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The best indication to determine the local prevalence of children with developmental disability is from international studies which have suggested that more than 10% of all children in the world have developmental disability (Amar 2008). Applying this rate to local population under 15 years old with the figure of 9.2 million (Department of Statistics Malaysia 2011), approximate 920,000 children with disability would be found in Malaysia.
Speech Language Pathologists (SLPs) play a crucial role in helping the communication development of persons (ASHA 2005) so that they are able to live inclusively in society as stated in Persons with Disabilities Act 2008 (Government of Malaysia 2008). In the mid-1990, only less than five Speech Language Pathologists who trained overseas were working locally in Malaysia which resulting of astonishing 1: 2.5 million Speech Language Pathologist to people ratio (Ahmad 2010). Eventually, formal local Speech Language Pathologist training started in the late 1990 (Sharma 2008). Universiti Kebangsaan Malaysia (UKM) is the pioneer to offer Bachelor of Speech Science with Honors while Universiti Sains Malaysia (USM) began offering their Speech Pathology program in 2004-2005. By 2011, more than 175 Speech Language Pathologists had graduated from the universities (Aishah 2012- unpublished) and are serving to the community in different settings.
Lian & Abdullah (2001) found that the profession of Speech Language Pathologist is still in its infancy stage in Malaysia. The profession still needs years to grow and mature (Kosta 2005). Indeed, many Malaysian Speech Language Pathologists have indicated that they face great challenges to maintain good profession practices. The challenges are unfavorable working environment, shortage of Speech Language Pathologists, high caseload, little opportunities for continuing education and other factors (Ahmad 2010; Sharma 2008). Despite many challenges that affect Malaysian Speech Language Pathologists practices when managing cases, the balance between pragmatism and professionalism should be achieved in order to provide equity and quality of service provision (Ahmad 2010; Taylor-Goh 2005).
American Speech-Language-Hearing Association (ASHA) and Centers for Disease Control and Prevention (CDC) define Developmental Disability (DD) as severe chronic conditions that occur in an individual due to physical and or mental impairment. Examples of developmental disability are intellectual disability such as Down's syndrome, neuromuscular disorders such as cerebral palsy, blindness, hearing impairment, learning disabilities, epilepsy, and Autism Spectrum Disorder (ASD) (Decouflé et al. 1994). The onset of the conditions is before 22 years of age and will usually remain throughout the individual's lifetime. People with developmental disability have limitations and problems in his or her major functional life activities such as learning, working, walking, speaking and other areas (ASHA 2005 & CDC 2011).
Paul (2001) described children in the Developing Language Stage (DLS) as group of children who are still at the period of learning to combine words into sentences and they have expressive vocabularies larger than 50 words. Developing Language Stage occurs between 2 and 5 years of age for typical developing children. Another way to describe Developing Language Stage is that it refers to language level in Brown's Stage II-V. This indicated mean lengths of utterance (MLU) of more than two but less than five morphemes. The type of sentence produced by them are at the range of linear simple sentences with emergence of grammatical morphemes, like "my cat's eating" to compound sentences, like "I drink milk and daddy drink coffee" (Shipley & McAfee 2009).
Developing Language Stage is the most explosive stage of language development for preschooler to develop from telegraphic utterances to basic sentence structures (Paul 2001). For children with developmental disability, they needs appropriate intervention to go through this stage (Paul 2001; International Centre for Allied Health Evidence 2007; Law et al. 2010). Hence, this is an important transition gate for them to either remain at the same stage or to grow and enter the Language for Learning Stage. Malaysian Speech Language Pathologists play great role to facilitate the learning of this group of children. This is because average caseload seen by Malaysian Speech Language Pathologists especially those who are working general hospital consists of pediatric cases (Aishah 2012- unpublished; Sharma 2008). From all the pediatric case, Speech Language Disorder (SLD) is the most prevalent type of communication impairment seen by Speech Language Pathologists in general hospital (Aishah 2012- unpublished).
Thus, this study will serve as a reference for the professionals in speech and language pathology about the practice by Malaysian Speech Language Pathologists in managing children with Developmental Disability in the Developing Language Stage. Opinions and recommendations by Malaysian Speech Language Pathologists regarding the existing issues will also be collected to give more in-depth understanding about the practice by Malaysian Speech Language Pathologists. Besides, this study will provide feedbacks to the professional associations & universities about the development of Malaysian Speech Language Pathologists.
Clinical practice guidelines related to communication disorder in children are well documented by professional association from western countries because they provide relevant statements regarding clinical management that are based on the available current evidences including expert clinical opinions (Hargrove et al. 2008 & Taylor-Goh 2005). The guidelines also assist Speech Language Pathologists in clinical decision making process and to provide high standards of minimum best practices services (Hargrove et al. 2008; SPA 2001; Taylor-Goh 2005). Looking back to Malaysia, guideline establishment for the profession of speech language pathology in the local context is still underdeveloped due to limited resources and manpower. Based on the guidelines documented by American Speech-Language-Hearing Association and Royal College of Speech Language Therapists (RCSLP), few mutual main clinical processes are highlighted and excessively discussed to ensure minimum best practice to be practiced by the Speech Language Pathologists. The processes are approach used in management, assessment, planning and treatment (ASHA 2005; Gerber & Prizant 2008; Taylor-Goh 2005).
Approach used in speech language pathology management could be delivered using different approaches according to the situation by either working independently or in close partnership with team members (SPA 2001). However, collaboration that involves family centered, team working and culturally appropriate services is able to ensure effective management to the children with Developmental Disability in the Developing Language Stage (ASHA 2005; Diane 2011; SPA 2001; Taylor-Goh 2005). Family-centered is a set of interconnected beliefs, principles and values that practiced by the facilitators including Speech Language Pathologists to support and strengthen the child's family capacity to enhance and promote his development and learning (Dunst 2002). Through working in a multidisciplinary or interdisciplinary team, Speech Language Pathologists do not provides services in isolation. Instead, this teaming establishes a joint purpose and shared goals throughout the management among the families, professionals and the child (ASHA 2005). The cultural background of the families and the child with Developmental Disability is very meaningful in service provision especially in Malaysia, a nation which is well known by its multi-ethnicity, multi-cultures and multi-linguistics. Multicultural variations that always encountered by Speech Language Pathologists are values about learning, beliefs and perception about child roles in the family, expectations for child behavior at different developmental levels and family perceptions and attitudes toward a "disability" (Diane & Froma 2011).
Assessment involves collecting relevant data about the child's conditions to reach a diagnosis while diagnosis entails identifying and understanding the problems or deficits of the child (Paul 2001). Both assessment and diagnosis are on-going processes because the diagnosis of the child could change over time as the growing and development of him or her are also on-going (Haynes & Pindzola 2004). The main reasons for assessment are to arrive at a good understanding of the child's problem, to establish the baseline level of functioning, to facilitate goals planning for intervention and to measure the progress of the child in treatment (Haynes & Pindzola 2004; Paul 2001). Assessment with children with Developmental Disability in the Developing Language Stage is encouraged to consider all relevant modalities across different contexts using appropriate assessment tools (Paul 2001; Taylor-Goh 2005; Haynes & Pindzola 2004). In addition, estimation of developmental age or mental age is commonly used by Speech Language Pathologists during diagnosis to characterize the child's functional skills. But, many Speech Language Pathologists too have been discouraged to rely solely on the use of developmental age estimation during diagnosis because it could not reflect the high variability among the children (DeVeney et al. 2012).
Based on the assessment findings, the planning of intervention program specifies the goals and the process of intervention by considering the child's impairment, needs and expectations (Paul 2001; SPA 2001; Taylor-Goh 2005). The planning aims to identify and develop meaningful and conducive learning environment for the children with Developmental Disability in the Developing Language Stage in functional daily activities (ASHA 2005). Hence, relevant and possible strategies, contexts, issues, outcome and timeline should be documented to facilitate the service provided by Speech Language Pathologists is coordinated, comprehensive and holistic (Diane 2011; Paul 2001; SPA 2001; Taylor-Goh 2005). Besides, Speech Language Pathologists are strongly encouraged to adopt Evidence-Based Practice (EBP) to aid clinical decision (ASHA 2005; Brankenbury 2008; Diane 2011; Johnson 2006; SPA 2001; Taylor-Goh 2005). Evidence-Based Practice (EBP) encourages the Speech Language Pathologists to take consideration of (a) current high-quality scientific research; (b) Speech Language Pathologists expertise and experience; and (c) family's preferences, values, and interests (Diane 2011). It is an important part of effective and ethical managements as it guides Speech Language Pathologists to eliminate methods which appear no or minimum clinical effects (Brankenbury 2008; Taylor-Goh 2005). Besides, Evidence-Based Practice also helps the profession of speech language pathology to achieve higher accountability and credibility (Johnson 2006).
Effective teaching techniques (ASHA 2005; Dunst et al. 2011; Law et al. 1999; Law 2003) are very important to determine the outcome of the treatment program. There are three types' of intervention methods that are didactic, naturalistic, and combination of didactic & naturalistic approaches (Dunst et al. 2011; Law et al. 1999; Law 2003). The categorization of different type of intervention methods is not aims for Speech Language Pathologists to choose only one method and use it consistently. In fact, it prepares a repertoire of methods available for Speech Language Pathologists to match the learning of the child with the specific goals that have targeted (Paul 2001). In this way, the efficiency of the treatment for the child with Developmental Disability in the Developing Language Stage is maximized. Introduction of appropriate materials or activities (ASHA 2005), individual learning environment (ASHA 2005; Dunst et al. 2011), assistive technologies (Sandra & Sahoby 2006) and Augmentative and Alternative Communication (AAC) systems (Millar et al. 2006; Rose et al. 1999) are all part of responsibilities of Speech Language Pathologists in giving treatment to the children with Developmental Disability in the Developing Language Stage. These components facilitate the learning and growing of the child in a familiar nature environment which is filled with interactive communication and social routines/activities. Besides, the introduction also promotes the child to generalize the new skills to new situation that would happen in everyday contexts.
Back to Malaysia, Joginder Singh et al. (2011) reported that Malaysian Speech Language Pathologists demonstrated best practice in many areas but fail to reach in some other areas when providing services to pre-symbolic children. Approach used in speech language pathology management which consist the collaboration of family centred, team management and culturally appropriate services is found scarcely practiced (Lim 2008-unpublish); Diane 2011; Joginder Singh et al. 2011; Othman 2010). Furthermore, Lian & Abdullah (2001) found that Malaysian Speech Language Pathologists were likely to rely on informal assessments because formal assessments are limited in the local market. When assessing pre-symbolic children, Malaysian Speech Language Pathologists showed low reliance of collecting communication sample and collecting data out of clinic (Joginder Singh et al. 2011). Looking into intervention practice, Malaysian Speech Language Pathologists demonstrate different intervention approaches and techniques across different settings (Lian & Abdullah 2001). In other hands, Augmentative and Alternative Communication (AAC) systems and assistive technologies are not famously introduced by Malaysian Speech Language Pathologists to improve the efficiency of the treatment program (Joginder Singh et al. 2011).
2.0 RESEARCH QUESTIONS
How Malaysian Speech Language Pathologists holistically manage children with Developmental Disability in the Developing Language Stage?
What are the existing issues faced by Malaysian Speech Language Pathologists when managing children with Developmental Disability in the Developing Language Stage?
What are the recommendations for better practice suggested by Malaysian Speech Language Pathologists when managing children with Developmental Disability in the Developing Language Stage?
3.0 RESEARCH OBJECTIVE
3.1 General Objective
To study Malaysian Speech Language Pathologists' practices in managing children with Developmental Disability in the Developing Language Stage.
3.2 Specific Objectives
To determine the specific clinical components practiced by Malaysian Speech Language Pathologists in managing children with Developmental Disability in the Developing Language Stage as are approaches used, assessment, planning and treatment.
To determine the existing issues faced by Malaysian Speech Language Pathologists in managing children with Developmental Disability in the Developing Language Stage.
To describe the recommendations suggested by Malaysian Speech Language Pathologists of better practice in managing children with Developmental Disability in the Developing Language Stage.
4.1 Research Design
This is a cross-sectional qualitative and quantitative study via survey.
4.2 Sampling Population
The population of this study covers all Malaysian Speech Language Pathologists.
4.3 Study Site
Participants will be recruited from all 14 states in Malaysia.
4.4 Sampling Method
Purposive sampling method is used for this study. All participants who fulfill the inclusion criterions (Please refer to 4.6) will be recruited.
4.5 Sampling Frame
The contact lists of Speech Language Pathologists who graduated from Universiti Kebangsaan Malaysia (UKM) and Universiti Sains Malaysia (USM) will be obtained in order to distribute the survey to all alumni members. The survey will be also mailed or/and posted to all Speech Language Pathologists working with Ministry of Health and to all members listed in the directories of local professional bodies (i.e. Malaysian Association of Speech-Language & Hearing (MASH) and others).
4.6 Sample Inclusion Criterion
Participants inclusion criterions: Qualified Speech Language Pathologists and practicing locally.
However, Speech Language Pathologists who have not had experience in managing children with Developmental Disability in the Developing Language Stage will be indicated in the survey to return the survey without further responses (Please refer Appendix A).
4.7 Sample Size Calculation
Aishah (2012-unpublish) reported that there are 175 SLPs registered in the UKM and USM alumni from local universities by the year 2011. Besides Speech Language Pathologists who have obtained their qualifications locally, Speech Language Pathologists who graduated from overseas are also included in the study, with the condition that they are currently practicing locally. Hence, the population of Malaysian Speech Language Pathologists is estimated to be between the range of 175 to 250 Speech Language Pathologists. The mean of the range of 210 Speech Language Pathologists will be used as N, in the following calculation:
Ï‡²NP(1-P) = 3.84 x (210)(0.5)(1-0.5)
d²(N-1) + Ï‡²P(1-P) 0.05²(210-1) + 3.84(0.5)(0.5)
= 137 participants
Occurrence of withdrawal and drop out of 10% is further considered in the sample size calculation.
Total subjects = nn__
= 152 participantssubjects
Thus, a total of 152 subjects participants will be recruited in this study.
6.54.8 Data Collection
The survey utilized for this study is adapted from several studies that focus on finding similar outcomes on SLP practices (Joginder Singh et al. 2011; Mustaffa Kamal et al. 2012; Othman 2010; Stuck 2012) . The survey is constructed using English because the participants involved in this study are qualified Malaysian Speech Language Pathologists who have English proficiency.
The survey contains the following sections:
Part A : Demographic Data
Part B : Specific Clinical Components
7 parts that are Demographic data, Approaches used, Assessment, Planning, Treatment, Opinions regarding existing issue and Recommendations of better practice. Close-ended questions using 5 points LikertLikert scaling and multiple choices are included in the survey. Besides, and open-eopen-ended questions are also included. nded questions are included. (Please refer to Appendix A).
Survey and information sheet will be distributed to the Speech Language Pathologists SLPs via email and/or gpost. QuestionPro's online survey software will be used to distribute the survey via email. Meanwhile, Ffor Speech Language Pathologists SLPs who will receive the survey and information sheet via postmailing, a reply-paid envelope is included for them to return the survey. SLPs will be informed that the returning of completed questionnaire survey indicate consent to participate in this study.
A follow-up reminder email or phone call will be sent to Speech Language Pathologists SLP ten 10 days after the initial distribution. A second reminder email or phone call will be sent 2 weeks later.
64..96 Validity and Reliability of Survey
The survey will be piloted on 10 participants. Construct, content and face validity will be determined by modifying the items accordingly (following the pilot study) through feedback from the participants. To determine how closely related the set of items are grouped in the survey, internal reliability of the survey components will be assessedachieved by calculating Cronbach's Alpha Coefficientusing Cronbach's alpha. This will show how closely related the set of items are as a group in the survey.
6.74.10 Statistical Test
The quantitative data obtained from closed-ended questions in the survey will be analyzed using descriptive statistics. From the survey, 11 out of 20 closed-ended questions are further divided into sub-items. Hence, factor analysis via principal component analysis (PCA) is used as a data reduction technique. Items in the survey that measured the same underlying construct will be grouped together.
Analysis method used by Mathers-Schmidt & Kurlinski (2003) will be adopted in this study. Descriptive statistics (percentages) of the grouped-items is calculated to investigate the degree of which specific clinical components are used.
Firstly, to determine which specific clinical components of Speech Language PathologistsSLPs' practice are most commonly used, the percentage of responses for each answer option (never, rarely, sometime, usually, or always) will be calculated. Percentages of response for option "usually" and "always" are combined. The specific clinical components are then categorized into 3 groups: (1) components usually/always used by 90% or more of the subjects; (2) components usually/always used by 50-90% of the subjects; and (3) components usually/always used by less than 50% of the subjects.
Secondly, consistency of the specific clinical components practiced by the subjects will be determined. The data will be categorized as follows: (1) highly consistent-75% of subjects indicated the same frequency of use; (2) moderately consistent-50-75% subjects indicated the same frequency of use; (3) and inconsistent-less than 50% of subjects indicated the same frequency of use for a particular clinical component.
6.84.11 Research Procedure
6.94.12 Gantt Chart
Application for Ethics
6.104.13 Information Sheet and Consent Form
The information sheet that will distribute to the subjects is attached in Appendix B.
Meanwhile, the subjects will be informed that the returning of completed questionnaire indicate their consent to participate in this study.