Identifying early learning delays in preterm infants

Do you remember a few months back when we learned that preterm infants don’t seem to catch up to their peers’ language skills by school age? Well, this study took a look at how premature and full-term infants learn, and found some interesting differences we can add to our list of things to watch in our preterm cases.

The authors repeated assessments on 23 full term and 30 preterm infants over a period of 18 months to see if there were changes in how the infants performed on means-end tasks, which included a towel or a turntable as the means, and a fun toy as the end. In other words, the authors recorded whether the babies could pull the towel or turn the turntable to get a toy. Success requires a whole bunch of sensory, motor, and cognitive abilities to interact, and typical infants can complete a one-step means-end task like towel pulling by about 8 months (see here for an older study). They also recorded how much time the infants spent exploring, how many different ways the infants interacted with the task, and how many times the infants successfully completed the trials.


The authors found that all infants got better at getting the toy with age, but preterm infants as a group were less likely to succeed in both tasks compared to full-term infants (2.25 times less likely in the towel task and 1.55 times less likely in the turntable task). The authors also found differences in how the babies explored during the tasks. While everyone explored more over time, babies who explored more early in development had more success with the means-end tasks overall. Not only that, but preterm babies showed more variability in their exploration later in development than the full-term babies. As it turns out, we decrease the variability in exploration as we fine-tune our skills. Think about it this way—when we learn a new skill, we try it this way, try it that way, try it another way, and store maps for the most efficient ways to do the skill. We explore less as we get good at it, but pre-term babies continued to explore different behaviors longer than full-term babies in the means-end tasks.

OK, got it. But how can we use it? Diagnostically, we could use these tasks during assessments (the authors suggest the towel task for 5- to 7-month-olds and the turntable task for 11- to 13-month olds). Red flags would include lack of exploration in earlier ages and lots of variability in exploration later in infancy. For intervention, we should remember to encourage infants to explore solutions. Instead of modeling the solution, have fun in the learning process! We can also call attention to the end object so infant can see what happens to the toy when she acts on the towel or the turntable. Help these babies become the little scientists they were born to be!


Cunha, A. B., Babik, I., Ross, S. M., Logan, S. W., Galloway, J. C., Clary, E., & Lobo, M. A. (2018). Prematurity may negatively impact means-end problem solving across the first two years of life. Research in Developmental Disabilities. Advance online publication. doi: 10.1016/j.ridd.2018.03.007

Using fine motor skills to predict language outcomes

Wait... using fine motor skills to predict language outcomes? People who don’t know child development might do a double take on that one. EI SLPs, on the other hand, know that all aspects of early development are connected and there might be some information we can use here!

The authors of this study measured fine motor growth and expressive language over the first three years of life using the Mullen Scales of Early Learning (MSEL), and confirmed or ruled out a diagnosis of autism for at-risk children (kids who had a sibling with a diagnosis of ASD). They wanted to see if there were differences in fine motor development among kids at high risk who ended up with an ASD diagnosis (HRA+), kids at high risk who did not end up with a diagnosis (HRA-), and low risk kids who did not have a sibling with ASD (LRC). They also wanted to know if early fine motor skills predicted expressive language at 3 years.


Well? There was no difference in status of fine motor skills at 6 months. But the HRA+ group showed slower fine motor development between 6 months and 2 years of age compared to the LRC group. The authors state, "Only beginning in the second year of life, did high-risk infants who were later diagnosed with ASD score significantly lower on the MSEL Fine Motor scale than high- and low-risk infants without eventual diagnosis." The authors suggest, “Our finding is consistent with those from prior research indicating that fine motor differences may be a characteristic of infants at high risk for ASD, rather than a core characteristic of the disorder.” One thing we should note is that, even though there were differences between groups in the statistical analysis, all of these fine motor scores fell within average range, so in individual assessments there might not be a flashing red light around that fine motor score.

What is really relevant to EI SLPs is that children who had better fine motor skills in early development had better expressive language scores at 3 years, and this association held for all three groups. The authors cite literature suggesting we might support language development by encouraging fine motor development in infancy (but this remains a hypothesis—they don’t yet have data to show that would work). For those of you who work under a Primary Service Provider model, this might be a good study to share with your teams!


Choi, B., Leech., K. A., Tager-Flusberg, H., & Nelson, C. A. (2018). Development of fine motor skills is associated with expressive language outcomes in infants at high and low risk for autism spectrum disorder. Journal of Neurodevelopmental Disorders, 10(14), 1–11.

Facilitating parent–child playgroups: A how-to guide


Most of us early interventionists work with families one-on-one. But how great would it be to facilitate a parent/child playgroup? Not only could you work with multiple children at once, but you could also connect families going through similar experiences. Green et al. investigated a specific type of playgroup geared toward enhancing parent interaction in communication (referred to as EPIIC) playgroups.

The EPIIC playground was structured like a typical morning preschool session. They did a hello song, a play activity, story time, and snack. They also built in time to address each child’s individual IFSP goals. Each playgroup session had a different theme, such as “what makes me learn to love books” and “what makes me laugh.”

Instead of the teacher or SLP leading the group, the parents worked directly with their children while being coached by the SLP. For instance, the SLP might model a page or two of shared book-reading, and then let the parent take over. The SLP facilitates the session, while parents interact with their child, learn new strategies, and meet other parents in their same boat!

After seven playgroup sessions, all children demonstrated increased communication skills. All of the parents improved their use of communication strategies with their children. Informally, parents reported being very happy with the playgroup, and felt that they learned new strategies and gained knowledge. The EPIIC playgroup model seems like a pretty epic way to deliver evidence-based services to families. Get it?

For a specific breakdown of the playgroup schedule and a full list of the topics used, be sure to check out the original article here.


Green, K. B., Towson, J. A., Head, C., Janowski, B., & Smith, L. (2018). Facilitated playgroups to promote speech and language skills of young children with communication delays: A pilot study. Child Language and Teaching, 34(1) 37–52.

Hip hip hooray for symbolic play!


We know how important play is for the under-three crowd. But what types of play should we be focusing on to promote communication? Quinn & Kidd looked at two different types of play: functional vs. symbolic play. Which one promotes greater communication development? 

Functional play involves using toys for their intended purpose. To promote functional play, the children and parents in this study were provided with magnetic drawing boards, wooden peg and hammer sets, puzzles, and musical instruments. Conversely, symbolic play involves the non-literal use of objects, such as using one object to represent another. The authors added that this typically occurs ~in the spirit of enjoyment~ (lol). To promote symbolic play between parent and child, the pair was given toy household items, toy phones, a teddy bear, and ambiguous items like block shapes and a piece of cloth.

This study found that during symbolic play, parents and their children engaged in joint attention more often and for longer periods of time. Symbolic play also elicited significantly more symbolic gestures from both toddlers & their parents. Symbolic gestures are gestures that represent an object or action, such as using fingers to pretend to comb a doll’s hair.

Joint attention and use of symbolic gestures are both foundational skills that are crucial for language development. The authors suggest that symbolic play is so vital to communication development because it requires collective negotiation and agreement of the representational function of objects. Symbolic play cannot successfully occur unless both the parent and child understand what the objects represent. These negotiations occur naturally and without the use of language. Toddler’s brains are pretty amazing, huh?

This study contributes to our understanding of the importance of engaging in symbolic play when working with our population. Symbolic play naturally requires the use of foundational skills necessary for communication. So, feel free to keep on using that hairbrush as a microphone, SLPs!


Quinn, S., & Kidd, E. (2018). Symbolic play promotes non-verbal communicative exchange in infant-caregiver dyads. British Journal of Developmental Psychology. 10.1111/bjdp.12251.

Throwback (2014): Can toddlers learn language from participating in video chats?

Screen time, visual media, tablets, computers, video games, Skype, FaceTime…

Young kids are exposed to a variety of technology whether directly or indirectly on a daily basis. The American Academy of Pediatrics has provided recommendations for the amount of exposure and screen time for young children based on their age. But, these suggestions don’t answer the question of whether toddlers and preschoolers are actually getting anything out of the language they’re being exposed to through screen media.

Previous research (e.g., Kuhl, Tsao & Liu, 2003) has demonstrated what is referred to as a “video deficit” (Anderson & Pemek, 2005), which suggests that mode of input (live person versus a comparable media source) matters when it comes to language acquisition. While this is good information, the real question is—what’s happening during the live interaction compared to the video-based interaction that makes the difference for language learning? And, does that mean that kids can never benefit from linguistic input provided in a video?

Evidence outside of the field of speech–language pathology has shown that socially contingent interactions (Troseth, Saylor & Archer, 2006; Zimmerman et al., 2007) make all the difference when it comes to early language development. Socially contingent conversational partners provide immediate, reliable, and accurate responses, use the child’s name, make eye contact, ask questions, and take conversational turns (e.g., Csibra, 2010). 

Given this information paired with the rising popularity of video chat platforms like Skype, FaceTime, and Google Chat, the authors of this study wanted to determine the role of social contingency in word learning by comparing live interaction, video chat, and a prerecorded video chat. Thirty-six two-year-olds were randomly assigned to one of these three training conditions, and were taught one of four novel verbs:                                                                                         

blicking (= bouncing)

twilling (= swinging)

frapping (= shaking)

meeping (= turning)

In addition to measuring the children’s ability to learn one of these verbs, the researchers also collected eye-tracking data to determine whether eye contact had a relationship to word learning.


Results from the study suggested that the toddlers were only able to learn novel words from video chats and live interaction—the two conditions that included socially contingent interactions—but, not from the prerecorded video formats. And, the children who learned the verbs in these conditions were able to generalize their understanding to different contexts. Eye contact also played a role in word learning: the children who attended to the experimenter’s eyes learned the novel words better than those that had less consistent eye contact.

Put together, these results suggest that social contingency is, in fact, the key ingredient when we’re thinking about teaching children under the age of three new words. Regardless of whether we’re interacting with the child in person or via video chat (think, telepractice!), including all of the elements of social contingency—eye contact, immediate responses, using the child’s name, asking questions, and taking and encouraging conversational turns—can make the difference in terms of the child actually benefiting linguistically.*

(*In fact, previous research (e.g., O’Doherty et al., 2011) has shown that toddlers learn better from watching a social interaction between two characters versus watching shows that follow a similar format to the prerecorded video chat condition. So, shows like Blue Clues that attempt to interact with the audience indirectly by posing questions, pausing, and then providing a response, may not be as beneficial as one might think.)


Roseberry, S., Hirsh-Pasek, K., & Golinkoff, R. (2014). Skype me! Socially Contingent Interactions Help Toddlers Learn Language. Child Development, 85(3), 956–970.

Perspectives & Tutorials

Sentence diversity in early language development: Recommendations for target selection and progress monitoring

Recall that we don’t review Perspectives, Tutorials, or Opinion pieces. Only empirical research. Technically, these tutorials are lower evidence. But, here’s the tough thing: they’re often very clinically useful, and based upon high-quality empirical research! So what’s an Informed SLP to do?

We’ll tell you when we come across these papers, and if there’s a lot to say, we’ll discuss it on our Evidence Answers page. This article (above) is one such situation. Read more here.

A History of EI/ECSE in the United States: A Personal Perspective

This is a really fantastic perspective on the history of Early Intervention and where we should go next. A must read for anyone making decisions for Early Intervention programs!

And more

  • Bavin et al. found that in children with cochlear implants, pre-implant early receptive communication skills and early gesture use were the strongest predictors of vocabulary one year post-implant. Targeting receptive language and use of gestures may be the way to go if you are working with toddlers with hearing loss, prior to receiving a cochlear implant.
  • Cunningham et al remind clinicians and researchers alike to consider growth in outcomes related to engagement and participation rather than just impairment, and discuss predictors of communication participation outcomes. This is actually a very large study, with some strong data to show that speech­–language services, in general, work to improve the outcomes in early intervention. They also have intensity data here. So if you need a study to show that what we do really matters, this is a good one to add to your stack!
  • Although the research base that focuses on decoding, fluency, and reading comprehension in older children with autism continues to expand, relatively less is known about the emergent literacy skills of young children with ASD. Fluery and Lease (2018) examined code- and meaning-focused emergent literacy skills of 3 to 5-year-olds with ASD as well as their parents’ beliefs about their early reading development. Findings from this study have important clinical applications: First, variability in the children’s emergent literacy skills suggests that reading interventions for young children with ASD should be tailored to meet the individual needs of each child. Second, results suggested that parents of children with stronger communication skills had a more positive outlook on their child’s ability to benefit from reading exposure and instruction. This finding suggests that we need to provide extra support and education to parents whose children with ASD have more complex communication needs.
  • Eye gaze and, specifically, gaze following serves as an important social and language-learning tool for infants. What is still unclear is specifically what motivates an infant to follow a caregiver’s gaze. Findings from Gredeback, Astor, and Fawcett’s (2018) recent study suggest that social, attention-grabbing events (e.g., something as simple as a head turn) may be just as a strong of a motivator for infants to follow a caregiver’s gaze as previously recognized perceived communicative intent.
  • Ibanez et al examined the efficacy of a web-based program for training parents of children with ASD to use behavioral strategies in day-to-day routines such as bath time and snack. Parents in the tutorial group reported that they used more strategies, felt they parented more efficiently and experienced less stress, and reported that their children engaged and communicated more during daily routines. The article directs readers to an example of the tutorial and menu of current tutorials
  • Neuman et al. analyzed over 2000 scenes from language-focused educational media. Videos with attention-directing cues (basically zooming in on the target) were most successful in helping children learn new vocabulary. However, children with higher language scores were more likely to use these cues to learn vocabulary, so educational videos may not be as helpful for those with language delays.
  • Pearson, Oliver, and Waite surveyed parents of children with rare genetic syndromes to see what types of information these families felt they needed most to help their children. They found that concerns associated with Angelman syndrome included sleep, communication, and health, while parents of children with Cri du Chat syndrome were most concerned with health, behavior, and daily living skills, and parents of children with Cornelia de Lange syndrome often wanted information on behavior, health, and self-injury. The authors highlight the need for clinicians to be aware of and address parents’ perceptions and concerns about their children’s disorders.
  • Spinelli & Mesman found that both the prosody of infant-directed speech and caregiver sensitivity to infants’ social–emotional cues contribute together to infant social–emotional development. We can’t do “motherese” alone, we have to be able to read and respond to baby’s cues and interactive attempts. (Also, see here for more information on the effect of motherese on infant development).
  • We know that exposing young children to decontextualized language, or, abstract talk that’s removed from the here-and-now, can improve their later vocabulary, narrative skills, and reading comprehension. Uccelli et al.’s recent study provides a unique perspective by demonstrating a link between toddlers’ use of decontextualized talk and higher levels of academic language proficiency 10 years later.


Bavin, E.L., Sarant, J., Leigh, G., Prendergast, L., Busby, P., & Peterson, C. (2018). Children with cochlear implants in infancy: predictors of early vocabulary. International Journal of Language & Communication Disorders. Advance online publication. doi: 10.1111/1460-6984.12383

Cunningham, B. J., Hanna, S. E., Rosenbaum, P., Thomas-Stonell, N., & Oddson, B. (2018). Factors contributing to preschoolers’ communicative participation outcomes: Findings from a population-based longitudinal cohort study in Ontario, Canada. American Journal of Speech-Language Pathology, 27(2), 737-750. doi: 10.1044/2017_AJSLP-17-0079.

Fleury, V. P., & Lease, E. M. (2018). Early indication of reading difficulty? A descriptive analysis of emergent literacy skills in children with Autism Spectrum Disorder. Topics in Early Childhood Special Education, 0, 1 – 12.

Gredeback, G., Astor, K., & Fawcett, C. (2018). Gaze following is not dependent on ostensive cues: A critical test of natural pedagogy. Child Development. Advance online publication. doi: 10.1111/cdev.13026.

Ibanez, L. V., Kobak, K., Swanson, A., Wallace, L., Warren, Z., & Stone, W. L. (2018). Enhancing interactions during daily routines: A randomized controlled trial of a web-based tutorial for parents of young children with ASD. Autism Research, 11(2), 667–678.

Neuman, S. B., Wong, K.M., Flynn, R., & Kaefer, T. (2018). Learning vocabulary from educational media: The role of pedagogical supports for low-income preschoolers. Journal of Educational Psychology. Advance online publication. doi: 10.1037/edu0000278

Spinelli, M. &b Mesman, J. (2018). The regulation of infant negative emotions: The role of maternal sensitivity and infant-directed speech prosody. Infancy, 23(4), 502–518.

Uccelli, P., Demir-Lira, O. E., Rowe, M. L., Levine, M., & Goldin-Meadow, S. (2018). Children’s early decontextualized talk predicts academic language proficiency in midadolescence. Child Development. Advance online publication. doi:

Parent training: vocabulary growth for toddlers with hearing loss


Toddlers with hearing loss do not gain vocabulary at the same rate as toddlers with normal hearing. Some of the reasons for this delay are out of our control as therapists. We cannot change a child’s speech perception or the age at which the child received amplification. What we can do is manipulate the child’s environment to promote vocabulary growth.

Lund trained six parents of toddlers with hearing loss in two strategies: transparent naming and linguistic mapping.

Transparent naming is using a new vocabulary word while visually signaling (pointing) to the referent. This has been found to increase children’s vocabulary skills (groundbreaking, I know).  All six parents were able to increase their use of transparent naming with just two 45-minute training sessions.

Linguistic mapping is a little more complex. It involves overlaying words on a child’s communicative act after that child has initiated intentional communication. This is not simply narrating the actions of a child. It requires the communication partner to correctly interpret a child’s communicative attempt and quickly generate an appropriate utterance to go with it.  Only half of parents were able to adequately demonstrate linguistic mapping after two training sessions, which suggests that a little more time might be needed to teach parents this particular skill.

After training sessions were completed, four out of six children increased their rate of word learning. If you have any tots on your caseload with hearing loss, or who are struggling with word learning, you might consider training parents in transparent naming and linguistic mapping.

Lund, E. (2018). Effects of parent training on vocabulary scores of young children with hearing loss. American Journal of Speech-Language Pathology, 1–13. Advance online publication. doi: 10.1044/2018_AJSLP-16-0239

Parent training: supporting complex communication needs

Many early intervention centers are moving from a direct therapy model to a parent training/coaching model. This shift in philosophy can be challenging for many therapists, especially those who have heard “all you do is play!” from parents a few too many times. Teaching our intricate strategies to a parent with no background in language development is not easy!

Douglas et al., sheds some light on effective parent training and coaching. The study included four children with complex communication needs, multiple developmental areas impacted. At baseline, parents struggled to provide communication opportunities and often did not give adequate wait time. Parents then participated in training sessions based on the POWR method which involved the following steps:

  1. Prepare” a developmentally appropriate activity
  2. Offer opportunities for communication” (e.g. giving choices, asking questions, commenting)
  3. Wait for the child’s communication” (at least 5 seconds)
  4. Respond” appropriately to child’s communication

The best part of this training? It was all provided online. Parents participated in the training by watching videos on various modules on their own time. Their skills were then assessed in person. Do you see kids at daycare? Do you work with kids whose parents clean the kitchen during therapy? Of course you do. Providing training for parents to watch on their own time might motivate them to become more involved in their child’s communication. 

After receiving this online training parents increased their communication opportunities provided to the child and increased their responses to the child’s communication. The children also showed increased communicative attempts. Parent feedback indicated that they would prefer to have in-person coaching sessions to go along with the online trainings (us too!), as well as more video examples of strategies being implemented. This is definitely something to consider if you’re working with a parent training model for your EI students.

Douglas, S. N., Nordquist, E., Kammes, R., & Gerde, H. (2018). Online parent training to support children with complex communication needs. Infants & Young Children, 30(4), 299–303.

Parents' role in the identification of early signs of autism

There have been many advances in the early identification of autism in recent years, but did you know that the average age of diagnosis is still around 4 years old???!!!. I’m sure you’re thinking the same thing that I am—We need to do better than that!

When it comes to early identification of autism, previous research has shown that one way we can make sure we’re getting all of the information needed to make a well-informed decisions is by including more than one person’s input in the process. And, if we’re talking about the birth to 3 population and we’re talking about autism, we naturally think of including the parent, right? Many of the well-known, most frequently-used screening tools for identifying early signs of autism and communication delays are designed to be completed by the parent, or at least include a parent questionnaire component (think: M-CHAT and CSBS DP).


But, exactly how should we be using parent input? Should we be putting more or less weight on our clinical observations? When we’re talking about children under two, how accurately is a parent able to identify the early signs of ASD compared to an experienced clinician? If you’ve wondered these same kinds of things, I have some good news for you: the results from this study help to clarify the role that parents play in the early identification of autism. 

This study included 188 siblings of children with ASD and their primary caregivers. Parents completed the Autism Parent Screen for Infants [APSI], and SLPs completed the corresponding Autism Observation Scale for Infants [AOSI] when the children were 12 months, and then again at 18 months. Parent response to the 19 items included in both the APSI and the AOSI (e.g., vocalizing back and forth, showing interest and pleasure, imitating, eye contact) were compared to the clinicians’ responses. And, the results were not only interesting, but also extremely informative: parents identified more behaviors on the APSI that differentiated children diagnosed with ASD from typically-developing children compared to clinicians’ identification of behaviors on the AOSI.

So, based on this information, when it comes to early identification of autism, we really should be viewing parents as a first line of defense. The setting as well as the context of our assessments limit our ability to get all of the information. We need to rely on parents to help us fill in the gaps, adding specificity and depth to our understanding of the developing communication skills of children under 18 months of age. Now more than ever, we need to see parents as our allies, and as key contributors to the assessment process.

Sacrey, et al., (2018). Parent and clinician agreement regarding early behavioral signs in 12- and 18-month-old infants at-risk of Autism Spectrum Disorder. Autism Research, 11(3), 539–547.