A case for the assessment of gestures

We know that early gesture use is strongly related to language outcomes in toddlers. This study by O’Neill et al. found that, in fact, two-year-olds’ performance on standardized measures of gesture comprehension and use were correlated with expressive language skills at kindergarten entry.

Unfortunately, many of our traditional language assessments don’t dive deeply into this nonverbal form of communication. So how can an Early Intervention SLP measure early gesture use?

In this study, they used standardized play-based assessments of comprehension and use of gestures and symbols—the Communication and Symbolic Behavior Scales and the Early Sociocognitive Battery (not yet commercially available; coming late 2019). These assessments use structured but flexible activities that provide the child with opportunities to use or interpret gestures or symbols. For instance, the assessor gestures the use of an object (such as pretending to use a hammer or comb one’s hair), which then prompts the child to find the appropriate item and roll it down a chute. These tasks are nonverbal, which may help the child to feel successful. 

Although the use of a standardized measure of gesture use and comprehension provides valuable insight into how children are communicating nonverbally compared to their peers, using these formal assessments obviously isn’t required. SLPs could easily develop their own informal tool based on these important prerequisite skills for communication.

As the authors point out, assessment of gesture provides a ton of useful information, including:

  • How the child functionally communicates

  • The child’s communicative intent

  • The frequency, type, and means by which the child compensates for their communication delay

  • Where to start with intervention

  • Prediction of later language outcomes

Thus, gesture use is more than just a meaningful way for nonverbal toddlers to communicate. It is a clinically useful measure of nonverbal skills that correlate with later language outcomes and should be considered in our Early Intervention evaluations.

 

O’Neill, H., Murphy, C., & Chiat, S. (2019). What our hands tell us: A two-year follow up investigating outcomes in subgroups of children with language delay. Journal of Speech, Language, and Hearing Research. doi:10.1044/2018_JSLHR-L-17-0261

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.

Parent-delivered communication intervention for infants and toddlers who are DHH

If you’re an early intervention SLP, you’ve probably had a child who is deaf or hard of hearing (DHH) on your caseload at one time or another. Why? Well, advances in hearing aid and cochlear implant technology have certainly improved the speech and language outcomes of children who are DHH, but aided hearing isn’t the same as typical hearing. And even with early amplification, these children often still miss out on language stimulation pre-amplification, which can lead to delays.

In this study, they taught the parents of nine 6 to 24-month-olds with hearing loss to use four different strategies to promote and reinforce their communicative attempts. This included visual strategies such as moving toys in the child’s line of sight, and interactive strategies such as following the child’s lead and modeling target language to their actions. Parents were also taught responsive strategies like balancing the number of conversational turns that they took when communicating with their child, and linguistically stimulating strategies like expanding on their child’s spontaneous utterances.

The parents who participated in the training and delivered the intervention used more strategies that support communication compared to the parents in the control group. And, by the end of the study, the infants and toddlers who received the intervention demonstrated more prelinguistic communication skills compared to the children in the control group.  

The beauty of this study is twofold: 

First, the strategies that were included in the intervention are all things that we as EI providers are already well-versed in. {That’s because we’re all pretty darn familiar with enhanced milieu teaching (Hemmeter & Kaiser, 1993), prelinguistic milieu teaching (Yoder & Warren, 2002), and The Hanen Program (Girolametto, Pearce, & Weitzman, 1996)}. Second, if you’re an EI therapist, a big part of your job already involves parent training and coaching. This article provides a very simple, clear description of the key strategies that you can teach parents of infants and toddlers on your caseload who are DHH. Definitely the kind of article that you can read and then immediately apply to your practice, which is the best kind of article, am I right?!

 

Roberts, M. (2018). Parent-Implemented Communication Treatment for Infants and Toddlers With Hearing Loss: A Randomized Pilot Trial. Journal of Speech, Language, and Hearing Research. Advance online publication. doi: 10.1044/2018_JSLHR-L-18-0079

Early object exploration linked to communication skills in preterm and full-term infants

A few months ago, we reviewed a study on identifying early learning delays in preterm infants. Well, this study provides us with an additional skill to keep an eye on when working with preterm and full-term infants. Keep reading to learn how object exploration at 6 months can predict communication skills at 12 months.

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Researchers observed 20 extremely preterm infants* (gestational age < 28 weeks) and 20 full-term infants engage in play with their mothers at 6 months and 12 months of age. (Note: the preterm infants were observed at their corrected ages; more on age correction here.) At 6 months, the researchers measured how often infants engaged in oral and manual exploration of toys. For example, an infant could engage in oral exploration by mouthing a rattle and manual exploration by transferring the rattle from hand to hand. Then at 12 months, the researchers measured the infants’ gestures, vocal productions, cognitive skills, and word comprehension.

Not surprisingly, the preterm infants tended to score lower on measures of cognitive skills and language skills than full-term infants. This fits with the broader findings of previous research showing that “preterm infants as a group, do not tend to catch up to peers’ language by school-age.” 

But what may take you by surprise is that neither neonatal condition (preterm vs full-term) nor cognitive performance were significant predictors of 12-month word comprehension, gestures, or vocal production when also considering object exploration. For all infants in this study, oral exploration at 6 months was a significant predictor of word comprehension at 12 months and manual exploration at 6 months was a significant predictor of gesture and vocal production at 12 months.

So what does this mean for EI SLPs? Diagnostically, we would certainly still consider preterm birth a risk factor for future language difficulties. However, we may also consider object exploration skills at 6 months as a possible predictor of communication skills at 12 months for both preterm and full-term infants. As for intervention, the authors note that supporting object exploration could enhance communication skills, but they didn’t explicitly examine whether or not this is the case. We’ll keep you posted as more comes out on this topic!

*One limitation of this study is that the extremely preterm infants selected to participate were deemed “healthy.” Many extremely preterm infants receiving EI services have health complications relating to preterm birth.

NOTE: Interested in another paper on the link between motor skills and communication? Check out this recent review on infant siblings of children with autism. 

Zuccarini, M., Guarini, A., Iverson, J.M., Benassi, E., Savini, S., Alessandroni, R., Faldella, G., & Sansavini, A. (2018). Does early object exploration support gesture and language development in extremely preterm infants and full-term infants? Journal of Communication Disorders, 76, 91–100.

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.

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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.