Let’s hear it for the verbs! Parents’ early verb use predicts children with ASD’s later verb vocabulary

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Verbs are important for early language development; they are the building blocks for early sentences and help kids tell us about the things that are happening around them. But as we know, many of our children with ASD struggle to learn and use them flexibly. We know from the literature that for typically developing children, parents’ verb use can predict their later verb vocabulary. These researchers wanted to know if the same was true for children with ASD.

To do this, they measured the verbs that parents of children with ASD used during “follow-in utterances.” Follow-in utterances are comments that parents make during moments when they and their child are both focused on the same thing. So if a child knocked down a tower of blocks and looked up at his mom, her saying, “The tower crashed!” would be a follow-in utterance. The researchers looked at three aspects of parent verb use during follow-in utterances:

  1. The quantity of verb input, i.e., how often parents said verbs

  2. The diversity of verb input, i.e. how many different verbs parents said

  3. The grammatical informativeness of verb input, i.e. how much rich morphological information surrounded the verb. For example, “We’re jumping” would be more grammatically informative than “jump.” (See the article’s appendix for additional definitions and examples.)

They found that together, these three aspects of parent verb use during follow-in utterances predicted children with ASD’s later verb vocabulary. Because this is a correlational study (and doesn’t tell us what causes what), we’ll need further research to tell us if teaching parents to increase their quantity and quality of verb use will improve their children’s verb vocabulary. That being said, here are some ways authors describe that this line of research may impact what we teach parents:

  • We could teach parents to expand what their child says by adding a verb. For example, if the child says, “baby,” we could teach the parent to respond with, “the baby is sleeping,” rather than adding on to the noun phrase (e.g. “little baby”).

  • We could encourage parents to use diverse verbs during follow-in utterances, rather than over-relying on a small number of verbs and verb forms (such as “I want _____,” or “I need ______”).

  • We could teach parents to use grammatical language, rather than telegraphic. Because including grammatical morphemes seems to support children’s learning of verbs, we could teach parents to model fully grammatical language. For more research about using grammatical vs telegraphic language, see our previous review here.

 

Crandall, M.C., McDaniel, J., Watson, L.R., Yoder, P.J. (2019). The relation between early parent verb input and later expressive verb vocabulary in children with autism spectrum disorder. Journal of Speech, Language, and Hearing Research. doi:10.1044/2019_JSLHR-L-18-0081.

Perspectives & Tutorials

Providing supportive hospital environments to promote the language development of infants and children born prematurely: insights from neuroscience

 This article is an excellent intro (or reminder) of the basics of best-practice for developmental care in the NICU, with an emphasis on language development and tips for training parents and hospital caregivers on how to support these babies.

 

How meaningful is more? Considerations regarding intensity in early intensive behavioral intervention

Most SLPs who work with young children with autism are well-aware of the 10–40 hours per week of EIBI (Early Intensive Behavioral Intervention) that’s often recommended by private practices, centers, and the Behavior Analyst Certification Board (BACB). This editorial turns those recommendations upside down, pointing out that:

  • There is no strong evidence to show that a high level of EIBI is necessary or appropriate for all children with autism.

  • There is no strong evidence to show that increasing the hours of EIBI leads to better child outcomes. There simply aren’t many studies on treatment dose.

  • Recommending high levels of EIBI ends up excluding other educational opportunities and services the child may need (like speech­–language therapy) which can be detrimental.

  • Overall, this editorial doesn’t advise against a high dose of ABA treatment; rather, they’re saying that recommending high doses across the board, for all children with autism, isn’t backed by the science.

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

Measuring the earliest forms of communication

As you may have realized (with frustration!) by now, we have limited options for evaluating the expressive communication skills of children who are minimally verbal. Enter: the Communication Complexity Scale (CCS), designed to measure just that. Prior papers have described the development of the CCS and determined its validity and reliability, but in this study, we get to see it in action with a peer-mediated intervention.

First, a little bit about the tool. It’s a coding scale—not a standardized assessment—that can be used during observations. Because prelinguistic communication skills often take time to develop with this population, this tool helps us think about all the incremental steps along the way and accounts for the variety of communicative modes the children might use. It’s a 12-point scale following this pattern:

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The researchers found that the CCS could measure improvement in overall communication complexity and behavior regulation for preschoolers with autism after a peer-mediated intervention (the same one we reviewed here!).

So far in the research, the CCS has only been used during structured tasks meant to elicit communicative responses (see the supplemental material), such as holding a clear bag with toys where the child can see it, but can’t access it independently. We know it's crucial to observe our students in natural communication opportunities, though, so we'd have to be a little flexible in using the CCS during unstructured observations. The scale could definitely be useful when describing communication behaviors during evaluations or when monitoring progress. Wouldn’t it be much more helpful to say “The child consistently stopped moving (i.e. changed her behavior) in response to the wind-up toy stopping” instead of “The child was not observed to demonstrate joint attention”? Using the CCS, we have new ways of describing those “small” behaviors that really aren’t small at all!

NOTE: This study crosses over our Early Intervention vs. Preschool cut-offs, with kids from 2 to 5 years old. So is published in our School-Age section, too!

Find links to the scale and score sheets, here.


Thiemann-Bourque, K. S., Brady, N., & Hoffman, L. (2018). Application of the communication complexity scale in peer and adult assessment contexts for preschoolers with autism spectrum disorders. American Journal of Speech-Language Pathology. doi:10.1044/2018_AJSLP-18-0054

“Try this at home” isn’t enough

The effects of coaching on teaching parents reciprocal imitation training

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There is an ever-growing research base for parent-implemented interventions for children with ASD, and for good reason! We know that in order for children with autism to make progress, they need high treatment intensity. The most cost-effective, naturalistic way of reaching that treatment intensity is by teaching their parents how to use intervention strategies with their children on a daily basis. The other side of this coin, however, is that we also know that treatment fidelity is an important factor in child outcomes; how closely parents adhere to the intervention will impact their child’s progress.  

This study looked at how one-on-one coaching affected parents’ ability to implement an evidence-based intervention for their child with ASD, and how their use of the strategies impacted their child’s outcomes. The intervention taught to parents was reciprocal imitation training (RIT). RIT is a naturalistic developmental behavioral intervention (NDBI; Schreibman et al., 2015) that teaches young children with ASD to spontaneously imitate within a social interaction. It uses naturalistic behavioral strategies such as following the child’s lead, modeling, prompting, and reinforcement.  

Three parents and their children with ASD participated in this study. The parents attended a training where they learned all of the ins and outs of how to do the intervention. Then they went home and video recorded their attempts to use the strategies once per day. After a few weeks, a clinician came to their home and provided coaching on the strategies once per week for 6-7 weeks. The researchers then went through the recordings and measured both the parents’ use of the strategies over time and the children’s growth in imitation skills. They found that parents were able to implement RIT with high accuracy (yay!), but only after individualized coaching support. While some of the parents improved significantly after the initial training, they all needed a therapist to come to their house and coach them in order to master the strategies. The children in the study all increased their spontaneous imitation, but only after their parents became consistent and accurate with at least some of the components of the intervention.

This study extends our understanding of the importance of coaching parents on strategies rather than relying solely on verbal instruction or suggestions. Here we have data to show how these parents needed more than just verbal instruction; they needed live feedback and training in order to use the strategies accurately and consistently, and only then did child outcomes improve. Providing parents with active coaching provides parents with the tools needed in order to support their children’s social communication. 

Note: If you are interested in learning more about RIT, you can check out this article. And here is the measure that the researchers used to evaluate the parents’ use of the strategies.

 

Penney, A. & Schwartz, I. (2018). Effects of coaching on the fidelity of parent implementation of reciprocal imitation training. Autism. doi: 10.1177/1362361318816688.

And more...

  • Do you find the coaching model challenging? You’re not alone! Sometimes it can feel like scientists are telling us what to do without considering how challenging it is to implement their interventions in the real world. That’s why articles like this one are so exciting for practicing SLPs. These researchers interviewed early intervention SLPs about their experiences attempting to implement the coaching model. They gleaned insight from SLPs about their barriers, benefits, and experiences, and perspective. The bottom line? SLPs see the value in the coaching model, but need more and better training and ongoing support in order to be confident and competent in using it.

  •  Did you know that onomatopoeia (words that represent sounds, like “buzz”) are especially common in infant’s speech? Liang discovered that onomatopoeia are phonologically easier to recall, plan, and produce, which explains why infants acquire them at such a young age. The easiest forms for infants to produce are CV words like “moo”, and words with consonant harmony like “pop.”

  • When it comes to diagnosing autism, we all have two goals—to do it as early as possible, and to do it as quickly as possible, because both factors lead to the child receiving early intervention services sooner, and this is key. Mayes’ study showed that using the condensed version of a commercially available interview and checklist—the Short Form of the Checklist for Autism Spectrum Disorder—was just as effective at identifying toddlers and preschoolers with ASD as the full Checklist. I don’t know about you, but the idea of being able to reliably and accurately identify young children with ASD using 6 instead of 30 items is pretty encouraging news!

  • Reisinger et al. examined data on the vocalizations of 11 young boys with a diagnosis of Fragile X and their caregivers compared to peers matched by chronological age and developmental age.  They found that caregivers of children with Fragile X vocalized less often and took fewer conversational turns than caregivers of typically developing children, possibly contributing to a cycle of poor language development and a less than ideal language environment.

  • As EI providers, we’re always looking for new ways to support children with ASD through collaboration and coaching. Shire and colleagues’ recent study looked at training teaching assistants (TAs) to provide the play-based intervention, JASPER—Joint Attention, Symbolic Play, Engagement, and Regulation—to toddlers with ASD in an early intervention classroom. Through extensive coaching and support from a supervisor during the first year and assistance from group leaders during the second year, the TAs were able to effectively implement the JASPER program. And, the children showed the same level of improvement in joint attention during the first and second year of the study. But, play skills only significantly improved during year one, when the TAs were receiving the highest level of support. These results suggest that training TAs and other support staff to provide language intervention with children with ASD can be effective, but if we want long lasting effects, we may need to provide a high level of consistent support.

  

Douglas, S., Meadan, H., Kammes, R. (2019). Early interventionists’ caregiver coaching: A mixed methods approach exploring experiences and practices. Topics in Early Childhood Special Education. doi:10.1177/0271121419829899.

Liang, C.E. (2019). Phonological motivation for the acquisition of onomatopoeia: An analysis of early words. Language and Learning Development. doi:10.1177%2F0142723714550110.

Mayes, S. D. (2019). Assessing toddlers and preschool children using the checklist for Autism Spectrum Disorder. Infants & Young Children. doi:10.1097/IYC.0000000000000136.

Shire, S. Y., Shih, W., Ya-Chih, C., Bracaglis, S., Kodjoe, M., & Kasari, C. (2019). Sustained community implementation of JASPER intervention with toddlers with Autism. Journal of Autism and Developmental Disorders. doi: 10.1007/s10803-018-03875-0.

Reisinger, D. L., Shaffer, R. C., Pedapati, E. V., Dominick, K. C., & Erickson, C. A. (2019). A pilot quantitative evaluation of early life language development in Fragile X syndrome. Brain Sciences. doi:10.3390/brainsci9020027 

Imitation: a simple and powerful strategy for parents of toddlers at-risk for ASD

While we all know that involving parents in early intervention for toddlers with ASD is important, knowing where to start can be another matter altogether. What if there was one simple and effective strategy that we could teach parents right off the bat--one they could master easily with a big impact? Imitation might fit that bill.

Imitation is a strategy you already have in your toolbox: it’s as simple as copying what a child says or does. It’s been researched in different forms for decades, and it belongs to a family of strategies called “responsive” language strategies. Other responsive strategies include following the child’s interests, avoiding questions and directions, and responding to his communication attempts.

The great thing about imitation as a strategy is that it naturally incorporates many components of other responsive strategies. If a parent is imitating his child, then he is probably following his child’s interests, reducing the number of questions he asks, and paying more attention to how his child is communicating. If we teach parents to imitate, maybe we won’t need to explicitly teach the other responsive strategies!

These researchers did a small study in which they taught three parents of toddlers with ASD* to imitate their children’s actions, gestures, and words (the format of the sessions is fully described in the article!) Generally speaking, the sessions had these components:

  1. The therapist reviewed the parent’s questions or concerns that had come up since the previous session.

  2. The therapist explicitly taught the parent about why imitation is important and how to use it.

  3. The therapist played with the child and pointed out when she imitated the child.

  4. The parent played with the child while the therapist provided the parent with constructive coaching and feedback.

  5. The therapist summarized the session and answered the parent’s questions.

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The results showed that all three of the parents were able to master the imitation strategy, and all three children made improvements in their social eye gaze. An extra cool bonus? As parents started imitating their children, the number of questions and directions they gave naturally decreased without the therapist explicitly instructing them to do so. Talk about getting some great bang for your buck! Imitation shows promise of being a simple and efficient “first strategy” to teach parents. 

*or suspected ASD

 

Killmeyer, S., Kaczmarek, L., Kostewicz, D., & Yelich, A. (2018). Contingent Imitation and Young Children At-Risk for Autism Spectrum Disorder. Journal of Early Intervention. doi:10.1177/1053815118819230.

Is early regression in autism a thing?

Short answer:

Sometimes!

Long answer:  

Note: What we’re talking about here = loss of language and other skills between 15 and 30 months of age in children with ASD (Barger et al., 2013).

First, it’s important to understand where data to answer this question comes from. Historically, it’s been from retrospective studies (parent report, home video). More recently, we’ve combined this with prospective studies (e.g. tracking infants at high familial risk of autism from birth, so you can measure as they grow!) The combination of the two is powerful, and has illuminated things not previously captured (e.g. declining visual attention in the first year for kids with ASD (Elsabbagh et al., 2013).

Second, what we’re measuring matters: skills slowly diverging from the typical path is different than a skill plateau, which is different than actual regression—and we have to keep this straight across studies. Also, how you measure it matters—for example, a decline in standard scores on tests over time could represent any of the previously-mentioned phenomena. Further, it’s likely that all three of these things exist in autism—it’s not a homogenous group! 

Finally, don’t forget that there are other conditions that are characterized by regression (e.g. Rett syndrome, Heller’s syndrome), and sometimes autism combined with something else (e.g. epilepsy) will show marked regression. So be aware that regression is associated with many childhood disorders.

But, yes, lots of studies point toward there being a notable group of children with autism who show true regression from infancy to toddlerhood. (Do any of you remember how there for a while we thought regression in autism wasn’t a thing, and the parents were wrong? Yeah… The parents weren’t wrong.)

Longer (and obviously the most thorough) answer:

Pearson, N. , Charman, T. , Happé, F. , Bolton, P. F. and McEwen, F. S. (2018). Regression in autism spectrum disorder: Reconciling findings from retrospective and prospective research. Autism Research, 11, 160–1620.

A bit more. We were chatting with Dr. McEwen about this article, and she had a helpful comment we wanted to share:

“…regression seems to occur gradually in some children, and a very slow loss of skills is likely to be harder to pick up than a sudden, dramatic loss of skills. The former might involve a gradual loss of social engagement, whereas the latter could be a child who suddenly loses language. So it's important for speech and language professionals to be aware that it's not just dramatic loss of language that they should be alert to.”

How gesture and word development intertwine in toddlers

We know that children with ASD have difficulty with gestures. If a child comes to us who doesn’t point to share attention, we have red flags waving in our heads. Children with ASD are delayed in their use of gestures, use them less frequently, and have a smaller repertoire. We also know that in typically developing children, gestures come before speech and predict later language abilities. Little research, however, has actually delved into what gesture development looks like in toddlers with ASD and how it relates to their overall language development. Does their gesture development follow a predictable sequence, and does that sequence match that of their TD peers? How are gestures and verbal language linked for toddlers with ASD?

These researchers examined the gesture development of 42 toddlers with ASD and found:

  • Toddlers with ASD’s gesture and language development followed a predictable path that mirrors typically developing peers. This path differed in one interesting and important way, though: typically developing children use pointing as a pre-verbal means of communication, but for many toddlers with ASD, pointing emerged after they began to use words.

  • For toddlers with ASD, as well as their TD peers, combining gestures with single words precedes and predicts when they will begin to use word combinations.

So what does this mean for us?

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First, a point of caution: this study looked at the development of gesture use in toddlers with ASD, but this study design can’t tell us what causes what. Simply because combining words and gestures comes before phrase speech does not necessarily mean that teaching a child to combine words and gestures will result in a child using phrase speech. In order to make that claim, we will need a randomized controlled trial of an intervention that attempts to teach toddlers with ASD phrase speech through targeting gesture and word combinations.

Nonetheless, these findings lend some support to intervention approaches that follow typical development. If a child is not yet using words, targeting early gesture use may support intentional communication and first words. If a child is speaking but not combining his words and gestures together, targeting combining words and gestures may support the development of phrase speech. 

 

Talbott, M. R., Young, G. S., Munson, J., Estes, A., Vismara, L. A., & Rogers, S. J. (2018). The Developmental Sequence and Relations Between Gesture and Spoken Language in Toddlers With Autism Spectrum Disorder. Child Development. Advance online publication. doi: 10.1111/cdev.13203.

And more...

  • Dai et al. found that bilingual caregivers of children with ASD and DD can communicate with their children in both languages without adverse effect on their children’s language functioning. (Feel like you already knew that? Well here’s a citation for ya!)

  • Fusaroli et al. found that parents’ language complexity predicted the complexity of their toddler with ASD’s language four months down the road. This finding suggests that modeling grammatically rich and complex language for toddlers with ASD may benefit their language development (as opposed to over-simplified telegraphic speech). While we need an intervention study to tell us if that is truly the case, research has already demonstrated this for toddlers with language delays (which you can read about in a previous review here).

  • To get a better feel for how underserved and under-identified families access health information about development, Gallagher et al. conducted focus groups of parents of typically developing and children with disabilities who lived in an urban area and experienced low income and low literacy skills. The authors found that while these parents knew about a variety of sources of information, they experienced and reported barriers to health literacy resources (e.g., printed materials were too dense, or not literal enough). The parents in the focus groups offered suggestions for making developmental health information accessible to a more diverse audience. This is a good read if you are ever in a position to develop marketing or awareness materials.

  • EI SLPs sometimes encounter (and experience!) mom-guilt when serving families whose mothers work. This study was exploratory but offers us a bit of information we can share when the need arises. Laing and Bergelson found that 17-month-olds’ vocabulary measures of noun type and token did not differ significantly between toddlers of full-time working and stay-at-home mothers. Interestingly, toddlers who experienced mixed care (so their moms worked part time, or stayed home early and went back to work as their children got older), did have more noun types and tokens than kids who experienced one type of care.

  • McLeod et al. examined teacher–child interactions during Enhanced Milieu Teaching (EMT) sessions. All children in the study had DLD and attended Head Start. Two teacher inputs were linked to greater usage of target vocabulary words by children during EMT sessions: (1) following the child’s attentional or communicative lead and (2) providing vocabulary supports to teach or clarify the meanings of target words. We’ve written about parent-implemented EMT for children with DLD before. For more descriptive info about teacher input and child vocabulary go check out the article.

  • Can you screen “everybody” (e.g. via routine pediatricians’ checkups) and reliably catch autism early, between 14–36 months, without over-identification? Yes, probably! This meta-analysis by Sanchez-Garcia provides quantitative data in support of universal toddler screenings for ASD.

  

Dai, Y.G., Burke, J.D., Naigles, L., Eigsti, I.M., & Fein, D.A. (2018). Language abilities in monolingual- and bilingual- exposed children with autism or other developmental disorders. Research in Autism Spectrum Disorders. Advanced online publication. doi: 10.1016/j.rasd.2018.08.001.

Fusaroli, R., Weed, E., Fein, D., & Naigles, L. (2019). Hearing me hearing you: Reciprocal effects between child and parent language in autism and typical development. Cognition183, 1–18.

Gallagher, P. A., Greenberg, D., Campbell, J. M., Stoneman, Z., & Feinberg, I. Z. (2018). Early identification and connection to services among urban parents who have low income and low-literacy skills. Focus on Autism and Other Developmental Disabilities. Advance online publication. doi: 10.1177/1088357618794913.

Laing, C. & Bergelson, E. (2019). Mothers’ work status and 17-month olds’ productive vocabulary. Infancy, 24(1), 101–109.

McLeod, R.H., Kaiser, A.P., & Hardy, J.K. (2018). The relation between teacher vocabulary use in play and child vocabulary outcomes. Topics in Early Childhood Special Education. Advance online publication. doi: 10.1177/0271121418812675

Sánchez-García, A.B., Galindo-Villardón, P., Nieto-Librero, A.B. et al. (2019). Toddler Screening for Autism Spectrum Disorder: A Meta-Analysis of Diagnostic Accuracy. Journal of Autism and Developmental Disorders. Advance online publication. doi: 10.1007/s10803-018-03865-2.