Plenary 1

Assessing implementation of the C-BiLLT: A language comprehension test for children with complex communication needs

Dr. Johanna Geytenbeek

Children with Cerebral Palsy and Complex Communication Needs

Cerebral palsy (CP) and other neurodevelopmental disabilities can result in significant motor and speech impairments, making children non-speaking or unintelligible (Nordberg et al., 2013; Hustad et al., 2014). Speech-language pathologists (SLPs) work to provide Augmentative and Alternative Communication (AAC) assessment and intervention in many of these cases (Andersen et al., 2010), and it is critical that they assess children’s language comprehension reliably so AAC systems can be recommended at developmentally appropriate levels, and interventions can be tailored accordingly. Unfortunately, this is challenging to assess in children who have limitations in their use of the motor skills needed to point, grasp, and produce speech because existing language assessment tools require fine motor control (e.g., finger pointing) and/or verbal responses (Geytenbeek et al., 2010).

Because of this lack in validated assessment of language comprehension for children worldwide who have severe motor and speech difficulties and cannot respond to conventional language tests that demand children manipulate objects or speak their answers, a computerised assessment, the C-BiLLT, which requires minimal physical response, has been developed in Dutch by Johanna Geytenbeek in collaboration with a neuropsychologist, K.J. Oostrom and pediatric neurologist, R.J. Vermeulen in the Netherlands. C BiLLT stands for Computer-Based Instrument for Low motor Language Testing. Administration of the C-BiLLT provides information on the child’s ability to understand spoken language by means of responding to items presented orally by the test leader, and visually on a personal computer.

It was developed so as to require very limited motoric responses from the child being assessed. In other words, the uniqueness and innovation of the C-BiLLT is that children can respond using a method that suits their needs, which includes a variety in access methods such as, touch screen, special buttons that can be operated by any body part, eye-gaze computer control etc, allowing even the most severely motoric handicapped children to respond reliably and unambiguously to the presented tasks of the test. Therefore, the C BiLLT is ideal for diagnostics in unintelligible or non-speaking children with (severe) motor impairments. During her presentation Johanna Geytenbeek will present the background and different parts of the C-BiLLT and video’s of children using different access methods.

The C-BiLLT is a valid, reliable, and accessible tool that fills a critical practice gap by reliably measure language comprehension in children with complex communication needs who have low speech and motor function (Geytenbeek et al., 2010; 2014). It is the first standardized assessment tool to evaluate a child’s comprehension without requiring a spoken or fine motor response, and children can complete the test using access methods that meet their needs. The C-BiLLT provides normdata for children aged 1;6 to 7 years. For children older than 7 years, age-equivalents are calculated. The C-BiLLT is used since 2015 in the Netherlands and Belgium and since 2019 in Norway and currently undergoing validation in many other countries of Europe. It was also translated and validated in English by a team in Canada in 2021 (Bootsma, Campbell et al., accepted). More information about the C-BiLLT is available at: https://c-billt.com/.

European Implementation Studies

As the C-BiLLT had been used in Europe since 2015, it was important to engage clinicians to understand their experiences and perceptions of the factors that influenced implementation in practice. European implementation was assessed using surveys and interviews.

Clinicians in the Netherlands, Norway, and Belgium who had been trained to use the C-BiLLT reported using the C-BiLLT with children with CP, but also with children with a range of disabilities other than speech and motor impairments. Users reported barriers and facilitators related to the instrument itself, children assessed, clinicians, and the clinical context (Bootsma, Stadskleiv et al., accepted).

North American Implementation Work

In collaboration with Johanna Geytenbeek a research team of professionals form CanChild, Holland Bloorview Hospital and Western University was recently awarded funding to bring the C-BiLLT to North America. This work will involve integrating knowledge from the above-mentioned studies, but also working to understand the necessary conditions for implementing the C-BiLLT in the North American clinical context. This will include: (1) Understanding clinicians’ and families’ perceived barriers to using the C-BiLLT, including modifications that may be required for the North American clinical context, (2) Incorporating and testing additional C-BiLLT access methods for children in North America, and (3) Developing training materials and resources to support implementation. This project will support children and families by allowing for the accurate assessment of language comprehension leading to more meaningful rehabilitation services, the prescription of developmentally appropriate communication aids, and relevant rehabilitation and educational programming for children. More information about the North American implementation project is available at: https://www.uwo.ca/fhs/bjclab/our_research.html. Additional information about C-BiLLT research in North America is available at: https://www.canchild.ca/en/research-in-practice/current-studies/c-billt.

Example quote from a mother of a child with CP

“I have been waiting a long time for this kind of technology… A quicker and reliable way to assess my son’s comprehension and provide a report would be incredibly valuable. This would give us a deeper understanding of what he knows, his strengths, and where support is needed. When I say ‘us’ I mean the family, school staff, and health-care providers – it would impact many areas of his life.” (D. Grahovac, 2021)

Key References

Andersen, G., Mjøen, T.R., & Vik, T. (2010). Prevalence of speech problems and the use of augmentative and alternative communication in children with Cerebral Palsy: A registry-based study in Norway. Perspectives on Augmentative and Alternative Communication, 19(1), 1-28.

Bootsma, J.N., Campbell, F., Hopmans, S.H., McCauley, D., Grahovac, Cunningham, B.J., Phoenix, M., Kraus de Camargo, O., Geytenbeek, J.M., & Gorter, J.W. The psychometric properties of the Canadian English version of the C-BiLLT, an accessible test of spoken language comprehension for children with severe motor and speech impairments. Journal of Pediatric Rehabilitation Medicine, accepted.

Bootsma, J.N., Stadskleiv, K., Gorter, J.W., Geytenbeek, J.J.M., Phoenix, M., McCauley, D., Fiske, S., Crews, N., & Cunningham, B.J. Implementation of a novel accessible web-based tool to assess verbal language comprehension in individuals with motor and speech impairments: an international survey among clinicians. Augmentative and Alternative Communication, accepted.

Bootsma, J.N., Phoenix, M., Geytenbeek, J.J.M., Stadskleiv K., Gorter, J.W., Fiske, S., & Cunningham, B.J. Clinicians’ experiences implementing the C-BiLLT into practice: an interview study. BMC Health Services Research, accepted.

Braun, V. & Clarke, V. (2021). Thematic Analysis: A practical Guide. Sage Publishing.

Geytenbeek, J., Harlaar, L., Stam, M., Ket, H., Becher, J.G., Oostrom, K., et al. (2010). Utility of language comprehension tests for unintelligible or non-speaking children with cerebral palsy: a systematic review. Developmental Medicine and Child Neurology, 52(12), e267–77.

Geytenbeek, J.J., Mokkink, L.B., Knol, D.L., Vermeulen, R.J., Oostrom, K.J. (2014). Reliability and Validity of the C-BiLLT: A new Instrument to Assess Comprehension of Spoken Language in young Children with Cerebral Palsy and Complex Communication Needs. Augmentative and Alternative Communication, 30(3), 252–66.

Hustad, K.C., Allison, K., McFadd, E., & Riehle, K. (2014). Speech and language development in 2-year-old children with cerebral palsy. Developmental Neurorehabilitation, 17(3), 167-175.

Michie, S., van Stralen, M.M., & West, R. (2011). The Behaviour Change Wheel: A New Method for Characterising and Designing Behaviour Change Interventions. Implementation Science 6(1).

Nordberg, A., Miniscalo, C., Lohmander, A., & Himmelmann, K. (2013). Speech problems affect more than one in two children with cerebral palsy: Swedish population‐based study. Acta Paediatrica, 102(2), 161-166.

Weiner, B.J., Lewis, C.C., Stanick, C., Powell, B.J., Dorsey, C.N., Clary, A.S., et al. (2017). Psychometric assessment of three newly developed implementation science outcome measures. Implementation Science, 12(1), 1–12