and speech and language is one part
of this assessment. At six months to one year,
health visitors are recommending book sharing and
giving invitations to groups for songs, music and
interactive activities, to promote speech and language
development. Similar groups are recommended at
the two- to two-and-a-half-year review, along with
other relevant signposting to additional support.
Health visitors also encourage early years education
to promote child development. At the two- to
two-and-a-half-year review, Bookstart is also shared
to promote books and shared reading. One of the
aims of HCP is to narrow the gap in educational
achievement between children from low-income and
disadvantaged backgrounds and their peers. Indeed,
this has been the focus of the articulation of the care
pathway for managing families and children in the first
three years of life, which has just been developed:
Health Visiting Programme: Supporting implementation
of the new service model: No. 1: Health visiting and
midwifery partnership – pathway for pregnancy and
early weeks (78).
Policy across the UK
All the parts of the UK with devolved government
(75, 79–81) have addressed the issue of the early
identification of developmental difficulties in general,
and language delays in particular, but they do so
in slightly different ways. They all recognise the
importance of early identification in relation to
later outcomes. All aim to identify difficulties as
early as possible, and health visitors and early-years
practitioners can direct parents to the relevant
additional support, such as Sure Start, or speech and
language therapy, if language is a particular concern.
Wales has a programme (82) which is delivered in
targeted areas to families where particular concern
has been addressed. This enables families to access
parenting programmes, childcare, and enhanced health
visiting, as well as language and play programmes.
The Bercow Report
The above policy-related documents highlight the
policy priority attached to early child development
in general. The Bercow Report (58) addressed
some of the issues related to language delay as
part of a broader category of SLCN. Funded by the
Department for Education, the report was based
on ten months’ extensive gathering and analysis
of evidence, as well as consultation with a wide
range of stakeholders. It made recommendations
to the government about the steps it should take
to transform the provision for, and experiences of,
children and young people with SLCN and their
families. The report emphasised the importance of
early identification and intervention and argued that
joint working by the different professional groups
with a responsibility for children with SLCN is critical.
It also reported a need for a continuum of services
designed around the family. The report set out 40
recommendations to improve services for children
and young people with SLCN, and many of these were
accepted in the response.
This review led to the Better Communication Action
Plan, which recommended setting up the Year of
Communication in 2011 and creating the post of a
Communication Champion to promote change and
improvement, which after two years saw measurable
improvements in language skills of children in the
early years (84). Finally, the review commissioned a
programme of research, the Better Communication
Research Programme (BCRP) (85), which was to
look at how services are delivered for children with
SLCN. The reports from this programme were
published in December 2012.10 The programme was
not intended to address the issue of language delay
and social disadvantage directly, but it did show that
the numbers of children identified with SLCN in
schools have increased, from 0.94% to 1.61%, although
it is noteworthy how far short of the prevalence
figures discussed above this falls. More disadvantaged
children are likely to be labelled as ‘SLCN’. More than
a quarter of those with SLCN were eligible for FSM.
The likelihood of being identified as having SLCN was
2.3 times greater for pupils entitled to FSM and living
in more deprived neighbourhoods (15). Interestingly,
those with statements of educational need as a
result of SLCN are not as socially disadvantaged
as those without statements (19% versus 24%).
Social disadvantage predicts performance on school
measures and change between five and seven years,
early communication skills predicts performance
at Key Stage 1, and children whose attainment is
below the nationally expected level in reading at the
end of KS1 are typically characterised by delayed
development of Communication, Language and
Literacy. But when the programme looked at what
else predicted the rate of change between five
and seven years it found that gender, whether the
children’s mother tongue was English, whether they
received FSM and the extent to which they came
from deprived postcodes were all important. There
was a strong association between deprivation and
attainments at the end of Key Stage 1. The proportion
of children scoring above the national expectation
(at level 3) increased from 42% in the most deprived
homes (deprivation ranks 1 and 2) to 70% in the
least deprived homes. Similarly, 17% of children from
the most disadvantaged backgrounds were failing to
show expected progress in reading, 25% in writing
and 12% in mathematics. The research also showed
that social disadvantage is associated with behaviour
problems, which in turn are associated with SLCN
and particularly autistic spectrum disorders (70).
The All-Party Parliamentary
Group on Speech and Language
This is similar to the provision in the other parts of
the UK but targets families with particular needs.
In Scotland, the Early Years Collaborative (81) aims
to improve child and maternal mental health and
reduce the percentage of children (at 24 months)
with difficulties in early language and communication,
by recording and addressing needs at the 24- to
30-month review.
The policy environment has also been expanded
by the role of the All-Party Parliamentary Group
on Speech and Language, in the UK parliament,
which in early 2012 opted to focus its energies on
a consultation regarding the relationship between
SLCN and social disadvantage. The group undertook
this consultation under the chairmanship of Lord
Ramsbotham over the summer of 2012, and its
report (86) was launched in the House of Commons
on 27 February 2013. It is to be hoped this will
be discussed along with the findings of the BCRP
in parliament.
Campaigning and the role of
the independent sector
Underpinning the recognition of the importance of
early communication skills is the need to ensure that
the messages, widely acknowledged by practitioners
for many years, reach a wider audience. The Bercow
Report acted as a catalyst for two campaigns related
to communication. The first, the Hello campaign (87),
was co-ordinated by the umbrella body for voluntary
sector organisations with a specific interest in
communication skills, the Communication Trust.
The Communication Trust also hosted the national
year of communication, 2011. Hello produced and
distributed a large range of resources to improve the
communication skills of children, and many of these
are still available online for people working with
children. Hello supported three strategic projects to
test ways of supporting children, young people and
their families, which would continue past the year of
communication (88). The Communication Trust has
set out a five-year strategy to “ensure that every child
and young person is enabled to communicate to the
very best of their ability” (89). The second campaign,
Giving Voice, was co-ordinated by the Royal College
of Speech and Language Therapists, the professional
organisation representing speech and language
therapists in the UK. Giving Voice aims to raise
awareness and demonstrate the effectiveness of the
SLT profession specifically, and is an ongoing campaign.
Speech and language therapists provide training to the
wider workforce as an integral part of their role, as
outcomes for children are improved when the whole
workforce can contribute to care pathways (90); they
also work with the wider workforce, contributing
to the public health agenda by promoting health
and wellbeing.
In summary, there are already a great many
convergent policy recommendations suggesting that
the focus on early child development and language
in particular is an important societal priority. This
clearly raises awareness of the issues, but it does not
necessarily lead to an improvement in the evidence
base or to a focusing of resources to address the
issues concerned. Indeed, the rolling back of Sure
Start facilities demonstrates the effect that financial
stringency, which is currently such a feature at local
government level, can have on such services. Policy is a
necessary but not a sufficient condition for developing
services for young children with developmental needs.
We need the growth of evidence-based interventions
to meet the needs of these children. And in particular
we need to evaluate interventions and demonstrate
improved outcomes, especially for those from more
socially disadvantaged backgrounds.
Considerable attention has already been
paid to developing, evaluating and providing
interventions for very young children. Most
of these interventions focus on fostering the
child’s emotional wellbeing and resilience.
They rarely focus on the child’s language
skills, although there is no reason why this
could not be the case, given the relationship
between (a) the parents’ engagement with the
child and their early language development
and (b) the importance of early language as a
bridge to school readiness.
Nevertheless, since some of these interventions
have been evaluated and are used locally in the UK,
we highlight below some of the more signficant
ones which have already been evaluated or for
which formal evaluations are currently underway. It
is important to note that this is not intended to be
comprehensive; the reader is referred to Allen (65)
for the most up-to-date list.
Sure Start
In the UK we have seen the Sure Start programme
develop in England over the last decade. The
programme was supported by a number of
key principles:
• To co-ordinate, streamline and add value to
existing services for young children and their
families in local communities.
• To involve parents.
• To avoid stigma.
• To ensure lasting support.
• To be sensitive to local families’ needs.
• To promote the participation of all local families.
Sure Start also, however, focused on early language
development and on specifically recognised
interventions that are aimed at compensating for the
developmental and educational impact of poverty (91).
Such recognition is made explicit in the measurement
of language skills in evaluations of Sure Start. Sure
Start was a government-led initiative aimed at
giving every child the best possible start in life, by
offering a broad range of services focusing on family
health, early years care and education and improved
wellbeing programmes for children aged four and
under (although the age range was subsequently
extended). The Sure Start programme was formally
evaluated, although without the use of a randomised
controlled methodology. Relatively few differences
were found between children who received the
Sure Start intervention and those in comparable
areas that did not (92). Concern was raised about
the lack of a consistent curriculum, the fact that
the different elements of the intervention had not
been previously evaluated under optimal conditions,
and the lack of differentiation between the groups
served. Some populations within Sure Start areas may
be in need of different levels of help. Interestingly,
there was a strong language focus in many Sure Start
Local Programmes (SSLPs), and the language skills of
children in programmes in England were audited on
three occasions (93).
Family Nurse Partnership
The Family Nurse Partnership (FNP) (94, 95) is a
preventative programme which offers intensive and
structured home visiting for young first-time mothers
and is delivered by specially trained nurses (family
nurses). It has been tested in England since 2007, with
more than 6,000 families having been involved so far. It
is currently being tested in Scotland in NHS Lothian.
The home visits take place from early pregnancy until
the child is two years old, with 22 visits taking place
in toddlerhood (fortnightly for nine months when
the child is aged 12–21 months, and monthly until the
child is two) (96). The FNP is often delivered through
Sure Start Children’s Centres, and family nurses
encourage clients to use these services, particularly
in preparation for when the children reach the end
of the programme, aged two. Randomised control
trials (RCTs) are being carried out in 18 locations in
England to assess whether the FNP benefits families
over and above universal services and provides
good value for money (the results of the RCTs are
due to be reported in 2013). A report from the
Audit Commission (97) states that the FNP has
a positive impact on some aspects of early years
support (eg, improvements in smoking cessation
and breastfeeding prevalence). This report states
that a 2009 evaluation showed that issues with the
programme still remained, such as the fact that 14%
of the women involved dropped out during pregnancy,
difficulty in the sustainability of the pilots and ongoing
service, a need for better integration into children’s
centres, and the fact that the FNP is targeted at
a specific population group (first-time parents
under 20). The Audit Commission also reports
that health outcomes for under-fives on the whole
changed only marginally between 1999 and 2008.
In a recent report (65), Allen examined the quality
of evidence on a number of early interventions and
their cost-effectiveness. The FNP was one of these
interventions and was reported to meet many of the
criteria he was looking for. He also reported that the
benefit-to-cost ratio ranges from 3:1 to 5:1 (based on
data in the USA). No specific language outcomes are
reported for the FNP.
Positive Parenting Programme
(Triple P)
Triple P is a multi-level behavioural family intervention
delivered on a whole-population basis with additional
use on a targeted level. A large amount of research
has been carried out to assess the effectiveness of
Triple P, and a recent systematic review and metaanalysis has looked at this in more detail (98). Results
from the review suggest that a group-based Triple P
intervention may be effective in the short term
(according to parental reports of child behaviour),
but given the high risk of bias in parental reporting,
studies do provide evidence to support the view
that Triple P provides other benefits to children.
For maternally reported outcomes the summary
effect size was a moderate 0.61 (95% CI 0.42, 0.79).
Paternally reported outcomes following Triple
P intervention were smaller and did not differ
significantly from the control condition (effect size
0.42 [95% CI –0.02, 0.87]). The review suggests that
there is a lack of convincing evidence to support the
cost-effectiveness of Triple P, but that some benefit
may be achieved if interventions are focused on
the families of children with more severe problems.
Allen (65) reports that Triple P had an overall score
of ‘good enough’ when he applied the evidence
criteria (it met 16 out of 22), and that clinical changes
have been noted in behaviour. No specific language
outcomes are reported for Triple P.
Mellow Babies
Mellow Babies (99) is a specialised version of Mellow
Parenting and has been developed for parents and
vulnerable babies under one year. The programme
incorporates adult mental health, childcare skills, child
protection, and activities suitable for parents and
babies. The Mellow Babies programme has undergone
a randomised waiting list controlled trial with
clinically and statistically significant effects on maternal
depression and mother–child interaction (100).
The trial reports statistically significant differences
in positive interactions between the intervention
and control group (p=0.015). No specific language
outcomes are reported for Mellow Babies.
Other relevant interventions
With the exception of Sure Start these interventions
do not include the explicit promotion of language
skills. Yet they all foster parent-child interaction
skills, which, as we have seen above, are often closely
associated with the development of early language.
There are also examples of targeted interventions
that have a primary focus on interaction. One such
approach is Video Interaction Guidance (VIG) (101),
an intervention that usually involves a client and a
practitioner (ie, a parent and an SLT, or a teacher
and an educational psychologist) reviewing short
clips of successful interaction in order to achieve
goals to do with communication, interaction,
relationship or attunement. It is an intervention that
Language interventions
Bookstart has been widely used and was supported by
many staff groups, including early-years librarians and
health visitors, although in some cases the latter had
insufficient time to model the optimal use of books
with very young children. Some SSLPs were aware of
the importance of developing rhyme awareness but
there was much less evidence of other pre-literacy
work. In some SSLPs there was close collaboration
between early-year’s library workers and SLTs. Many
parents were grateful for the advice and information
offered by the early-years librarians, and those who
had rarely used libraries before found their support
helpful and encouraging. In some SSLPs, SLT support
for Ready for Nursery Groups had focused on a
speech, language and literacy link between schools
and Sure Start programmes. There were variations
in the ease with which different agencies could
collaborate and focus on speech, language and literacy
development or give priority to speech, language and
literacy practice in their communication with parents.
Evidence from a number of well-designed intervention
studies focusing on speech and language skills has
shown a variety of interventions to be effective
for children with primary speech and language
difficulties (106), but these studies rarely focus on
children from disadvantaged backgrounds. However,
a recent meta-analysis of the effects of vocabulary
intervention on young children’s word learning
showed not only that this skill was very responsive
to intervention but also that the effects were greater
for more advantaged rather than for less advantaged
children (107). In the light of Hart and Risley’s findings
about the marked differences in vocabulary across
social groups before children go to school, one might
have hoped that this would have gone the other way.
So although both more and less advantaged children
benefit, there is little sense that the less advantaged
groups catch up in any meaningful way, although it is
important to point out that the intensity and duration
of the interventions described were relatively
limited, and this may be an important issue as far as
intervention for low-SES children is concerned.
In view of the need to identify interventions which
have been developed for very young children
with language delay, it is important to flag up the
experience of the Ward Infant Language Screening
Test, Assessment, Acceleration and Remediation
(WILSTAAR) (108). WILSTAAR was designed
to provide a tool for the early identification and
treatment of children at risk of developing language
and cognitive difficulties. It is a structured reactive
programme used to promote the language skills of
children who have been identified as ‘at risk’. The
WILSTAAR screening assessment was administered
at eight to ten months of age to assess whether
the infant is showing age-appropriate, pre-linguistic
listening and babbling behaviours (109). Following the
screening assessment, research has filmed interactions
between parents and their infant to observe the social
interaction and play in this situation (110). Children
deemed to be ‘at risk’ following the screening test
were indeed found to have less focused attention,
with lower levels of communication between mother
and child (109). Children were then provided with
intervention by a team of SLTs in their home with
their parents. The intervention was trialled, but the
results were somewhat inconclusive (111–113).
Interventions in the BCRP
Current best practice in terms of children with
delayed language development (114) was reviewed
as part of the BCRP (85), mentioned on page 15.
This report brought together the experience of
practitioners with the best available intervention
evidence. It identified 58 interventions either
currently in use or published in the research
literature. It also identified two other interventions
which it called ‘Up and coming’ because they were
under development and there was insufficient
evidence to judge their value. Of those identified,
three (5%) were found to have a strong level of
evidence, 32 (56%) had moderate evidence and
22 (39%) had indicative evidence. Seventeen (30%)
of the interventions were specifically relevant for
improving a child’s speech, 22 (39%) targeted language,
and the remainder were aimed at a combination of
speech, language, communication, and complex needs.
Five were Universal or Tier 1 interventions, 13 were
has demonstrated impact in improving mother–
child relationships and is recommended in National
Institute for Health and Clinical Excellence (NICE)
guidelines on social and emotional wellbeing in the
early years (102). There is convincing, good-quality
experimental evidence of the value of VIG (103), and
there are meta-analyses (104, 105) looking at effects
of VIG-related interventions on the relationship
between infants and care givers, although it has not
yet been shown to improve language skills.
Targeted or Tier 2, and 16 were specialist or Tier 3
interventions. The remainder were considered likely
to be used across waves, adapted to meet the needs
of individual children. The report concluded that there
was a sound emerging evidence base with relative
strengths in some areas. It said there have been too
few large-scale intervention studies to draw firm
conclusions about how services should be delivered,
but there was plenty of positive evidence about
individual techniques. Nevertheless, it identified
two specific interventions which showed promise,
and a third, ‘Talk of the Town’, where some of the
better evaluated elements of interventions had been
woven together into a programme in response to
demands from head-teachers in one specific locality
in northern England.
The Grasping the Nettle report (52) summarised a
range of evidence for early-years intervention. It
outlined some examples of effective local practice.
For example, the charity ICAN’s programme ‘Early
Talk’ has been used in Kent as a targeted, multi-agency
approach to supporting young children with severe
SLCN so that they could participate in everyday
activities and attend their local primary school.
The programme was delivered to 37 children at a
project cost of £46,300, indicating a social return
on investment of £1.37 for every £1 invested. The
main findings of Grasping the Nettle are that early
intervention clearly works when it is appropriate
and applied well. It identified a clear need for more
research into the effectiveness and the relative
cost-effectiveness of early intervention strategies.
Recent research has begun to explore the possibility
that the effects of neighbourhood disadvantage are
multigenerational (115), with a family’s exposure
to neighbourhood poverty over two consecutive
generations reducing the average child’s cognitive
ability by more than half a standard deviation
(SD .61), and potentially influencing developmental
trajectories (115).
Talking Time (116–118)
Talking Time is an interactive oral language
intervention package designed to support language
and to foster communication with and between
pre-school children. The programme aims to develop
children’s language before they reach primary school,
so that they are at a level where they can make the
best use of language for learning and socialising when
they start school. Talking Time supports the goals of
the English foundation stage curriculum by providing
opportunities for children to communicate their
thoughts, ideas and feelings and to share stories and
experiences. It targets three key language skills –
namely, vocabulary development, the ability to make
inferences and the ability to recount a narrative
(eg, describe a recent event or retell a simple story).
An evaluation of the programme in nursery schools
demonstrated that it was effective in improving oral
language skills when children exposed to Talking
Time were compared with those exposed to an
alternative intervention (117, 118). Children in the
Talking Time intervention made significantly more
progress than children in the alternative intervention
in terms of both their understanding and use of
vocabulary; they understood and produced more
words than the comparison children did. Talking Time
also improved children’s development of expressive
language, with significantly more progress in the
Talking Time children’s ability to repeat increasingly
complex sentences, and to say longer sentences when
they were talking. Thus, there was evidence that the
building blocks of narrative skill were beginning to be
put in place, although the children’s oral language skills
remained a cause for concern.
The Nuffield Early Language
Intervention Programme (119)
A recent research study (120) aimed to test the
efficacy of language intervention in the early years and
found that a 30-week intervention produced gains
in reading comprehension mediated by gains in oral
language. The 30-week intervention was delivered by
teaching assistants, and the oral language programme
aimed to improve children’s vocabulary, develop
narrative skills, encourage active listening and build
confidence in independent speaking. The intervention
appeared to be good at teaching vocabulary in weeks
11–30 (effect sizes 0.83–1.18) and letter-sound
knowledge in weeks 21–30 (effect size 0.41). At a
six-month follow-up, the intervention group showed
higher scores in reading comprehension than the
control group. This research has been the driving
force behind the Nuffield Early Language Intervention
Programme (119), which spans the pre-school and
reception class age range.
Talk of the Town (TOTT) (see case study below) was
set up following discussion with senior educational
leaders in a specific area in the UK, who were keen
to take a strategic, sustainable view of what could be
done to improve the language skills of the children
in their area, with a long-term view of this issue
and emphasis on its sustainability. In Figure 5 we
provide an approach to conceptualising TOTT. For
sustainability, all elements of the programme need to
be included. Each element of the programme is tied to
specific elements of the evaluation literature. Key to
this programme, and unlike many of the interventions
that have been carried out with regard to language
development particularly, is the conceptualisation of
the programme at population and neighbourhood
level and its inclusion of workforce development as an
intrinsic element of the programme.
The role of teachers
While it is possible to provide children with specific
interventions such as the type covered in the BCRP
review or the VIG model described above, in the
end it is clearly the practice of teachers themselves
which is key to what happens in the classroom.
Where teachers are concerned that a child’s language
development is below what is ‘normal’ for the year
group, this could result in the child being placed at
‘School action’ on the Special Educational Needs
(SEN) Code of Practice or possibly at ‘School action
plus’. The latter of these would require some external
agency’s involvement such as speech and language
therapy, language support services or educational
psychology. It is important to acknowledge that
language delay per se is not specifically identified
as a priority area within SEN and that the needs of
children with delayed language would be addressed
under general policy related to children with Special
Educational Needs and Disability (SEND). A number
of reports published over the last decade have sought
to improve the education of children with SEND
and to promote inclusion (130, 122, 123), which may
affect teacher education and the development of the
profession, the availability of appropriate resources,
the inspection framework and the school curriculum.
However, the standards most relevant to meeting
the needs of children with delayed language are
standards three and five. Standard three requires that
teachers “demonstrate good subject and curriculum
knowledge” and “demonstrate an understanding of
and take responsibility for promoting high levels of
literacy, articulacy and the correct use of standard
English”. It is teaching standard five (“adapt teaching
to respond to the strengths and needs of all pupils”)
which most fully allows teachers to demonstrate how
children with language delay are taught. The standard
stipulates that teachers
“demonstrate an awareness of the physical, social and
intellectual development of children, and know how to
adapt teaching to support pupils’ education at different
stages of development; have a clear understanding
of the needs of all pupils, including those with special
educational needs… and be able to use and evaluate
distinctive teaching approaches to engage and
support them”.
Practising teachers will be subject to the revised
Ofsted framework for school inspection (124), which
includes new judgements on “how well teaching
enables pupils to develop skills in reading, writing,
communication and mathematics” (p 15) and “how
well pupils develop a range of skills, including reading,
writing, communication and mathematical skills, and
how well they apply these across the curriculum”
(p 14). The inspection framework also ensures a focus
on different groups of pupils, including those with
SEND, and reports “how well gaps are narrowing
between different groups of pupils in the school
and compared to all pupils nationally” (p 14). This
emphasis ensures that teachers will be required to
make appropriate provision for all pupils with SEN
to make enhanced progress. There is also a focus in
inspection on the progress of the lowest-attaining
20% of pupils in each school. New measures in the
performance tables will provide information on the
progress of disadvantaged pupils and the lowestattaining 20% of pupils.
Talk of the Town (TOTT) (121)
Within education there is ongoing pressure to adhere
to the standards agenda – ie, where concerns are
expressed about current standards most references
are made to maths and literacy. Within literacy,
reading has been identified as an issue summarised by
a deficit model of all that needs to change concerning
the reading skills, attitudes and habits of pupils in
England. The emphasis on reading is important for
children with language delay, as evidenced in the
Cambridge Primary Review’s statement that “language
development, along with perceptual and spatial
development, underpins children’s progress in
reading” (125). Robin Alexander, the key editor
of the report, also proposed that each primary
school should have an oracy expert who would
be responsible for the development of teachers’
classroom interaction skills and pupils’ oracy, affording
both a high priority. The review of the National
Curriculum for England (due for completion in 2014)
may have an impact on children who are languagedelayed, as it reiterates that speech and language
should play a key role across the curriculum (126).
A recent publication (127) from the Communication
Trust outlines the importance of giving speech,
language and communication a central role in
policy and practice in schools, and aims to bring
together evidence to substantiate this. It highlights
the gap between national policy and local practice
and outlines the Communication Commitment
resource, which will provide schools with a userfriendly route to develop a whole-school approach
to communication. The document highlights concerns
about the number of children in schools with
unidentified SLCN and about the fact that Talk of the
Town (121) has identified more children with SLCN.
CASE STUDY: TALK of the TOWN (121)
The principles
TOTT is supported by a series of guiding principles:
• A focus on prevention and early identification (at
whatever phase).
• Service co-ordination (shared vision) and
strategic long-term planning.
• Evidence-based models, approaches and
interventions are used wherever possible.
• Embedded strategies, building on current practice
and provision, are fundamental and would include:
– a communication-supportive environment
– appropriate and timely interventions at all
three tiers.
• Tracking, monitoring, evaluation.
• Planning and implementation of systematic
workforce development.
• Inclusion and partnership with parents, children
and families.
• Use of ‘Talking Time’ nursery intervention (117).
• Teaching children to listen (132).
At a targeted (Tier 2) level
A range of evidence-based interventions have been
put into place to support the large numbers of
children with language delay, for example:
• A narrative intervention by Becky Shanks.
• Talk Boost (134): a ten-week wave 2
intervention to support the speech, language and
communication skills of children aged between
four and seven years with delayed language.
• Focused stimulation techniques (135).
• Comprehension monitoring approaches within
mainstream classrooms (136). Elements of
colourful semantics programme (137) and shape
coding (138). Language for thinking for children
in key stage 2 (139).
• I CAN secondary talk (140).
Provision and interventions
A range of interventions have been implemented,
where possible, all with a solid evidence base – for
• Across all levels, use of a range of visual
approaches (128) (see intervention No. 54 below).
At a universal (Tier 1) level
• Elements of ‘Thinking Together’ at the universal
level (129).
• Audit of practice using the BCRP
Communication Supporting Classrooms
Observation Tool with guidance on developing
best practice (130). Use of Living Language/
Teaching Talking vocabulary approaches (131).
At a specialist (Tier 3) level
• A speech and language therapist supports the
programme at all levels and provides some
support for children at the specialist level, in
collaboration with the local speech and language
therapy team.
• Makaton training for staff to use with pupils
with SLCN (141).
• A psycholinguistic framework to support
phonological awareness (142).
• Support and interventions from relevant
Overcoming early language delay is the province
of a wide range of professionals working with the
parents at home and with the children in early-years
settings and schools. As indicated earlier, language
delays are linked to many other aspects of a child’s
profile and, with the possible exception of the SLT, no
one professional specialises in language on its own.
The key is that all those working with young children
need to be aware of these issues and prioritise the
development of the child’s language skills, something
to which everyone should contribute. While there
may be value in assessing the children individually
at certain points in their development, most of the
work with language-delayed children will take place
in groups and in early years centres, mirroring their
natural environment. This issue of collaborative
working has been picked out by virtually all the above
reports aiming to promote early child development.
Teachers, educational psychologists, health visitors
and SLTs need to work closely together with
common aims. In practice this tends to happen where
considerable energy has been devoted to building
teams of the professionals concerned.
Costing services for children
with language delay
Much has been made of the claims in Nobel laureate
economist James Heckman’s statement drawn from
his work on prospective data from Head Start and
other early intervention evaluations (143):
The highest rate of return in early childhood
development comes from investing as early as
possible, from birth through age five, in disadvantaged
families. Starting at age three or four is too little too
late, as it fails to recognize that skills beget skills in
a complementary and dynamic way. Efforts should
focus on the first years for the greatest efficiency
and effectiveness. The best investment is in quality
early childhood development from birth to five for
disadvantaged children and their families.11
The potential for interventions to promote early
language skills is rather less clear, primarily because
so few studies have specifically addressed this
issue (144). A recent study looking at the longer-term
costs and benefits of enhanced speech and language
therapy (145, 146) suggests that certain interventions
could deliver six-fold in terms of lifetime savings.
Such studies are often based on models in which
data from a number of studies are fitted together
to identify future impacts. In the absence of goodquality comparative research evidence, assumptions
are sometimes used for some parameters. The lower
the availability of good-quality comparative evidence
for these models, the less sure one can be that the
savings or monetary benefits identified by the model
will actually appear.
In summary, much is known about what constitutes
good practice for promoting child development in
schools and nurseries, and much has been done to
change practice over recent years, although we know
less about how well such interventions are distributed
over the UK. The best evaluated early interventions
which have been used in community settings show
promise but rarely include language development
as an outcome. There is a case for addressing this.
Language interventions have often been developed for
‘clinical or referred’ populations, and there is relatively
little evidence for their use in more disadvantaged
populations. By the time children reach school age,
programmes may be less important in the classroom,
and the training and support of teachers to encourage
them to specifically work on enhancing the more
vulnerable children’s language development becomes
a critical issue. Language development has, as we
have seen, received increased prominence in recent
years, but the body of evidence available to make
judgements about what interventions to roll out
remains relatively weak. While many interventions
have been shown to ‘work’ at some level, the fact
remains that interventions need to accelerate
language development, not just improve it, if the
intervention is to genuinely narrow the achievement
gap (107). Again, we know too little about the costs in
relation to the benefits of most of the interventions
currently in use to be clear about what provides the
best buy as far as public investment is concerned.
Professional roles and
collaborative working
6 next steps
• After 40 years of research, a great deal is known
about what needs to be done for children who
experience early language delays.
• Much of what can be done to promote children’s
early skills is not exclusive to language, but a focus
on language, given its importance to modern
society in terms of school achievement and
employability, is important for any intervention
• There is a need to make sure that all professionals
are aware of what is needed and that their input
is monitored through the most appropriate means
• Parents, teachers and specialists need to be actively
involved in subsequent developments.
• The picture is muddied by the fact that many
children who are late talkers go on to have
reasonable language skills. We need to know more
about the developmental paths that children follow
and what it is about some children that makes
them more resilient than others. Nevertheless, it
is clear that there is a risk of later difficulties, for
which society needs to take a responsibility.
• In the current economic climate, services will
only develop if they are underpinned by a strong
evidence base. Any steps to develop interventions
need to be supported by effectiveness research
built into the design of the intervention, not bolted
on after the intervention has been started, as is
too often the case in government policy.
• It is relevant to develop interventions at any age.
But given the genetic evidence and the evidence
about the role of specific environmental features
that make a difference to language development
in the first three years of life, there is a strong
case for developing and robustly evaluating
interventions targeting early language before the
age of three years.
• One of the features of such an intervention
should be the involvement of different agencies
and professional groups with an interest in these
children. There is a potentially strong role for the
charitable sector to take a lead in catalysing this
type of activity.
• The evidence base is developing, especially in
the light of the recent Better Communication
Research Programme. The priority is more and
better evaluation of promising interventions (both
universal and targeted) which can be delivered in a
sustainable manner.
• There is much to be learned from the Sure
Start experience in terms of both the specifics
of the interventions and the way in which the
interventions were evaluated.
• While clinic- and school-based interventions
are important, the role of the family and
neighbourhood are central to developing
interventions for young children.
Early communication skills have implications
for the child’s social and educational
development across the early years. There is
evidence that language competence is critical
scaffolding for readiness to learn, as welldeveloped communication and word skills are
fundamental to a good start in the early years
at school. Children with primary language
difficulties are at higher risk of developing
behavioural, emotional and social difficulties.
This increases the risk of their exclusion from
school and, in the most extreme cases, can
lead to young people entering the criminal
justice system. Communication, therefore,
plays a key role in fostering life chances in
early childhood.
This report draws on evidence which suggests
that environmental influences, particularly human
relationships and interactions, play a strong role in the
early years, and that this is especially true of verbal
comprehension, or the child’s ability to understand
what is said to them. There is strong evidence that
the extent to which the child is spoken to and the
way in which they are spoken to makes a difference,
alongside related factors such as the type of positive
language learning experiences to which the child is
exposed. This starts at birth and includes immediate
and extended family and the wider community around
the child.
Studies of whole populations reveal a clear social
gradient for language, with children from the most
disadvantaged groups having lower language skills than
those in the least disadvantaged groups. However,
there is clearly a great deal more that we need to find
out about how children come to be language-delayed.
A number of early intervention programmes have
been developed and evaluated, but they are not
necessarily widely available, particularly interventions
which specifically tackle both social disadvantage
and language development as an outcome. There is
therefore a need to scale up and roll out interventions
that have been shown to work, and to test their value
over time across whole populations. Any programme
that is developed should be supported by effectiveness
research built into the design of the intervention and
should emphasise the whole child, their family and
their community and be focused on the early years.
There are already a great many convergent policy
recommendations suggesting that the focus on
early child development and language in particular
is an important societal priority. The time is right,
therefore, to sustain pressure on policy-makers and
commissioners to direct resources towards effective
practice and to improve services to meet the needs
of children from more socially deprived backgrounds
– who are at a greater risk of having limited skills
in language and communication. We know what can
make the most difference to enabling young children
to learn and develop to their full potential. We have a
joint responsibility to work together more effectively
than ever before to ensure that all children have a fair
chance of succeeding at school and in life.
Appendix 1: Measuring
social disadvantage
Social disadvantage (or more recently ‘socio-economic
position’) is defined in a number of ways. One of the
most commonly used composite measures is the
Index of Multiple Deprivation (IMD), constructed by
the Social Disadvantage Research Centre, University
of Oxford (UK Department of Communities
and Local Government, 2011) http://webarchive.
deprivation07/. The IMD consists of seven separate
“deprivation domains”, of which one (Health
deprivation and disability) was excluded, since this
study aims to examine the effect of “social factors”
on (child) health. The remaining six deprivation indices
comprise the range of factors to be considered in
this review as the “social factors” in which a child
grows up/develops: (1) parental income, (2) parental
employment, (3) parental education, skills and training,
(4) access/barriers to housing and services, (5) crime,
(6) the living environment.
It is important to note that the application of these
terms varies across the UK. For example, there is
a separate Scottish Index of Multiple Deprivation.
In practice, studies employ different techniques
according to their different objectives. The most
common consistent measure used is parental, or
more specifically maternal, education. This is especially
relevant for early language development because it
operates as a proxy for parent–child interaction. A
current review of the relationship between social
factors and child development has laid out the
different techniques that have been used in cohorts
across 31 countries in Europe (149).
In a report to the Centre for Research on the Wider
Benefits of Learning, which draws on data from the
Avon Longitudinal Study of Parents and children,
Gutman, Feinstein and colleagues (37) concluded
that “Maternal education had a particularly marked
effect on the relationship between parenting
behaviour and child development. In general the effect
of parenting was stronger (i.e., more positive) for
children of mothers with low levels of education.”
p 7 (37). It may be useful to use more ‘distal’ measures
such as SES or IMD, which combine a wide range of
information. Some of these can only tangentially be
seen as related to language development, such as car
ownership, others are more ‘proximal’ to the child,
such as provision of communication opportunities
or book reading, which may stand on their own or
be seen as more naturally associated with parental
education levels.
5–12 years
mean 107.2
median 3;06
Horwitz et al
(2003) (150)
Law, McBean
& Rush (2011)
Locke et al
(2002) (42)
All the nurseries
were in areas
of social and
18 and 30
Henrichs et al
(2011) (23)
240 children
recruited on
entering four
138 children
30 m: 3,759
18 m: 5,289
Language delay
Language delay
language delay
Early expressive
British Abilities Scales II
WASI; SDQ (teacher
Parenting stress
index – short form;
ITSEA; Social-Emotional
competence domain;
Measured by the
proportion of children
receiving free school
96.9% of children in
this region are in 1st
quintile of SIMD
Severe LD 2SD below
Moderate-Severe LD
1.5–2SD below norm
Moderate LD 1–1.5SD
below norm
Severe LD 2SD below
continued overleaf
Total – 55.6%
Expressive – 48.3%
Receptive – 49.3%
10% severe language
Moderate-Severe LD
1.5–2SD below mean
SES and maternal
education effects at
24 months
39% any language
18% (30–35 months)
15% (24–29 months)
12.5% (18–23 months)
Persistent early
vocabulary delay –
Moderate LD 1–1.5SD
below mean
Children with
productive vocabulary
scores in the lowest
10% for their age
and sex group were
considered to have
delayed productive
Parents answered
questions on their
MCDI – short
form (parent
reported productive
Late onset vocabulary
delay – 6%
Large diverse
population study –
PARCA – non-verbal
Score <10th
Parental education,
family income
CDI-N receptive and
expressive vocabulary
Measure of SES
Prevalence in
prevalence low SES
Appendix 2: Most recent prevalence data summarised
*Low language
4 years
24 months
Reilly et al
(2010) (151)
Zubrick et al
Late Language
*SLI (for analysis
– excluded if
≤86 on KBIT2,
from nonEnglish-speaking
diagnosis of ASD
or permanent
hearing problem
Late talkers
24 months
Reilly et al
(2007) (22)
– family characteristics
– 42-item DASS
– Parenting scale
– Maternal
Matrices subtest
of Kaufman Brief
Intelligence Test
4 years: CELF-P2
(receptive and
2 years: Words and
sentences version of
MacArthur-Bates CDI
MacArthur Bates CDI
– SEIFA disadvantage
SEIFA disadvantage
Maternal Education
SEIFA disadvantage
– Maternal
characteristics (age,
educational level,
CELF-P2 composite
score >1.25 SDs
below the mean
(receptive or
Late talkers if scores
<10th percentile
<10th centile for
vocabulary production
1SD below the mean
on LDS
19.7% classified as
Late Talkers
13.4% classified as late
language emergence
17.2% met criterion
for SLI ≥1 of receptive
and expressive
20.6% low language
results for ≥ 1
of receptive and
expressive composite
Measure of SES
Prevalence in
prevalence low SES
appendix 2 continued
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Address for correspondence: Professor James Law, School of Education,
Communication and Language Sciences, Victoria Road, Newcastle
University, Newcastle-upon-Tyne NE1 7RU, UK.
E: [email protected]
A wide variety of terms is used to describe the skills of children who
are slow to start speaking. Language delay is probably the most common
term for young children, but we also hear the term ‘late talker’ being used.
If difficulties persist, the terms ‘language impairment’, ‘specific language
impairment’ or ‘language disorder’ are used. A distinction is sometimes
drawn between language delay and speech delay or even communication
delay, although not always clearly. Most recently the term ‘Speech, Language
and Communication Needs’ (SLCN) has been adopted after the Bercow
Report, to describe the whole range of children whose communication
skills are affected across childhood.
With thanks to Tom King, statistician, School of Education,
Communication and Language Sciences, Newcastle University, UK.
With thanks to Paul Bradshaw from Scotcen, Edinburgh, UK.
With thanks to Professor Sheena Reilly and Dr Eileen Cini, Murdoch
Children’s Research Institute, Melbourne, Victoria, Australia.
COVER Photo: anna kari/save the children
A child’s first few years are when their communications
skills develop. It’s a time for first words and sentences,
and when children begin to express feelings and
understand the world around them.
However some children’s language skills develop
more slowly than others, and while some catch up,
others may experience difficulties learning to read or
contributing in the classroom – it can even impact
their long-term futures.
This report highlights the importance of addressing
‘language delays’ in the early years and rolling out
effective interventions to help more children reach
their full potential.
cover photo: hildren