Input–output symmetry: why it matters for AAC users, and a word list to help

Child output = speech

Adult input = speech

Child output = AAC

Adult input = speech……. Whoops!? See how that might be a problem for learning?

How about:

Child output = AAC

Adult input = aided input (pointing to graphic symbols during speech)

“Among children with complex communication needs, vocabulary selection for aided AAC has almost exclusively been driven by consideration of expressive language needs. However, receptive language is critical to expres.png

No matter a child’s mode(s) of expressive communication, it’s our job to help ensure that they are getting receptive examples that match their expressive output, as often as possible. How? Encourage parents to use aided input, right? Simple!

Not simple. Consider this—are the words the family uses most frequently on the child’s device? Often times children’s AAC is programmed only for the child’s lexicon. But shouldn’t it also be set up for the words s/he is learning?

To help tackle the input–output asymmetry issue, this paper provides a list of words you may want to consider for programming young clients’ communication systems. The list is a compilation and comparison of data from three large sets, identifying words mothers use most frequently when speaking to their toddlers, as well as words most commonly spoken by toddlers and preschoolers.

They found that just over 250 words comprise most of mothers’ child-directed speech, with considerable overlap between mothers’ most frequent words and the words used by children (and this includes children unrelated to the mothers!… but arguably from similar cultural backgrounds). Another interesting finding: some mothers talk more than others (like, four times more), but the difference in lexical diversity among mothers (that is, number of different words) isn’t so high.

Though limitations include the fact that this research was done on typically-developing children, and it’s a new analysis of a ton of old data (from the late 80s forward), it “…provides a beginning place for guiding vocabulary selection.” So, basically, this list could be very useful as long as you take generational and cultural considerations in mind. So maybe add words like “tablet”? And please just ignore the fact that the data is on “mothers”, not parents in general—the world wasn’t as woke 20 years ago. 

This review is published in both the Early Intervention & Preschool & School-Age sections. 

Quick, N., Erickson, K., Mccright, J. (2019). The most frequently used words: Comparing child-directed speech and young children's speech to inform vocabulary selection for aided input. Augmentative and Alternative Communication. doi: 10.1080/07434618.201

Note: You can also find a link to this research at the author’s institutional repository, here.

And more...

Benítez-Barrera et al. found that when caregivers of young children with hearing loss used a remote microphone system (RMS) at home, their children were able to potentially access about 12% more child-directed speech (CDS). The RMS allowed children to access CDS that they’d otherwise miss because their caregivers were physically too far away. With an RMS running about $200 a unit, we thought it was worth bringing to your attention the potential benefit of parents using this technology in the home setting.

In a meta-analysis, Edmunds et al. found that how responsive parents of children with ASD were to their child’s communication was directly related to their child’s communication skills. They also looked at studies on responsiveness interventions, but found the evidence to be inconclusive. According to their analysis, more research is needed to conclude whether or not teaching parent responsiveness alone is enough to improve child outcomes—and if so, which ones. 

Hustad et al.  looked at development of speech intelligibility in children with cerebral palsy (CP), and the results can be used to guide decisions that we make in terms of timing of intervention. Specifically, the findings suggest that a child with CP is a good candidate for speech therapy if they do not:

  • demonstrate at least 25% intelligibility for single words by 29 months

  • demonstrate at least 50% intelligibility by 40 months

  • demonstrate at least 75% intelligibility by 58 months

And, by the age of 40 months, the authors suggest that therapy may also need to include some type of AAC system. The authors state, "Intelligibility focused therapy may still be beneficial, but as children enter a reduction in rate of growth after 5 years, progress may be slower with regard to change in speech." 

Justice et al.’s  study of language development in children from very low-income households, shows significantly lower receptive language skills in these children, much of which was found to be explained by dysregulated parent–child interactions, which is associated with parent distress.

Research gets us closer and closer to being able to really predict autism as early as possible. This study of 12-month-olds by Kadlaskar et al. found that those who end up with an autism diagnosis respond differently to caregiver touch—they’re more likely to a) not attend to the touch as a communicative act, and/or b) turn away from touch; also, their response predicts later autism severity.

We’ve discussed the topic of early regression in autism recently here, and Ozonoff and Iosif’s recent review of the research further confirms that language regression in the first year occurs for the majority of children with autism. Findings from their meta-analysis also suggest that standardized, normed checklists and questionnaires (like the Communication and Social Behavior Scales) completed by parents can be an effective way to identify lack of language development and loss of skills. 


Benítez-Barrera, C.R., Thompson, E.C., Angley, G.P., Woynaroski, T., & Tharpe, A.M. (2019). Remote microphone system use at home: Impact on child-directed speech. Journal of Speech, Language, and Hearing Research. doi: 10.1044/2019_JSLHR-H-18-0325

Edmunds, S.R., Kover, S.T., Stone, W. (2019). The relation between parent verbal responsiveness and child communication in young children with or at risk for autism spectrum disorder: A systematic review and meta‐analysis. Autism Research. doi: 10.1002/aur.2100

Hustad, K., Sakash, A., Natzke, P., Broman, A., & Rathouz, P. (2019). Longitudinal growth in single word intelligibility among children with cerebral palsy from 24 to 96 months of age: Predicting later outcomes from early speech production. Journal of Speech, Language, and Hearing Research. doi: 10.1044/2018_JSLHR-S-18-0319

Justice, L.M., Jiang, H., Purtell, K.M., Schmeer, K., Boone, K., Bates, R., Salsberry, P.J. (2019). Conditions of Poverty, Parent-Child Interactions, and Toddlers' Early Language Skills in Low- Income Families. Maternal and Child Health Journal. doi: 10.1007/s10995-018-02726-9.

Kadlaskar G., Seidl A., Tager-Flusberg H., Nelson C.A., Keehn B. (2019). Atypical Response to Caregiver Touch in Infants at High Risk for Autism Spectrum Disorder. Journal of Autism and Developmental Disorders. doi: 10.1007/s10803-019-04021-0 

Ozonoff, S. & Iosif, A. (2019). Changing conceptualization of regression: What prospective studies reveal about the onset of autism spectrum disorder. Neuroscience & Biobehavioral Reviews. doi: 10.1016/j.neubiorev.2019.03.012

And more...

  • Bilgin et al. found that infants with difficulties regulating their feeding, sleeping, and crying have an increased risk of attention problems later in childhood. And many adults who had regulatory problems as infants still demonstrated attentional difficulties throughout adulthood.

  • Bontinck et al. used observations in the home setting to compare interactions between 2-year-olds and their older sibling with ASD with interactions between 2-year-olds and their older, typically developing sibling. Findings suggested that the 2-year-olds whose sibling had ASD attempted to initiate social interactions less frequently, demonstrated fewer positive responses to their sibling’s attempt to communicate or interact, and attempted to imitate their older sibling with ASD less frequently. And, when the researchers looked at total interactions—both positive and negative—between the sibling pairs, they found that higher levels related to more parent-reported ASD characteristics. What does this mean? Well, it suggests that younger siblings of children with ASD might be learning positive and negative behaviors. And, given that siblings provide the earliest form of social interaction, paired with the fact that siblings of children with ASD are at high risk for receiving the same diagnosis, findings from this study suggest that examining social interactions between siblings may provide insight into the development of young children whose sibling has ASD.

  • Typical disfluencies (e.g. revisions, phrase repetitions, filled pauses) are a normal part of preschoolers’ speech, and “appear at times of rapid language growth”. Generally, while children are learning new words and new sentence structures, typical disfluency rates can increase (see article for review). So how would this play out for bilingual children? That’s unknown, and the aim of Brundage & Rowe. In this study, they examined young (30-month-old) simultaneous Spanish–English bilingual children (with roughly 50-50 exposure to English and Spanish at home). They found slightly lower disfluency rates in Spanish, and lower disfluency rates, overall, compared to similar studies. Because their data is a bit unexpected compared to similar research on monolinguals, it’s difficult to know how to interpret this data. But, maybe that’s exactly the point? That it’s different for bilinguals? Future research should help clarify that.

  • After English, Spanish is the most common language spoken in the homes of U.S. children who are deaf or hard of hearing (DHH). Yet, we know very little about language and, specifically, vocabulary outcomes for this population. de Diego-Lázaront et al. looked at a variety of demographic, hearing-, and intervention-related factors to determine which might have a relationship with Spanish expressive vocabulary skills in 8 to 36-month-olds who are DHH. Results suggested that degree of hearing loss, range of functional hearing, and chronological age and age of intervention separately and combined predicted Spanish expressive vocabulary development. And, more specifically, the researchers found that the children who began receiving therapy early—by 6 months of age—received significantly higher scores on expressive vocabulary measures in Spanish.

  • Donegan-Ritter & Van Meeteren coached Early Head Start teachers on language strategies using video self-reflection and focused feedback. Teachers were able to increase their use of questioning, back and forth exchanges, and parallel talk with both infants and toddlers. Practice-based coaching may be an effective method for training teachers to increase their use of language strategies.

  • Dowd et al. looked at how young toddlers responded when a parent or experimenter got “hurt” (e.g., adults faked injuries when playing with a toy or fiddling with a clipboard) and suggest that we can see signs of social impairments by about 15 months. While we usually consider social concepts like empathy and emotional thinking to be later developing skills, the study’s results show us that we can start to see impairment fairly early in development.

  • Within a child’s first few years, the total number of words he produces often reigns king with regards to assessing his language level. When a child comes to us with a small vocabulary, one of our primary goals is generally to increase the total vocabulary.  However, Galeote et al. explain that a more nuanced approach than “total number of words” is important for fully capturing a child’s language and creating meaningful intervention plans.  We need to make sure that we are considering the makeup of a child’s word classes so that we can understand the child’s strengths and weaknesses and plan our intervention appropriately. With that understanding, if a child’s vocabulary was made up almost entirely of nouns, we would know to target verbs more intensively in intervention.

  • Infants as young as six months old can adapt their communication behaviors to their social environments! Ganea et al. found that non-blind infants of blind parents interact differently with their blind parents compared to non-blind adults.

  • Greenslade et al. provide further data that decreased initiation of joint attention, expressive language, and social communication behaviors during the infant and toddler years can predict pragmatic communication difficulties in the school years, even if a child does not meet criteria for a diagnosis of ASD.

  • Noyes-Grosser et al. offer a program review of New York State’s Part C services, and more specifically how children with ASD and their families respond to services. We can’t apply the results of this review to all of our readers, because Part C is interpreted and services are delivered differently state-by-state and even county-by-county, but the article offers a great overview of why we do things some of the things we do (e.g., COS statements). The authors also over some good tools for program evaluation (see here for Record Review Protocol and here for an EI Family Survey). For SLPs working in Part C programs, you might want to keep this citation handy to offer to your EI coordinators and/or supervisors.

  • Severini et al. implemented the Stay-Play-Talk (SPT) routine with two children with Down Syndrome who used high-tech AAC as their primary mode of communication. They found when peers were trained to use SPT strategies during free play there was an increase in stay and play behaviors for both children. (Sound familiar? We’ve written about Stay–Play–Talk before for children with ASD who use AAC, here and here.)

  • The parent-implemented Early Start Denver Model (P-ESDM; Rogers et al., 2012a) is an intervention that combines principles from Applied Behavioral Analysis (ABA) with a developmental, socially-focused approach to increase parent interactions that promote positive developmental outcomes for young children with ASD. Vismara et al. looked at whether the P-ESDM might also be an effective intervention for young children with fragile X syndrome (FXS) with and without a combined diagnosis of ASD. The first author of the study provided coaching to promote the use of the P-ESDM with four 1 ½ to 4-year-old children and their parents either in person or via video-conferencing. The parent-related outcomes were encouraging: all of the parents improved in their ability to accurately and consistently implement the P-ESDM intervention goals, and they found the coaching experience to be generally positive. The child-related outcomes (e.g., spontaneous communication and initiated joint attention) were more variable, indicating the need for more studies that examine the use of the P-ESDM with children with FXS with and without ASD.  

Bilgin, A., Baumann, N., Jaekel, J., Breeman, L.D., Bartmann, P., Bäuml, J.G. … Wolke. D. (2018). Early crying, sleeping, and feeding probelsm and trajectories of attention problems from childhood to adulthood. Child Development. Advance online publication. doi: 10.1111/cdev.13155.

Bontinck, C., Warreyn, P., Demurie, E., Bruyneel, E., Boterberg, S., Roeyers, H. (2018). Social Interactions Between 24-Month-Old Children and Their Older Sibling with Autism Spectrum Disorder: Characteristics and Association with Social-Communicative Development. Journal of Autism and Developmental Disorders. Advance online publication. doi: 10.1007/s10803-018-3660-4.

Brundage & Rowe (2018). Rates of Typical Disfluency in the Conversational Speech of 30-Month-Old Spanish–English Simultaneous Bilinguals. American Journal of Speech–Language Pathology, 27, 1287–1298.

De Diego-Lázaro, B., Restrepo, A., Sedey, A.L., Yoshinaga-Itano, C. (2018). Predictors of Vocabulary Outcomes in Children Who Are Deaf or Hard of Hearing From Spanish-Speaking Families. Language, Speech, and Hearing Services in Schools. Advance online publication. doi: 10.1044/2018_LSHSS-17-0148.

Donegan-Ritter, M., & Van Meeteren, B. (2018). Using practice-based coaching to increase use of language facilitation strategies in early head start and community partners. Infants & Young Children, 31(3), 215–230.

Dowd, A. C., Martinez, K., Davidson, B. C., Hixon, J. G., & Neal-Beevers, A. R. (2018). Response to distress varies by social impairment and familiarity in infants at risk for autism. Journal of Autism and Developmental Disorders, 48(11), 3885–3898.

Galeote, M., Checa, E., Sebastián, E., & Robles-Bello, M. A. (2018). The acquisition of different classes of words in Spanish children with Down syndrome. Journal of Communication Disorders, 75, 57–71.

Ganea, N., Hudry, K., Tucker, L., Charman, T., Johnson, M.H., & Senju, A. (2018). Development of adaptive communication skills in infants of blind parents. Developmental Psychology, 54(12), 2265–2273.

Greenslade, K. J., Utter, E. A., & Landa, R. J. (2018). Predictors of pragmatic communication in school-age siblings of children with ASD and low-risk controls. Journal of Autism and Developmental Disorders. Advance online publication. doi: 10.1007/s10803-018-3837-x

Noyes-Grosser, D. M., Elbaum, B., Wu, Y, Siegenthaler, K. M., Cavalari, R. S., Gillis, J. M., & Romanczyk, R. G. (2018). Early intervention outcomes for toddlers with autism spectrum disorder and their families. Infants & Young Children, 31(3), 177–199.

Severini, K.E., Ledford, J.R., Barton, E.E., & Osborne, K.C. (2018). Implementing stay-play-talk with children who use AAC. Topics in Early Childhood Special Education. Advance online publication. doi: 10.1177/0271121418776091.

Vismara, L.A., McCormick, C.E.B., Shields, R., & Hessl D. (2018). Extending the Parent-Delivered Early Start Denver Model to Young Children with Fragile X Syndrome. Journal of Autism and Developmental Disorders. Advance online publication. doi: 10.1007/s1

Integrating therapists into the research: a how-to

Have you ever heard of Triadic Gaze Intervention? No? Me neither. Unless you went to the University of Washington for grad school, you probably don’t know that TGI is an evidence-based protocol with 20 years of research behind it. But hey, we have to give these researchers credit—they acknowledge this common research-to-practice gap, and are invested in working to fix it.

In this study, Feuerstein et al. sought to include early intervention practitioners in their research. Specifically, they used qualitative methods to assess practitioner’s perceptions of Triadic Gaze Intervention, in terms of acceptability and feasibility for implementation. Their overarching goal was to highlight the unique contribution of practitioners in implementing research to practice. #shoutout

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Triadic Gaze Intervention is a technique used to teach toddlers with physical disabilities to use gaze as a form of intentional communication. During play activities, therapists recognize a child’s potential communicative behavior, and shape that behavior toward a three-point triadic gaze. To read more about this method, see Olswang et al. (2014).

So what did SLPs have to say about implementing this highly researched technique in everyday practice? They felt that it closely aligned with their intervention priorities for this population. They found it easy to learn and implement into their current practice. They also thought it was an extremely acceptable and feasible intervention method.

SLPs also listed some potential barriers. They wanted TGI to be taught to a broad range of EI team members, not just SLPs. PTs and OTs are often the first service providers to see toddlers with disabilities, and TGI may align with the motor and social engagement goals targeted by these clinicians. SLPs also brought up the idea that most EI models use a parent training/coaching model. They wanted support from researchers for how to train parents to use this intervention.

So there you have it, folks! Collaboration between researchers and practitioners is not only useful, but necessary for implementing evidence-based protocols into everyday practice. Practitioners should not just be consulted, but integrated into research programs. When we collaborate with each other, everybody wins, including the children.

Feuerstein, J. L., Olswang, L. B., Greenslade, K. J., Dowden, P., Pinder, G.L., & Madden, J. (2018). Implementation research: Embracing practitioner’s views. Journal of Speech, Language, and Hearing Research. Advance online publication. doi: 10.1044/2017_JSLHR-L-17-0154