Cultural proficiency 101: Reconsidering the 30 million word gap


Back in the 1980s, Hart & Risley conducted a hallmark study documenting that children from poor communities hear 30 million fewer words than middle class children. This finding has been often cited to document why so many low SES children perform poorly when they enter school and score lower on measures of language and vocabulary.

Sperry et al. brought the results of this study into question, with the idea that the original methodology of the study may have been culturally biased and not applicable to real-life environments. In particular, the original study looked only at directed speech from the primary caregiver (usually the mother) to the child. They did not measure the number of words spoken by other members of the household, speech that the child may have overheard, and they encouraged the family members not to talk to each other so that they could focus on just the mother/child interaction.

While interaction between the primary caregiver is certainly important, Sperry et al. attempted to expand our knowledge of children’s verbal environments by measuring all speech directed to the child and all bystander or “overheard” speech. The findings were quite interesting. There was no significant gap between number of words heard among any social or economic class. Additionally, some working class and poor communities showed an advantage in the number of words the children heard. Additionally, there was significant variation within classes, rather than between classes. For instance, in this study, poor African American families in the south addressed far more words to their children compared to primary caregivers from other low SES communities (e.g. rural, working class).

These results are important to consider as EI therapists working with diverse families. Often times minority families are viewed in a “one size fits all” context, viewing the majority group (middle class American families) as the model. In fact, in many cultures, children are not spoken to directly during the first few years of life, but still reach developmental language milestones similarly to American children. In sum, different cultures have different preferred ways of interacting with their children, which may all have different benefits. As culturally proficient therapists, we need to look at the whole family.

P.S. This article sparked a bit of a debate:

For a response to this article from another group of researchers, click here.

For Sperry et al.’s reply, click here.

And for even more on different qualities of child-directed speech, see Tal & Arnon’s study, where they found the number of variation sets differed between high-SES and low-SES groups. Variation sets happen when an adult focuses on a theme, and then talks a lot about that theme in a series of comments and questions. The authors suggest more information is needed on the different qualities of child-directed speech in order to make predictions about language outcomes.


Sperry, D. E., Sperry, L. L., Miller, P.J., (2018). Reexamining the verbal environments of children from different socioeconomic backgrounds. Child Development. Advance online publication. doi: 10.1111/cdev.13072 

Cultural differences in conversational turn-taking


I think we’re all aware that amount and type of talk that young children are exposed to can have a big impact on their language development. But what about the influence of culture on caregiver–child interactions? Understanding this factor as it relates to the language development of each child that we work with is necessary if we’re committed to providing culturally sensitive, appropriate services and recommendations to families.

This study used the Language ENvironment Analysis (LENA) system to analyze conversational turn-taking between parents and two- and three-year-old Canadian and Vietnamese children with and without hearing loss. Main findings:

  • Vietnamese families verbally interacted significantly less than Canadian families, regardless of hearing status

  • Hearing status didn’t impact the amount of talk in the homes of Canadian or Vietnamese children

This study emphasizes the importance of placing culture at the forefront of our focus when it comes to identifying language delays and appropriate recommendations for families of young children with and without hearing loss. Findings from this study suggest that direct observations of parent–child interactions in a natural setting can provide important insight regarding cultural expectations and norms.

Ganek, H., Smyth, R., Nixon, S., & Eriks-Brophy. (2018). Using the Language Environment Analysis (LENA) system to investigate cultural differences in conversational turn count. Journal of Speech, Language, and Hearing Research, 61, 2246–2258.

Toddlers with ASD can use verbal input (without visuals!) to learn

Using visuals with toddlers with ASD is practically the gold standard in early intervention. Temple Grandin taught us that some people with ASD can more easily understand a picture than a sentence. However, Fitch et al. showed that toddlers with ASD can use verbal information to update their expectations of the world.

This study focused on mental representations, which is just a fancy term for pictures or concepts in our head. If a parent said to you “Jackson took three steps yesterday” you would probably form a mental representation of Jackson toddling along in his living room. If the parent then said “it happened at the park” you would update your mental representation to include the park as the setting, instead of the living room.


This seems simple for us, but it’s actually pretty complex, and typical infants can do this by their 2nd birthdays. For verbal updating to occur, the child must be able to understand that language can refer to something that is absent or that they cannot see. They must also retrieve the prior representation, comprehend the new verbal input, and then manipulate their representation to incorporate new information.

This study found that toddlers with ASD, who had significant language delays, were able to learn with solely verbal information just as well as typically developing peers.  The authors suggested that verbal comprehension abilities may be underestimated using traditional language testing in toddlers. And as an SLP, I personally might interpret these results as supporting use of narration and language modeling even in the absence of visual referents with toddlers, as they may actually be listening, learning and updating their knowledge.

Side note—the authors used a really interesting eye-tracking method to measure whether infants understood verbal information, so check out the original article for more information on that!    


Fitch, A., Valadez, A., Ganea, P.A., Carter, A.S., & Kaldy, Z. (2018). Toddlers with autism spectrum disorder can use language to update their expectations about the world. Journal of Autism and Developmental Disorders. Advance online publication. doi: 10.1007/s10803-018-3706-7

Coordination Station: Combining verbal & nonverbal skills for infants with ASD

As early interventionists, we work on joint attention and early vocalizations with children all the time. However, do you ever target joint attention & vocalization together?

Heymann et al. studied the coordination of joint attention and vocalization in infants at high risk for autism. Infants in this study already had an older sibling with a diagnosis of ASD. Researchers followed these infants from 5 months to 36 months to track development of joint attention, vocalization, and whether or not the infant was eventually diagnosed with ASD or a language delay.


As expected, infants who later developed ASD demonstrated lower joint attention and vocalization compared to their high-risk peers, and their communicative behaviors were less advanced. Interestingly, infants with ASD vocalized significantly less during joint attention moments compared to their peers as well. These differences in communicative skills have a feedback-loop effect on the child’s environment. Caregivers are less likely to respond to communicative attempts that do not include vocalization, so they might not even notice that a child is making a non-verbal bid for communication. Also, parents have been shown to use lower quality responses with infants who don’t use advanced behaviors. As you can see, infants with impaired communication skills may incite small or minimal changes in their home environment, and that is not ideal for language development!

So how can we take this information and apply it to our everyday therapy? The authors suggest targeting both vocalization & joint attention behaviors together could lead to enhanced communication skills in infants with ASD as well as their high-risk siblings. We can also coach parents to respond to less advanced and less salient communication bids from their infants. This information is also great to keep at the back of your mind while monitoring younger siblings of children with ASD so that they can receive intervention as early as possible!  


Heymann, P., Northrup, J.B., West, K. L., Parladé, M. V., Leezebaum, N.B., & Iverson, J.M. (2018). Coordination is key: Joint attention and vocalization in infant siblings of children with autism spectrum disorder. International Journal of Language & Communication Disorders, 53(5), 1007–1020.

On toddler vocabulary and categories

Picture this typical parent–child scenario:

A 2-year-old and his mom are walking through the grocery store together. As the parent puts food into the shopping cart, she labels some items that her child isn’t familiar with,  

{“Look, this is cauliflower. And, this is lettuce.”}

… while far more vegetables that she buys (like, green beans) go unlabeled because, quite frankly, it would be impossible for her to name every single new vegetable that they come across in the store. And, yet, her son learns what “cauliflower” and “lettuce” are, and that they’re both a vegetable. And, he also somehow (magically) develops an understanding of the far greater number of vegetables that went unlabeled during their shopping trip (including those green beans). How does this happen??? 

The authors of this study looked at whether infants and toddlers use what they refer to as “semi-supervised learning”. Basically, the idea is that the objects that are labeled for young children (in this case, cauliflower and lettuce) help them to develop an understanding of the category of those objects (vegetables). And, then they use what they know about that category to learn about the much larger number of items that go unlabeled (green beans) from that same category.


The results showed that two-year-olds only needed two items from a new category to be labeled for them to be able to identify other, unlabeled items from that same category. And, this was just as effective as providing labels for all of the objects (but, the children were unsuccessful when none of the items were labeled). 

There are two big take-aways from this study for those of us working with the birth to three population: First, it seems that less is more. In other words, it’s not necessary for us to label a million different objects to teach infants and toddlers a new category; in fact, just a few labels will do. The results also suggest that when we’re teaching vocabulary to infants and toddlers, the items that we do label should be clear representations of the category that they belong to so that they’re able to develop a strong understanding of that category.


LaTourrette, A. & Waxman, S. R. (2018). A little labeling goes a long way: Semi-supervised learning in infancy. Developmental Science. Advance online publication. doi: 10.1111/desc.12736

Dissecting joint attention

Reduced initiation of joint attention using gestures at 12 months of age. What’s that a sign of? Autism? (yep) Developmental language disorder*? (yes!)


How we know: 

This study classified infants into four groups*: 

  1. ASD

  2. Language Disorder

  3. High Risk, no disorder

  4. Low Risk, no disorder

Initiation of joint attention, or IJA, was measured by frequency (how often the children initiated joint attention), variety (how many different ways the children initiated joint attention, such as eye gaze or pointing), and quality (whether the children were able to coordinate different varieties of communication to establish joint attention). Initiations of behavioral requests (IBR) were also coded. IBR and IJA differ in the purpose of the gestures: with IBR, children are communicating for the purpose of getting something they want or need. IJA is more social and more related to sharing a moment with a caregiver. If you’ve ever given the ADOS or the M-CHAT-R/F, this distinction shouldn’t be new.  

IJA and IBR were also broken down into high- and low- level categories (see Table 2 in the study for more detailed descriptions):


Unsurprisingly, the ASD group showed less frequent, less varied, and lower quality IJA than the other three groups at 18 months. What was surprising was that both children with ASD and Language Disorder had fewer instances of high-level IJA and IBR at 12 months than the non-disordered groups, indicating that reduced gesture use could be a red flag for both ASD and language disorder in 1-year-olds.

Data from the Autism Observation Scale for Infants (AOSI), Mullen Scales of Early Learning (MSEL), the Autism Diagnostic Observation Schedule (ADOS), and video-recorded sessions.

*Developmental language disorder is the same as language impairment, and a broader term than specific language impairment (SLI). Not familiar with this new term? Read more here or here.

Franchini, M., Hamodat, T., Armstrong, V. L., Sacrey, L.-A R., Brian, J., Bryson, S. E., …, & Smith, I. M. (2018). Infants at risk for autism spectrum disorder: Frequency, quality, and variety of joint attention behaviors. Journal of Abnormal Child Psychology. Advance online publication. doi: 10.1007/s10802-018-0471-1.

Robots in preschool

When you hear the word, “technology” the first thing that pops into your head is probably a smart phone, tablet, or laptop, right? But, what about robots?

{Yes, I said robots.}

More and more early childhood learning centers are incorporating various robots into the classroom. This is a fairly new thing, but the available research on child learning has been very positive. From Bee-bots (that look like bees!) to DragonBots (small, soft, stretchy robots) to humanoid robots, benefits for language-learning, social skills, and attention have been found (see article for review).

The authors of this study examined the integration of humanoid robots into the curriculum to support 3-, 4-, and 5-year old children’s learning and development. Results suggested that despite the early childhood teachers’ and teaching assistants’ lack of experience in integrating this type of technology, they were enthusiastic about using the humanoid robot as part of the preschool curriculum. And, all of the students benefitted: presence of the robot resulted in increased talk, use of questions, eye contact, and other social skills such as turn taking and cooperation.

This is a small study, but paired with other, related research, the findings are encouraging; particularly, in considering the influence that a robot in the classroom or therapy session could have on a young child’s motivation and engagement. As we continue to incorporate more technology into our therapy sessions, use of a robot like the one included in this study may be another way to motivate young children who are reticent or may benefit from alternate learning modalities.


Crompton, H., Gregory, K., & Burke, D. (2018). Humanoid robots supporting children’s learning in an early childhood setting. British Journal of Educational Technology, 49(5), 911–927.

And more...

Normally we try to keep this section fairly brief for you all, but holy moly there was so much research this month!

  • Bradshaw, et al. examined differences in communication and play in groups of infants at high- and low-risk for ASD. High-risk 12-month-olds who were considered “prewalkers” (who didn’t stand or walk) showed significantly lower scores on the CSBS in terms of play skills, gesture use, word use, and behavior measures such as protesting. Even though both high-risk and low-risk groups had similar numbers of prewalkers, standers, and walkers, the authors suggest their results “confirm that the lower social communication scores observed in high-risk infant prewalkers are clinically significant and suggests that these infants may be at higher risk for social communication delays.” SLPs working in the PSP model could keep this information in mind while discussing intake and evaluation plans or while reviewing quarterly updates during teaming meetings. Note: the authors caution that the participants in their study were mostly white, highly educated families, and that results may not generalize to all populations.

  • In a study of over 1200 families in poor rural regions, Burchinal et al. confirmed the presence of a large gap in school readiness skills that emerges during the first five years of life. Specifically, children who experienced poverty before the age of two had more significant delays on their language, cognitive, social, and executive functioning. Self-regulation and executive functioning skills played an important role in school readiness at age five. Check out the original article for a more in-depth analysis of the relationship between poverty & school readiness.

  • If you’re an EI therapist, you’ve most likely evaluated a child who was born premature at one time or another, so you’re also most likely familiar with the idea of age correction. You may have corrected for age on one or more assessments, but you may have also wondered if that’s best practice. And, if it is, when should we stop correcting for age? Harel-Gardassi et al. used the Mullen Scales of Early Learning (MSEL) test to see how age correction impacted the scores of preterm infants at 1, 4, 8, 12, 18, 24, and 36 months of age. Not surprisingly, corrected age scores were found to be significantly higher than chronological scores at all ages, with factors such as gestational age and birth weight affecting the level of difference between the two scores. These findings also suggest that if you use the MSEL, you should be using age correction until the adjusted age of three, not the currently recommended age of two.

  • In terms of input, the large majority of what children, including infants, are exposed to on a day-to-day basis is connected speech, while isolated words are heard infrequently and inconsistently. So, do the single words that infants are exposed to have any kind of impact on their language development? This recent study by Keren-Portnoy et al. of 12-month-olds showed that isolated words, instead of words presented at the end of an utterance, were easier for the children to recognize and remember.

  • Lim and Charlop found that speaking a child’s heritage language during play-based intervention sessions seemed to help four bilingual children with ASD play in more functional and interactive ways. The experimenters followed scripts for giving play instructions, verbal praise, and making comments related to play in both English and each child’s heritage language (in this study, Korean or Spanish). None of the children played functionally or interactively before the intervention, but all of the children showed an increase in play during and after intervention sessions in both English and the heritage language, with more impressive gains seen in heritage language sessions. More research is needed, but SLPs should keep this in mind when working with bilingual children with ASD (note: study done on older children).

  • In a qualitative study by Núñez & Hughes, Latina mothers reported higher satisfaction with early intervention services when they had bilingual support through an interpreter or bilingual SLP, received clear explanations about services and paperwork, felt the SLP respected their wishes, and were provided with strategies to work on with their children outside of SLP sessions.

  • Rague et al. found that infants with Fragile X syndrome use fewer gestures than infants at both high and low risk for ASD. Children with Fragile X who used fewer gestures tended to have lower nonverbal abilities. A lack of early gesture use in infants with Fragile X may be an indicator of the child’s broad cognitive ability.  

  • Thrum et al. found that toddlers between 18 and 24 months with language delay had significantly more socioemotional and behavioral problems compared to toddlers without language delay. At 18 months, more than half of children with language delays had scores within the range of clinical concern! These results underscore the importance of early detection & treatment for children with language delays.

  • Torrisi et al. found that toddlers’ communication scores on the Ages and Stages Questionnaire (ASQCS) were not directly associated with mothers’ diagnoses of PTSD related interpersonal violence, but communication development was affected when mothers showed more controlling behavior and were less sensitive to their toddlers. Both of these qualities of maternal behavior were also correlated with severity of PTSD symptoms. This is important information to keep in mind when providing services to families at risk for experiencing or with a history of interpersonal violence.

  • Yu, et al measured 9-month-old typically-developing infants’ attention to objects and joint attention with their parents, to tease out what exactly contributes to vocabulary growth in the first year of life. They found that sustained attention with and without joint attention predicted vocabulary size at 12 and 15 months, but joint attention alone did not predict vocabulary growth. We need more research to figure out exactly how to use this information clinically, but in the meantime, we can always continue to help caregivers make the best use of their children’s interest and attention during play to support vocabulary growth.


Bradshaw, J., Klaiman, C., Gillespie, S., Brane, N., Lewis, M., & Saulnier, C. (2018). Walking ability is associated with social communication skills in infants at high risk for autism spectrum disorder. Infancy. Advance online publication. doi: 10.1111/infa.12242.

Burchinal, M., Carr, R.C., Vernon-Feagans, L.V., Blair, C., Cox, M. (2018). Depth, persistence, and timing of poverty and the development of school readiness skills in rural low-income regions: Results from the family life project. Early Childhood Research Quarterly, 45, 115–130.

Harel-Gadassi, A., Friedlander, E., Yaari, M., Bar-Oz, B., Eventov-Friedman, S., Mankuta, D., & Yirmiya, N. (2018). Development assessment of preterm infants: Chronological or corrected age? Research in Developmental Disabilities, 80, 35–43.

Keren-Portnoy, T., Vihman, M., & Lindop Fisher R. (2018). Do infants learn from isolated words? An ecological study. Language Learning and Development. Advance online publication. doi: 10.1080/15475441.2018.1503542.

Lim, N. & Charlop, M. H. (2018). Effects of English versus heritage language on play in bilingually exposed children with autism spectrum disorder. Behavioral Interventions. Advance online publication. doi: 10.1002/bin.1644.

Núñez, G., & Hughes, M. T. (2018). Latina mothers’ perceptions and experiences of home-based speech and language therapy. Perspectives of the ASHA Special Interest Groups, 14(3), 40–56.

Rague, L., Caravella, K., Tonnsen, B., Klusek, J., & Roberts, J. (2018). Early gesture use in fragile X syndrome. Journal of Intellectual Disability Research, 62(7), 625–636.

Thurm, A., Manwaring, S.S., Jimenez, C.C., Swineford, L., Farmer, C., Gallo, R., Maeda, M. (2018). Socioemotional and behavioral problems in toddlers with language delay. Infant Mental Health Journal, 38(5), 569–580. 

Torrisi, R., Arnautovic, E., Pointet Perizzolo, V. C., Vital, M., Manini, A., Suardi, F., …, & Schechter, D. S. (2018). Developmental delay in communication among toddlers and its relationship to caregiving behavior among violence-exposed, posttraumatically stressed mothers. Research in Developmental Disabilities. Advance online publication. doi: 10.1016/j.ridd.2018.04.008.

Yu, C., Suanda, S. H., & Smith, L. B. (2018). Infant sustained attention but not joint attention to objects at 9 months predicts vocabulary at 12 and 15 months. Developmental Science. Advance online publication. doi: 10.1111/desc.12735.

We can’t catch ‘em all; or can we?

Have you ever worked with one of those “quirky” children and thought, “I wonder how he’ll do later?” I mean, sometimes a quirk is just that, but how do we know when a quirk is something more? And why does it matter? Well, we know that early identification (for purposes of securing early intervention) is important for children with autism. But the false-negative rate from screening might be as high as 60% in some cases. That means that some children with autism are not being caught before school age, either because their symptoms aren’t that bad, or the skills they do have are compensating for the deficits. Without a crystal ball, what can we do for those kids who would otherwise fall through the cracks? The authors of this study looked to compare results of the Autism Diagnostic Interview-Revised (ADI-R) in two groups of children with ASD: early diagnosed (before age 5), and late diagnosed (after age 5).


They found no statistically significant difference between groups in Autism Diagnostic Observation Schedule (ADOS) scores or ADI-R scores, although the early diagnosed group had marginally worse communication scores and more often flagged on items such as “used another’s body to communicate”, repetitive use of objects/parts of objects, and pronominal reversal (when children use "he", "she", "you", or their own name instead of “I” or “me”). The later diagnosed group had fewer symptoms and better communication, but again these differences were marginal.

The authors also found some trends between groups in terms of demographics. Children who were Hispanic, of racial minority, had an additional diagnosis such as ADHD, and/or had higher verbal and full-scale IQs were significantly more likely to be diagnosed later.

Now, if you forget the rest of this review, remember this part: in comparing individual items from the ADI-R, there were five symptoms that ALL of the later-diagnosed children displayed. “Deficits in:

  • reciprocal conversation
  • offering to share
  • imaginative play with peers
  • social verbalization/chatting and
  • showing/directing attention.”

What is interesting about these symptoms is that they were all negative. In other words, kids diagnosed later seemed to “not do” stuff they should have, rather than do extra stuff that would raise a concern (like flapping or showing repetitive interests). The authors suggest that “attention to deficits in these behaviors may facilitate earlier identification of ASD without other obvious impairments.” Completing or referring for a more formal assessment when you notice a child has these symptoms could make a difference in outcomes for these children.

*Note: some skills, like being able to have a back-and-forth conversation, aren’t a major concern if toddlers haven’t quite mastered them, but if a child is still demonstrating these deficits by preschool, make that referral!

Goodwin, A., Matthews, N. L., & Smith, C. J. (2018). Parent-reported early symptoms of autism spectrum disorder in children without intellectual disability who were diagnosed at school age. Autism. Advance online publication. doi: 10.1177/1362361318777243

Screening for ASD? There’s an app for that!

Screening for autism in early intervention. From 16–30 months, we have the M-CHAT-R. What do you use beyond 30 months? The SRS-2 is an option now, but there is not a lot of research on how well it works yet. The SCQ starts at 4 years. And all of those are completed through parent report.

What if we had a screener that combined parent report with objective measurement, that could be administered on a parent’s smart phone? Enter Cognoa!


This two-part screener, intended for ages 18–72 months, is contained in a mobile app. Parents answer 15 questions (similar to the M-CHAT-R or SCQ), and then are prompted to record 1- to 2-minute videos of their children in everyday interactions. The questionnaire is scored immediately, and the videos are reviewed by experienced clinicians for a rating score. All of those scores go into algorithms (yay technology) to determine level of risk. Results are then sent to the family, physician, EI team, etc. Kanne, et al. evaluated Cognoa against other screening measures like the M-CHAT-R, SCQ, SRS, and CBCL and found it to be comparatively sensitive and more specific than those screenings. In other words, Cognoa correctly flagged for ASD evaluation as well as the screenings we already use, and it had fewer false positive screenings. Not bad! Unfortunately, there is a downside. Currently, Cognoa is only really available for parents whose employers buy access to the screenings as a health incentive to their employees. In the meantime, we might have to stick with the measures we already know, but keep your eyes and ears peeled in case this app picks up steam!


Kanne, S. M., Carpenter, L. A., & Warren. Z. (2018). Screening in toddlers and preschoolers at risk for autism spectrum disorder: Evaluating a novel mobile-health screening tool. Autism Research. Advance online publication. doi: 10.1002/aur.1959


Hey, wait! This isn’t the only article on autism screening tools found this month! Janvier et al. found that a simple picture-based developmental checklist could successfully differentiate children with and without ASD among low-income, minority families. This screening tool, The Developmental Check In, may be a useful way to screen for autism among underserved children, particularly when parents are not native English speakers.


Janvier, Y.M., Coffield, C.N., Harris, J.F., Mandell, D.S., & Cidav, Z. (2018). The Developmental Check-In: Development and initial testing of an autism screening tool targeting young children from underserved communities. Autism. Advance online publication: doi: 10.1177/1362361318770430