Throwback (2009 & 2015): Speech delay? Language delay? Measuring it, and what’s common in toddlers with autism

For all the SLPs who work with younger children with autism (so ages 2–4), this one’s for you! The following is a review of two studies from the last decade that can help you understand and characterize the various expressive language profiles you may see in these children, as well as brainstorm therapy!

The first paper reports on a meeting of experts in early autism and language development. (NOTE: If you’re a science groupie who gets googly-eyes for big names, pop on over and look at the author list; #sofamous). The purpose of the group was to create a list of measures of the expressive spoken language of children with autism from 12 to 48 months of age. These benchmarks can be used in assessment (as part of a comprehensive assessment including parent report, natural language samples, and/or direct assessment), or to guide intervention.  

In the article, you’re provided with a chart (see Table 1) divided into “First Words (12–18 mos)”, “Word Combinations (18–30 mos)”, and “Sentences (30–48 mos)”. Then within each of those categories, you have measures for:

  • Phonology

  • Vocabulary

  • Grammar

  • Pragmatics

…and within each of those categories, the child must meet at least one marker, at minimum, to be placed within that category.  

So, for example, for the Sentences (30–48 mos): Phonology section, markers are:

  • 70%+ intelligible from a speech–language sample

  • Consonant inventory of at least 16–24 different consonants (75% correct), from a speech–language sample

  • Age equivalent score of at least 36 months on a standardized test (e.g. GFTA or other)

…and the child must meet the intelligibility criteria or the standardized test criteria in order to be considered as meeting that benchmark. 

Then, you’d look across the other measures to (so vocabulary, grammar, and pragmatics) to see where they fit in each of those categories. 

Overall, this provides a really nice way to consider data from multiple sources (and, importantly, to know which pieces of data to prioritize), and supports SLPs in describing the spoken expressive language of kids with ASD in a systematic fashion.

 

So, how do most kids with ASD perform with these benchmarks?

Aha! That’s what the next paper looked at.

The authors of this article evaluated over 100 kids ages 2–3 years old using the “Spoken Language Benchmarks” (what we just described! From the last paper.) They found:

Considering phonology, vocabulary/grammar, and pragmatics as three separate skill sets…

  • Most of the children’s lowest score was in pragmatics (of course, right?! They have autism…)

  • And the two most common profiles were:

    • phonology > vocabulary/grammar > pragmatics

    • phonology = vocabulary/grammar > pragmatics

    • See Table 3 for six other profiles observed, too! That table is really fascinating, seeing what’s most versus least common…

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So let’s chat about this. Basically, they found that, “… phonology tends to be relatively intact for most individuals whereas pragmatic difficulties are nearly universal…” and “… in terms of pragmatics, 88% of the children fell into the Prelinguistic group, which reflects a developmental level of less than 12 months of age.”

Nearly half of the kids achieved higher phonology scores than vocabulary/grammar and pragmatics. So it’s an area of relative strength! And when we think about kids with ASD on our caseloads, I’m sure you can remember many kids fitting this profile—good speech skills, and expressive language and/or pragmatics not so much.

Overall, being able to weigh relative strengths of phonology, vocabulary, grammar, and pragmatics for our kids with ASD helps inform treatment, and also could be quite helpful in identifying which types of treatment tend to help which types of children with ASD in both clinical work and research.

 

Ellawadi, A.B., & Weismer, S.E. (2015). Using Spoken Language Benchmarks to Characterize the Expressive Language Skills of Young Children With Autism Spectrum Disorders. American Journal of Speech–Language Pathology, 24, 696–707.

Tager-Flusberg, H., Rogers, S., Cooper, J., Landa, R., Lord, C., Paul, R… Yoder, P. (2009). Defining Spoken Language Benchmarks and Selecting Measures of Expressive Language Development for Young Children With Autism Spectrum Disorders. Journal of Speech, Language, and Hearing Research, 52, 643–652.

A (free) decontextualized vocabulary test for toddlers

If only we had a crystal ball to predict late talkers’ later language skills (ok, those would be nice in so many areas of our field!). As SLPs we are always trying to get an accurate picture of how many words a child uses and understands. But because we don’t have a dedicated assessment of toddlers’ early vocabulary, we often do this through parent report, either formally (like an MCDI) or informally. However, researchers have found that parents' report of their child's vocabulary doesn't do as good of a job when we try to use it to predict later language. It seems that parent report may not be giving us all of the information that we need about a child’s vocabulary in order to predict their later language abilities.

We know that there’s a continuum of what “knowing a word” entails for a toddler. When they first learn to say the word “milk,” they may only know it within the context of breakfast. The word “dog” however, they may use all day long whenever they see a dog or a picture of one. A parent would rightly conclude that a child knows both “milk” and “dog,” even though the child’s “level of knowing” varies between the two words. Contrast this with a picture ID vocabulary assessment, in which all of the words are presented out of context. For a toddler to correctly identify a word during the assessment, he would have to have a strong understanding of what that word really means without all of the support that context provides.

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Because of this, Friend et al. (2018) set out to create a picture ID test for young children and test if it could better predict preschool language abilities than parent report. They developed the Computerized Comprehension Test (CCT) in which children are asked to identify decontextualized pictures from a field of two. They then tested it with 16-, 23-, and 36-month-old children. At 16 months, parent report continued to best predict preschool language abilities. However once the child reached 23 months, the CCT was a stronger predictor of later language abilities with great psychometric properties.

While the CCT is still in its early phases, it shows promise of becoming a useful instrument for EI SLPs to get a more accurate picture of toddlers’ vocabulary, especially after age two. In its current state, it could serve to complement other assessments already in your toolkit, such as an MCDI. And while we’ll never have a crystal ball to tell us what a child’s language will be like years down the road, assessments such as this may give clues to help us make more informed decisions about assessment and treatment.  

Note: The authors have published all of their CCT materials online, including the computerized assessment, training videos/instructions, and data sheets. I tested out the program myself, and while there was a learning curve, it didn’t prove to be too challenging! Let’s all take a moment and cheer for these scientists giving us access to the materials we need!

 

Friend, M., Smolak, E., Patrucco-Nanchen, T., Poulin-Dubois, D., & Zesiger, P. (2018). Language Status at Age 3: Group and Individual Prediction From Vocabulary Comprehension in theSecond Year. Developmental Psychology. Advance online publication. doi: 10.1037/dev0000617

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

  • Remember the Index of Productive Syntax (IPSyn) from grad school? Altenberg et al. modified the instructions to make them a little clearer and reminded us that IPSyn is great for describing toddlers’ and preschoolers’ grammatical development. See their updated instructions in the article Appendix and consider giving IPSyn another shot. (NOTE: If you’ve never heard of this thing before, it’s a way to measure syntax production in young children.)

 

  • It seems that we’re always looking for a quicker, easier way to quantify our young clients’ language skills and progress in therapy. This study looked at whether the automated language analysis system, LENA (Language Environment Analysis), a device that’s worn around the child’s neck, could provide a reliable measure of rate of vocalizations during short recording sessions. Results suggested that human transcribers were able to capture more reliable rates of child vocalizations when the recording was 25 minutes or less. So, although the LENA seems to be a useful tool for longer recordings, findings from this study suggest that when transcribing and analyzing short language samples, it’s best to stick to doing it the old-fashioned way—by hand.

 

  • Sharabi et al. found that mothers of children with ASD tend to be more involved in their child’s care, especially when they felt they had informal support from family and friends. Fathers with higher education levels tended to be more involved with their child’s care, especially single fathers.

 

Altenberg, E. P., Roberts, J. A., & Scarborough, H. S. (2018). Young children's structure production: A revision of the Index of Productive Syntax. Language, Speech, and Hearing Services in Schools. Advance online publication. doi: 10.1044/2018_LSHSS-17-0092.

Bredin-Oja, H., Fleming, K., & Warren, S. (2018). Clinician vs. machine: Estimating vocalization rates in young children with developmental disorders. American Journal of Speech-Language Pathology, 27, 1066–1072.

Sharabi, A., & Marom-Golan, D. (2018). Social support, education level, and parent’s involvement: A comparison between mothers and fathers of children with autism spectrum disorder. Topics in Early Childhood Special Education. Advance online publication. doi: 10.1177/0271121418762511

Facilitating parent–child playgroups: A how-to guide

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

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

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

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

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

 

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

And more

  • Bavin et al. found that in children with cochlear implants, pre-implant early receptive communication skills and early gesture use were the strongest predictors of vocabulary one year post-implant. Targeting receptive language and use of gestures may be the way to go if you are working with toddlers with hearing loss, prior to receiving a cochlear implant.

  • Cunningham et al remind clinicians and researchers alike to consider growth in outcomes related to engagement and participation rather than just impairment, and discuss predictors of communication participation outcomes. This is actually a very large study, with some strong data to show that speech­–language services, in general, work to improve the outcomes in early intervention. They also have intensity data here. So if you need a study to show that what we do really matters, this is a good one to add to your stack!

  • Although the research base that focuses on decoding, fluency, and reading comprehension in older children with autism continues to expand, relatively less is known about the emergent literacy skills of young children with ASD. Fluery and Lease (2018) examined code- and meaning-focused emergent literacy skills of 3 to 5-year-olds with ASD as well as their parents’ beliefs about their early reading development. Findings from this study have important clinical applications: First, variability in the children’s emergent literacy skills suggests that reading interventions for young children with ASD should be tailored to meet the individual needs of each child. Second, results suggested that parents of children with stronger communication skills had a more positive outlook on their child’s ability to benefit from reading exposure and instruction. This finding suggests that we need to provide extra support and education to parents whose children with ASD have more complex communication needs.

  • Eye gaze and, specifically, gaze following serves as an important social and language-learning tool for infants. What is still unclear is specifically what motivates an infant to follow a caregiver’s gaze. Findings from Gredeback, Astor, and Fawcett’s (2018) recent study suggest that social, attention-grabbing events (e.g., something as simple as a head turn) may be just as a strong of a motivator for infants to follow a caregiver’s gaze as previously recognized perceived communicative intent.

  • Ibanez et al examined the efficacy of a web-based program for training parents of children with ASD to use behavioral strategies in day-to-day routines such as bath time and snack. Parents in the tutorial group reported that they used more strategies, felt they parented more efficiently and experienced less stress, and reported that their children engaged and communicated more during daily routines. The article directs readers to an example of the tutorial and menu of current tutorials.

  • Neuman et al. analyzed over 2000 scenes from language-focused educational media. Videos with attention-directing cues (basically zooming in on the target) were most successful in helping children learn new vocabulary. However, children with higher language scores were more likely to use these cues to learn vocabulary, so educational videos may not be as helpful for those with language delays.

  • Pearson, Oliver, and Waite surveyed parents of children with rare genetic syndromes to see what types of information these families felt they needed most to help their children. They found that concerns associated with Angelman syndrome included sleep, communication, and health, while parents of children with Cri du Chat syndrome were most concerned with health, behavior, and daily living skills, and parents of children with Cornelia de Lange syndrome often wanted information on behavior, health, and self-injury. The authors highlight the need for clinicians to be aware of and address parents’ perceptions and concerns about their children’s disorders.

  • Spinelli & Mesman found that both the prosody of infant-directed speech and caregiver sensitivity to infants’ social–emotional cues contribute together to infant social–emotional development. We can’t do “motherese” alone, we have to be able to read and respond to baby’s cues and interactive attempts. (Also, see here for more information on the effect of motherese on infant development).

  • We know that exposing young children to decontextualized language, or, abstract talk that’s removed from the here-and-now, can improve their later vocabulary, narrative skills, and reading comprehension. Uccelli et al.’s recent study provides a unique perspective by demonstrating a link between toddlers’ use of decontextualized talk and higher levels of academic language proficiency 10 years later.

 

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

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

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

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

Ibanez, L. V., Kobak, K., Swanson, A., Wallace, L., Warren, Z., & Stone, W. L. (2018). Enhancing interactions during daily routines: A randomized controlled trial of a web-based tutorial for parents of young children with ASD. Autism Research, 11(2), 667–678. https://doi.org/10.1002/aur.1919

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

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

Uccelli, P., Demir-Lira, O. E., Rowe, M. L., Levine, M., & Goldin-Meadow, S. (2018). Children’s early decontextualized talk predicts academic language proficiency in midadolescence. Child Development. Advance online publication. doi: doi.org/10.1111/cdev.13034

What, who, when, or how: What matters in shared book reading?

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We all know reading books with our kids and clients is wonderful for language development, but what about shared reading makes it so beneficial to learning vocabulary? This meta-analysis included 38 studies to determine what elements of shared book reading contribute to word learning in typically developing* children ages 33 months–12 years. Good news, shared book reading works! The authors found that children learned almost half of the words they were exposed to during shared reading, but some factors seemed to matter more than others. For example, more exposures to target words was better for word learning, and a dialogic reading style helped children learn 1.22 more words on average than non-dialogic styles. In other words, interactive reading styles with many opportunities to hear and use new words contribute to word learning. No surprise there! What was surprising is that it didn’t matter who read the book. Across studies, children did just as well on word learning measures after shared reading with their parents as they did with researchers or teachers. And the length of time between reading and testing did not affect word learning, so either immediacy wasn’t an important factor for these children, or they retained knowledge of the words they learned during reading. So, if you aren’t already, try incorporating story books into your sessions, and include dialogic reading as part of a home program or coaching session!

*Note: This meta-analysis only included studies on typically developing children, but there are studies out there on implementing therapy techniques into dialogic reading: try here and here for some ideas, and here for more on dialogic reading!

This review appears in both our Early Intervention and Preschool & School-Age sections this month!

Flack, Z. M., Field, A. P, & Horst, J. (2017). The effects of shared storybook reading on word learning: a meta-analysis. Developmental Psychology. Advance online publication. doi: 10.1037/dev0000512.

Throwback Pub (2012): Training parents to support children with developmental language disorder

As SLPs working in EI, we know that developmental language disorder presents risk for later academic skills. We also know that parent-implemented language interventions can be effective (see Roberts & Kaiser, 2011, for a meta-analysis of parent-implemented language interventions). This study examined whether parent-implemented Enhanced Milieu Teaching (EMT) would impact receptive and expressive language growth in children with language disorder (with cognitive standard score > 80 and no other primary diagnoses; see article for full inclusion/exclusion criteria).

The researchers examined three groups of 24–42-month old children:

  • Typical language

  • Language disorder w/ no treatment, or a “wait-and-see” approach

  • Language disorder w/ parent-implemented Enhanced Milieu Teaching

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Families treatment group participated in parent training in 28 sessions (workshops, clinic, and home visits) over a three-month period. EMT strategies were trained in four phases: 1) setting a communicative context, 2) modeling and expanding communication, 3) time delay strategies, and 4) prompting strategies (see Table 5 for examples and description). During training at the clinic, therapists and parents practiced strategies using a specific set of toys. Home visits also included integrating strategies into functional family routines such as snack. All children were assessed with monthly language samples (MLU, total words, different words) plus the Preschool Language Scale, Fourth Edition (PLS-4), at the beginning and end of the study.

So what happened? Parent-implemented EMT was effective for improving language outcomes for children with LI, and parents in the treatment group used significantly more strategies than either other group! Parent use of strategies for typically-developing children and those with language disorder undergoing “wait and see” were about the same.

Children whose parents used EMT

  • significantly improved their PLS-4 Total and Expressive Communication scores and gained an average of 50 more words than untreated children with language disorder

  • gained an average of 15 more words per month compared to untreated children with language disorder

  • grew at about the same rate as children with typical language

Fantastic, right? But what about the kids with language disorder undergoing a “wait and see” approach? They showed significantly slower growth. Not only did those “wait and see” kids start out with lower language abilities, it looks like “waiting and seeing” might just hold them at a disadvantage when compared to those who have access to intervention. The authors stated, “Children in the LI-control group did not catch up but fell farther behind their peers with TL.”

How about a little extra info? The authors also looked at which child characteristics predicted language growth and outcomes. They examined risk at birth (e.g., a NICU stay), cognitive skills, and receptive skills (based on the Bayley-III scores). Risk at birth and cognitive skills were not predictive of expressive language analyses performed. However, “Receptive language at the start of the study predicted growth in language for all three groups of children after controlling for differences in IQ.”

The authors note that more research is needed to determine long-term outcomes. For example, how would these children progress over a period of 12 months? What kind of gains would come from 28 hours of traditional therapy in 3 months? Overall, parent-implemented EMT looks to be a promising model to add to our intervention options for young children with developmental language disorder.

Note: For our bilingual SLPs, see Peredo, Zelaya, & Kaiser, 2017 for a study on adapting parent-implemented EMT for Spanish-speaking families.

 

Roberts, M. Y., & Kaiser, A. P. (2012). Assessing the effects of a parent-implemented language intervention for children with language impairments using empirical benchmarks: A pilot study. Journal of Speech, Language, and Hearing Research55(6), 1655-1670.