Abstract
Speech–language pathologists (SLPs) may design and implement public health approaches that advance children’s language development. Universal, public health-informed SLP programmes could improve equity and access to SLP services for all children, including those from families that are historically underserved (e.g., socially and economically disadvantaged families). Social determinants of health, like food or housing insecurity, exposure to violence, or systemic inequalities (e.g., racism), may affect language development and also limit access to speech–language pathology services. This clinical focus article describes how a public health lens, trauma- and violence-informed care principles, and evidence about parent coaching in early language interventions were applied to develop a new programme titled Community Opportunities For Family Engagement and Empowerment, and Play and Learning Accessible for Youth (COFFEE and PLAY). The programme builds relationships between families and SLPs to (a) reduce barriers to service, (b) build parents’ capacity to support children’s language, and (c) promote school readiness.
Introduction
Language is used in every facet of our lives – it is how we organize our thoughts, rationalize, and regulate our emotions and behaviours, and communicate with others. It is essential to our social lives, educational success, and workforce participation. Childhood language disorders are associated with poor literacy skills and academic achievement (Conti-Ramsden et al., 2018; Feeney et al., 2012; Nudel et al., 2023) and significantly increase the risk of social, emotional, and behavioural difficulties later in life (Feeney et al., 2012; Nudel et al., 2023). Early speech–language interventions delivered in the home, healthcare setting, or via public health (e.g., universal publicity campaigns or drop-in programmes) have shown promise in improving children’s language outcomes and in promoting the parental behaviours that are associated with children’s early language and literacy development (Darcy Mahoney et al., 2020).
Child development is influenced by social determinants of health, broadly defined as the social, environmental, and political environments in which children are born, live, learn, and grow (Maggi et al., 2010). Children’s primary environment is their family, which can provide the foundation for secure attachment and cognitive and language stimulation. The absence of these positive and protective social determinants of health may compromise healthy developmental pathways and outcomes. Beyond the family unit, children’s growth and development are impacted by their neighbourhood, access to high-quality health and education, material resources, and policies (e.g., inclusion mandates). These social determinants of health also impact children with disabilities, advocacy roles for individuals and families, communities and organizations, and decision-makers and governments to promote inclusion and well-being (Filipe et al., 2021).
Often referred to as the inverse care law, it has been found that people who are adversely affected by the social determinants of health and have the highest need for service are also least likely to use existing services (The Lancet, 2021). Some families have been labelled as ‘hard-to-reach’ families when they are eligible for a service, but do not access it due to barriers such as lacking transportation, having poor physical or mental health, or being young parents; however, it is equally important to consider ‘hard-to-access services’ (Boag-Munroe & Evangelou, 2012; Phoenix et al., 2020b). Organizational barriers to children’s services might include poor communication with families, inaccessible or stigmatizing settings, and long waitlists (Boag-Munroe & Evangelou, 2012; Phoenix et al., 2020a; Phoenix & Rosenbaum, 2015b). Systemic inequalities that limit access to care may include ableism (e.g., referral materials that are inaccessible to screen readers), classism (e.g., services only available during working hours), and racism (e.g., assessment materials that are only available in English) that are embedded in care systems (Nixon, 2019). Consequently, even though parents may have a desire and need to participate in children’s speech and language services, they may face diverse barriers which limit their ability to participate and engage in traditional, in-centre models of service delivery that require parents to bring their child into a hospital, community-based centre to receive their assessment or intervention (Phoenix et al., 2020a, 2020b). As a result, alternate models of service delivery may be needed.
In recent years, increased attention has been given to exploring universal, population-level approaches to speech and language services for children from birth to school entry that may improve access to care by meeting families where they are comfortable, and building family and community capacity (Darcy Mahoney et al., 2020; Law et al., 2013; Marshall et al., 2017; Smith, Gibbard, & Higgins, 2017; Smith, Williams, & Bryan, 2017; Winkworth et al., 2010). The provision of universal services is a common public health strategy in which services are offered to an entire population as a means to promote health equity (National Collaborating Centre for Determinants of Health, 2013). In speech–language pathology, universal approaches to services aim to mitigate the effects of negative social determinants of health and increase access to speech and language services for hard-to-reach families, with the overall goal of prevention over remediation (Law et al., 2013). Several projects piloting universal and public health approaches to preschool speech and language services have been studied in recent years, including publicity campaigns, home visiting programmes, groups, and drop-in style programmes (Darcy Mahoney et al., 2020; Smith, Gibbard, & Higgins, 2017; Smith, Williams, & Bryan, 2017). For example, home visiting programmes included a trained home visitor who provided coaching with opportunities for feedback and self-reflection to develop parents’ responsiveness to their child and resulted in increased parent knowledge of language development and children’s social, emotional, communication, and cognitive skills (Darcy Mahoney et al., 2020). Other programmes targeted literacy skills and provided free books and information about the importance of reading, often through well-child or other primary care visits (Darcy Mahoney et al., 2020). These programmes reported positive outcomes, including increasing the frequency of caregivers reading to their child and having a child-centred literacy orientation (Darcy Mahoney et al., 2020). Some programmes are designed to engage children and caregivers in their everyday life environments, such as laundromats, which demonstrated an increase in literacy-based activities when developmentally appropriate activities and physical modifications (e.g., tables and couches) were added to the space and when librarians led enriching activities (Neuman & Knapczyk, 2022).
Given known barriers to accessing communication interventions for young children and families and the emerging evidence supporting universal and public health informed interventions, we developed a community-based, drop-in style programme called COFFEE and PLAY: Community Opportunities for Family Engagement and Empowerment, and Play and Learning Accessible for Youth. This programme aims to build relationships between families and speech–language pathologists (SLPs) in a socially and economically disadvantaged community to achieve the goals of reducing families’ barriers to service use, building families’ capacity to support their children’s language development, and increasing children’s school readiness.
In this clinical focus article, we will (a) briefly describe the COFFEE and PLAY programme, (b) review the literature that informed the development of COFFEE and PLAY to address the early language needs of children and families in a socially and economically disadvantaged community in Hamilton, Ontario, Canada and illustrate how key elements from that literature were applied in COFFEE and PLAY, (c) share authors’ reflections about the programme development and implementation.
COFFEE and PLAY Programme Description
COFFEE and PLAY was an 8-week freely available language-focused, community-based drop-in programme for preschool children (from birth to 4.5 years old) and their caregivers. The programme goals were to (a) build trusting relationships between the families, SLPs, and the community, (b) increase parent capacity in promoting language development with their children, and (c) increase children’s school readiness. The programme was designed to be offered on a school playground Hamilton, Ontario in a socially and economically disadvantaged neighbourhood. It was offered during the springtime to allow for suitable weather, with an indoor space available if there was rain. The timing of the programme was convenient and predictable, running from 8:45 am to 10:00 am Monday–Friday (coinciding with the morning school bell). This timing allowed caregivers to drop off an older child at school and attend the programme with their preschool-aged child/children. Caregivers included any family members who are caring for the child or other paid/unpaid caregivers. The caregiver was required to stay on-site for the duration of the programme and was responsible for the child under their care.
The programme delivery was unstructured, with no identifying information collected, no expectations around frequency of attendance, and no individualized documentation. Two SLP students implemented the programme with supervision from a community-based SLP. The two students who delivered the programme were in a second-year fieldwork placement of a 2-year clinical Master’s level graduate training programme in speech–language pathology. Therefore, they had completed coursework in paediatric assessment and intervention (including information about developmental norms and child-appropriate activities), family-centred care, tiered models of service delivery, and theories that inform service delivery (e.g., the International Classification of Functioning disability and Health) (World Health Organization, 2001), and the Canadian framework for social determinants of health and well-being among children with neurodisabilities and their families (Filipe et al., 2021). The supervising SLP had completed a Master’s level degree in speech–language pathology, had experience providing a variety of communication services to young children and families (e.g., parent training and group therapy), and was available to observe, answer questions, and to provide the students with feedback. Students were required to be culturally responsive and have adequate problem-solving skills, which were assessed through interviews and site visits when selecting the students.
During the programme, there were low-cost and age-appropriate toys available for exploration and play (e.g., books, puzzles, bubbles, plastic food and babies, balls, and blocks). Snacks and coffee and resources (e.g., speech–language norms sheets, contact information for local food or shelter programmes, and referral information for rehabilitation services) were available for families. The clinical focus of the programme was to provide universal resources and recommendations to the families that attended. These included general information about child development and strategies parents can use to promote development (e.g., modelling language and signs, providing communication temptations, observing and responding to children’s communication, and turn-taking in play and book reading); however, no formal screening of developmental skills was completed. If requested, families were given information about other community-based programmes (e.g., playgroups, food or housing programmes, and rehabilitation services).
COFFEE and PLAY was designed to be completed at a school that had a high percentage of socio-economically disadvantaged students who were at risk for developing language, social and learning difficulties. Our clinical team members selected the target school because the preschool and school-based SLPs and managers reported that there was a high number of children in the school who had communication needs, but had not accessed or had inconsistently accessed and left preschool speech–language services. Therefore, COFFEE and PLAY was developed as an alternate model of service delivery to improve access and family engagement in preschool SLP services.
Literature Reviewed and Application to COFFEE and PLAY
Three main bodies of literature informed the development of COFFEE and PLAY, including public health approaches to speech and language services, parent training in early communication interventions, and the application of trauma and violence-informed care in the field of speech–language pathology. Key sources and critical ideas that informed the development of COFFEE and PLAY are reported below, followed by a description of how we applied key concepts in the development of COFFEE and PLAY and a summary table.
Public Health Approach to Services
Law and colleagues (2013) advocated for a public health approach to children’s speech and language services, noting the need to address social determinants of health, improve access to services, and reduce language delays and their long-term negative consequences. They repositioned speech–language pathology services from an individually focused rehabilitation approach to a universally delivered prevention-focused model, suggesting that this can increase reach and decrease cost. Recently, Warren and colleagues (2024) expanded significantly upon this foundation by labelling and describing ‘communication public health’. This approach would integrate public health in speech–language pathology education, clinical service, advocacy and research and transform the SLP profession by improving access to care, moving beyond an individual medical model of service, towards a holistic and interdisciplinary approach that encompasses the social determinants of health. Consistent with this broader shift, there have been studies that have researched public health approaches that support child language development and those that most strongly influenced the COFFEE and PLAY programme development are described below.
Babytalk Home Visiting
Babytalk Home Visiting (BTHV) programme is a single-visit programme taking place in the family home and focusing on supporting child language development by providing information and advice to parents of babies between 0 and 18 months old (Smith, Gibbard, & Higgins, 2017). Initially located within a socially and economically disadvantaged area of Portsmouth city, UK, the programme later expanded to all of Portsmouth city, with each visit providing information on developmental norms, parent–child interaction advice, and information on local community services (Smith, Gibbard, & Higgins, 2017). BTHV also provided modelling of activities with age-appropriate toys together with supplying resources for families, such as a play bag with toys, a book-start pack, and a nursery rhyme CD (Smith, Gibbard, & Higgins, 2017). Almost all parents reported being satisfied with the BTHV service (95.6%), and 94.3% indicated that they had increased knowledge about child language development as a result of the home visit. Many respondents (74.6%) indicated that they would make a change as a result of the information gained in the service.
Room to Play
Evangelou and colleagues (2013) evaluated the impact of a developmental and play-based drop-in programme called Room to Play for hard-to-reach families. Room to Play was run as a 3-year pilot project in a shopping mall in the United Kingdom. The programme offered a variety of play-based activities in which staff modelled and encouraged caregiver–child interactions. The focus of the Room to Play project was on building trust with families who would otherwise not typically engage in such services, and therefore, most of the data collection in Year 1 involved unstructured observations and daily attendance figures (Evangelou et al., 2013). In Year 2, a quantitative questionnaire was distributed to gain a ‘snapshot’ of the families using the programme; however, attendance dropped by half during this questionnaire period (Evangelou et al., 2013).
The elements that were reported to make Room to Play most successful included selecting a community location that parents were already visiting and had low barrier access (e.g., shopping mall) and running the programme at a consistent time, allowing parents to view the programme and build the courage to drop in. Families were encouraged to join at their own pace, developing relationships with other parents and the staff, to increase confidence and reduce social isolation. Room to Play offered activities that may not have typically been available at home, such as play-dough and crafts (Evangelou et al., 2013). In general, spontaneous play was more acceptable than preplanned play, and a less prescriptive and more responsive approach by staff was favourable (Evangelou et al., 2013). Before and throughout Room to Play, staff were trained on various topics, including development, cultural diversity, and child protection issues (Evangelou et al., 2013). This enabled staff to provide resources and signpost families to available services. Evangelou and colleagues (2013) also emphasized the importance of the ability for staff to be able to ‘think on their feet’ and manage unpredictable events with tact and sensitivity.
Overall, the evidence on public health approaches to early intervention programmes is rich in describing key features of these programmes, which promoted service access, relationship and capacity building, and child development.
Application of Public Health Approaches in COFFEE and PLAY
The public health components that were drawn from the literature and used to inform the development of COFFEE and PLAY include a focus on prevention rather than remediation, designing the service to be easily accessible with consideration for location, space, time, and targeting universal goals.
Service Components
In terms of service components, aspects of COFFEE and PLAY were modelled from Room to Play and BTHV programmes. Similar to Room to Play, COFFEE and PLAY was provided in an easily accessible community location with a consistent time to promote participation of families who typically do not attend traditional SLP services (Evangelou et al., 2013). Information shared from Room to Play about the location, space, and time of the programme was valuable to COFFEE and PLAY in several ways. In terms of location, the programme was offered where the older siblings attended school, meaning parents who were already dropping their children off at school did not need to go to a separate destination to participate. COFFEE and PLAY took place outdoors in the schoolyard, which eliminated the idea of ‘crossing a threshold’, and was intended to reduce some of the barriers to participation by being in an openly accessible space.
COFFEE and PLAY ran as a drop-in programme each weekday morning for 8 weeks. This provided the opportunity for parents to see the programme, and build up any necessary courage to participate, without signing up or a formal referral. Framing the programme as an informal drop-in style, without formally collecting identifying information, taking notes, or formal screening and goal setting, shifted the focus from intervention to trust and relationship building with the families (Evangelou et al., 2013).
Aligned with public health literature, COFFEE and PLAY was developed as a play-based programme with open access to age-appropriate toys (Evangelou et al., 2013). Similar to BTHV, COFFEE and PLAY provided opportunities for children to interact with age-appropriate toys together with supplying resources for families to continue the play experiences outside of COFFEE and PLAY (Smith, Gibbard, & Higgins, 2017). Inspired by Room to Play, in which a less prescriptive and highly responsive approach to young children and families was preferred by staff (Evangelou et al., 2013), COFFEE and PLAY focused on spontaneous and unstructured play, following the needs of the parents and children in the group.
Programme Goals
The goals of COFFEE and PLAY aligned with other public health approaches and included improving parenting knowledge (e.g., information about developmental norms and signposting to other services; Evangelou et al., 2013; Smith, Gibbard, & Higgins, 2017) and behaviours (e.g., listening and turn-taking, scaffolding; Darcy Mahoney et al., 2020; Evangelou et al., 2013; Smith, Williams, & Bryan, 2017) to support children’s social and language development. Building trusting relationships between families and service providers and reducing social isolation of families were goals of COFFEE and PLAY that were supported by other public health perspectives (Evangelou et al., 2013).
Overall, the developers of COFFEE and PLAY drew upon the public health literature in many ways to inform the development of the programme in terms of service components and programme goals. Providing education to families and connecting families with appropriate and relevant resources for their child are cornerstones of public health SLP approaches, and of COFFEE and PLAY.
Parent Training and Early Language Facilitation
Strengthening parents’ ability to support their child’s language development during naturalistic caregiver–child interactions is a common recommendation for children with language delays (Roberts & Kaiser, 2011). Parents are key change agents in their child’s life because they are often highly motivated and spend time with their children in naturalistic settings (Leffel & Suskind, 2013; Roberts & Kaiser, 2011). As a result, parent-directed, home therapy approaches are often at the centre of many interventions for speech and language delay. Roberts and Kaiser (2011) conducted a meta-analysis of 18 studies to examine the effect of parent-implemented language interventions on linguistic outcomes. The authors found that parent-implemented language interventions had a positive effect on the receptive and expressive language development of 18- to 60-month-old children (Roberts & Kaiser, 2011). A more recent meta-analysis by Heidlage and colleagues (2020) extended Roberts and Kaiser’s (2011) work by including studies beyond 2010. Of the 25 studies included, six studies specifically examined children at-risk of language impairment due to low socioeconomic status (SES). The results of the meta-analysis were mostly consistent with Roberts and Kaiser’s (2011) review, and the authors concluded that the findings supported the use of parent-implemented language interventions for improving expressive language outcomes for children with primary language impairment and those at risk of secondary language impairment due to low SES (Heidlage et al., 2020).
Examples of parent-implemented language interventions that were included in the aforementioned reviews are the Hanen Parent Program, the Heidelberg Parent-Based Language Intervention, and Enhanced Milieu Teaching (Heidlage et al., 2020; Roberts & Kaiser, 2011). Common elements of these interventions include targeting parents’ abilities to model language, to be responsive to their children’s communication attempts and interests, and to build positive parent–child interactions (Leffel & Suskind, 2013; Roberts & Kaiser, 2011).
When implementing parent-implemented models, it is essential to consider the skills required by professionals to successfully teach and guide parents through implementing early language facilitation strategies. Specific training may be required to teach SLP students the skills required for coaching families in naturalistic communication techniques (Gallegos et al., 2024) and to consider the modifications that may be required when working in community-based programmes with low-income families and a range of caregivers (e.g., early childhood education providers; Romano and Woods, 2017). Instruction in coaching models may include topics such as goal setting, observation, and responsiveness to children’s communication attempts, providing models and communication temptations, and tracking data and providing feedback (Gallegos et al., 2024; Romano and Woods, 2017; UF Anita Zucker Centre for Excellence in Early Childhood Studies, n.d.). Child-health professionals who work in parent-implemented models must have the skill to coach and provide tactful and timely support, ensuring parents are successful in learning and implementing their new skill. In addition, feedback must be tailored to fit the parents’ education and reading levels, learning style, and skill at implementing the intervention (Kaiser & Hancock, 2003). Most importantly, as Kaiser and Hancock (2003) point out, parents need to feel valued as collaborators in this training process.
Our review of the literature indicated that there is evidence to support parent-implemented interventions for language impairments; therefore, we drew from the commonalities among these types of interventions and considered the unique role of the child-health professionals who work directly with parents when designing COFFEE and PLAY.
Application of Parent-Training Literature in COFFEE and PLAY
COFFEE and PLAY aligned with other parent-implemented language interventions in terms of the primary goals of the programmes, and the foundational knowledge that was required for the facilitators. In addition, the SLPs in COFFEE and PLAY adopted similar approaches to what is described in the parent-training literature to help parents facilitate their child’s language development.
Programme Goals
One of the primary aims of COFFEE and PLAY was to support parents in promoting child language development in everyday life by connecting SLPs with families of children who are at risk for developing language, social, and learning difficulties. This objective aligns with many other well-studied parent-training programmes such as the Hanen Parent Programs, the Heidelberg Parent-Based Language Intervention, and Enhanced Milieu Teaching (Heidlage et al., 2020; Roberts & Kaiser, 2011). All of these programmes include a professional (e.g., coach, facilitator, instructor and parent educator) to assist parents in learning new skills to support their child, similar to COFFEE and PLAY. However, these programmes differ from COFFEE and PLAY in terms of the standardized approach to assessment and intervention. COFFEE and PLAY did not provide direct assessment or intervention like these other programmes and instead focused on building trusting relationships with parents. Through relationship building, COFFEE and PLAY facilitators increased trust with families and began conversations about the child and their communication development. Once relationships were developed and parents had an understanding of children’s developmental skills, there was an opportunity for the SLPs to provide general strategies that enable caregivers to support their child’s speech and language development at home and in the community. The main objective of supporting parents to promote the language development of their child is similar across all of the parent-training programmes outlined in this article and COFFEE and PLAY (Heidlage et al., 2020; Roberts & Kaiser, 2011).
Foundational Knowledge and Support
To best support parents’ education, the facilitators needed to have foundational child and language development knowledge (Kaiser & Hancock, 2003). The SLP students who facilitated the programme were interviewed for the positions, and any gaps in knowledge were filled through appropriate training (e.g., about trauma-informed care) before the implementation of COFFEE and PLAY. In addition, ongoing supervision and support are recommended in the parent-training literature for those learning to teach parents strategies to support their child’s language development (Kaiser & Hancock, 2003). COFFEE and PLAY facilitators were supervised and mentored by a community-based SLP who has expertise in child language and development and experience supporting parent-implemented interventions. The programme developers (preschool and school-based SLPs and interdisciplinary researchers) prepared a resource package that included general child developmental norms, TIC principles and strategies, parent-implemented communication strategies, and community-based resources and referral information. This package was provided to students in advance of their clinical placement and was on hand during the programme.
Parent-Training Approaches
As the literature on parent-training states, professionals need to create safe learning environments and address the challenges parents may undergo with being adult learners (Kaiser & Hancock, 2003). The facilitators of COFFEE and PLAY did this by considering the various backgrounds of parents, including cultural considerations, educational and vocational levels, personal beliefs, and possible history of trauma (Kaiser & Hancock, 2003). This promoted a safe and welcoming environment for all families in the community. In addition, COFFEE and PLAY facilitators offered information using Universal Design for Learning (UDL) principles to allow parents to uptake information in ways that meet their learning needs (CAST, 2018; Kaiser & Hancock, 2003). Universal design aims to minimize barriers to learning by providing multiple means of engagement (e.g., considering individual identities and motivations), multiple means of representation (e.g., providing both hand-outs and modelling strategies), and multiple means of action and expression (e.g., allowing caregivers to express themselves via dialogue with the facilitators or interacting directly with their child). Providing information in a variety of means and allowing caregivers to participate in various ways allowed for maximum flexibility, tailoring and reduced barriers to learning and participation.
To summarize, various aspects of the parent education literature were utilized in the development of COFFEE and PLAY. In particular, COFFEE and PLAY had similar aims when compared to other parent-training SLP programmes (Heidlage et al., 2020; Roberts & Kaiser, 2011) and considered how to support programme facilitators in their efforts to support families, and how to create safe spaces to build trusting relationships with families (Kaiser & Hancock, 2003). By creating trusting relationships and applying learning principles such as UDL, families were able to meaningfully engage in COFFEE and PLAY programming.
Trauma- and Violence-Informed Care
Adverse childhood experiences (ACEs) are defined as exposures to abuse (i.e., psychological, physical, or sexual abuse) or household dysfunction (i.e., exposure to substance abuse, mental illness, violence, or criminal behaviour in the household; Felitti et al., 1998). In 1998, Felitti and colleagues published a seminal study looking at the prevalence of ACEs and their connection to negative health experiences later in life. Known as the original ACEs study, this research has received some criticism in recent years for being overly simplistic, deterministic, and potentially creating stigma (Kelly-Irving & Delpierre, 2019; Lacey & Minnis, 2020); nonetheless, it began an important dialogue on the biological and developmental impact of early adversity. Indeed, since the Felitti and colleagues (1998) study, a significant body of research has emerged explaining how early trauma can affect brain development and behaviour (De Bellis & Zisk, 2014; Gabowitz et al., 2008; Mackes et al., 2020; Popovic et al., 2020; Yu et al., 2019), what protective factors can be identified (Orbuch et al., 2022), and what measures can be taken to reduce the long-term impact of ACEs on developing children, such as trauma-informed care (TIC; Substance Abuse and Mental Health Services Administration, 2014). The term ‘trauma and violence-informed care’ appropriately directs attention to the systemic inequities that can increase the risk of harm among marginalized populations (Wathen et al., 2023). Systemic inequities may include, but are not limited to racism, ableism, (Nixon, 2019), and intergenerational trauma that may be felt especially by Indigenous peoples who experience ongoing and historical harms due to land theft, residential schools, and discrimination in health and education settings (Truth and Reconciliation Commission of Canada, 2015).
Integrating trauma and violence-informed care in SLP’s practice with young children includes awareness of the widespread prevalence of trauma, recognizing trauma’s effect on attachment and development, and resisting retraumatization in clinical services (Wiseman-Hakes et al., 2025). Application of TIC is recommended in infant and early childhood services as it is a relatively low-cost, low-risk approach (Bartlett & Smith, 2019; Fredrickson, 2019) that can be implemented in diverse settings with ‘the potential to improve patient engagement, treatment adherence, health outcomes, and provider and staff wellness’ (Menschner & Maul, 2016, p. 1). TIC has applications at the frontline clinical encounter, at an organizational level, and considers secondary trauma and staff well-being (Menschner & Maul, 2016). The Substance Abus and Mental Health Services Administration (SAMHSA) (2014) guidelines provide direction for programmes seeking to implement TIC through outlining a trauma-informed approach called the 4 R’s.
The 4 ‘R’s’ represent realize, recognize, respond, and resist retraumatization (SAMHSA, 2014). The first R, realize, involves service providers realizing the prevalence and impact of trauma on children and the developing brain (SAMHSA, 2014). Understanding that trauma impacts many children is the first step to practicing with a trauma-informed lens.
The second ‘R’, recognize, involves recognizing the signs and symptoms of trauma (SAMHSA, 2014). The Center for Excellence for Infant and Early Childhood Mental Health Consultation (ECMHC, n.d.) has compiled a list of the possible signs and symptoms of trauma that can be referenced by service providers, including a breakdown of signs and symptoms for children birth to 3 years (e.g., sleep disturbances and language delay) and 3 to 6 years (e.g., irritability and poor social relationships; ECMHC, n.d.).
The third ‘R’, respond, involves making awareness of trauma and its impact pervasive throughout the programme, organization, or system (SAMHSA, 2014). This point emphasizes the importance of trauma education for all members of a team, whether members are working directly with families or not.
The final ‘R’ in TIC is to resist retraumatization. This involves creating a safe environment, free from toxic stress (SAMHSA, 2014). It also requires individuals to be aware of potential topics or activities that may trigger painful memories or serve to retraumatize individuals with traumatic pasts. Racine et al. (2020) advocate for using TIC as a universal precaution, as trauma may not always be disclosed, and universal ACE screenings could lead to retraumatization.
Although there is recognition that trauma exposure in early childhood is widespread with impacts on parent–child attachment and early communication development, only 6% of 164 survey respondents, who were SLPs primarily from Canada and the United States, reported the inclusion of developmental trauma in their curriculum (Rupert & Bartlett, 2022). Therefore, SLPs may require additional training, resources, and guidelines to implement the elements of trauma-informed care, such as cultural responsiveness, being attuned to trauma and avoiding retraumatization, ability to work with an interprofessional early childhood team, readiness to refer to additional community supports as needed, using a strengths-based approach to care, and taking a universal approach to implementation (O’Leary et al., 2023; Rupert & Bartlett, 2022). Given that SLPs work with children in the context of child–parent interactions, they are well-positioned to integrate TIC into their practice and to create environments that promote safety and embodied regulation (O’Leary et al., 2023).
Application of TIC Literature in COFFEE and PLAY
The TIC literature discussed in this article emphasizes the importance of TIC in the formulation of healthcare initiatives for all young children and families (Bartlett & Smith, 2019; Fredrickson, 2019; Racine et al., 2020). Consequently, the reviewed literature has been instrumental in shaping COFFEE and PLAY and in ensuring a trauma-informed perspective in delivering this service. Training for the facilitators of COFFEE and PLAY included required learning for the facilitators about the education of what the four R’s – realize, recognize, respond, and resist retraumatization (SAMHSA, 2014) are and how they were incorporated in COFFEE and PLAY implementation. Additional optional learning opportunities and resources were made available as detailed below.
Realize
Facilitators and other members of the team reviewed relevant literature to realize the prevalence and impact of trauma in children. Studies covered topics about the integration of trauma-informed care into paediatric SLP practice and why this is important in parent attachment, neuropsychology, and communication development (Jethava et al., 2022; O’Leary et al., 2023). The resource package provided to SLP facilitators included options for continuing their learning about TIC in a variety of formats, including peer-reviewed literature, webinars, and structured courses.
Recognize
It is important to recognize that children, caregivers, and families can experience past or ongoing trauma that may affect their relationship and children’s development (Heffron et al., 2016). The COFFEE and PLAY programme package for facilitators listed the signs and symptoms of trauma and organized them by age. The lists for children aged birth to 5 years were highlighted, so that facilitators could easily use the resource to recognize signs of trauma responses when delivering the programme.
Respond
The SLP supervisor and SLP student facilitators reviewed literature specific to how trauma-informed care can be integrated into SLP practice (O’Leary et al., 2023; Rupert & Bartlett, 2022) to develop an understanding of how they can integrate key principles of TIC into the COFFEE and PLAY programme. Furthermore, a page describing the SAMHSA (2014) key principles of TIC was included in the COFFEE and PLAY programme package provided to the facilitators for them to reference as needed. Additional courses in TIC training were available if needed, for example, Trauma-Informed Care in Speech–Language Pathology (George Hull Centre for Children and Families, n.d.) or an asynchronous course about Trauma- and Violence-Informed Care Foundations (University of British Columbia, 2024).
Resist Retraumatization
Detailed case histories were not collected as part of COFFEE and PLAY. Therefore, families’ exposure to trauma was unknown to facilitators, and the programme was designed to resist retraumatization for all participants. For example, it was located at a familiar community location, and there was minimal structure or demands embedded in the programme. Facilitators were guided to critically reflect on their own identities, biases, privileges, and systemic inequities that may be embedded in care to redress power differentials and attend to issues of social justice.
Overall, the literature suggests the implementation of TIC is a universal precautionary lens to apply in all public health programmes, especially those working with families with young children. COFFEE and PLAY sought to meet this need through education of team members and the implementation of the four ‘R’s in a trauma-informed approach (Table 1).
Key Concepts From the Literature on Public Health Approaches, Parent Training in Early Language Facilitation, and TIC and a Summary of How They Were Applied in COFFEE and PLAY.
Author’s Reflection
While a full report on evaluation and outcomes is forthcoming, the authors provide a reflection on their experiences with developing and implementing the COFFEE and PLAY programme. While it was helpful to draw guidance from existing literature about public health-informed models of communication programmes, parent coaching and training programmes, and trauma-informed care, it took many meetings with clinical partners to determine how these could be applied in our specific context. For example, when determining how to create a safe environment, we learnt from the school principal that we could not use the playground that was adjacent to the school yard because it sometimes had used needles on the ground and that we should do a visual check of our space before welcoming children and families. The student facilitators consulted with their supervisors about when to approach families to invite them to the programme, feeling that multiple invitations may feel intrusive, but sometimes repeated invitations could be used to build comfort and trust. While the programme was well attended by some families, it was noted that the same set of families joined regularly, and it was challenging to attract new families, especially those who may have children with communication needs and might benefit from being connected with speech–language pathology services. The parent partner who collaborated as a member of our team suggested that improvements could be made in how the programme was advertised (e.g., using local parent groups online) and that programme use may depend more on logistic factors (e.g., children’s sleep schedules and parents’ work schedules) than on caregivers’ satisfaction with the programme.
Conclusion
There is a significant need for SLPs to play a greater role in public health approaches to preschool speech and language development. Universal, public health programmes have the potential to improve equity and access to speech and language support for all children, including those from families that have traditionally been viewed as ‘hard-to-reach.’ The COFFEE and PLAY programme is an evidence-informed, early intervention SLP programme using public health and trauma-informed approaches to service delivery. This programme aims to build relationships between families and SLPs in a socially and economically disadvantaged community to achieve the goals of (a) reducing families’ barriers to service use, (b) building families’ capacity to support their children’s language development, and (c) increasing children’s school readiness. Using evidence from public health approaches, parent training and early language facilitation strategies, and TIC, COFFEE and PLAY will serve as a model to generate ideas about how SLPs can embrace public health approaches to improve care in socially and economically disadvantaged communities that may face barriers to using traditional models of SLP services. Our team’s next steps include evaluating the programme and exploring partnerships that will enable programme sustainability.
Footnotes
Acknowledgements
The authors are grateful to our partners at Early Words and the Hamilton Wentworth Catholic District School Board, who helped to develop, deliver, and evaluate this programme.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by a CanChild Internal Grant Opportunity (2019-2024) and the Hamilton Community Foundation: Community Health, Education & Research Fund (2023-2025).
Declaration of Conflicting Interests
The authors have no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.