Teaching parents language strategies during shared book reading

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As early intervention SLPs, we know the importance of teaching parents to use language facilitation strategies (see the Heidlage & Roberts meta-analyses we discuss in the last bullet point, here). We also know the value of shared book reading as a context for language learning. These researchers decided to take a close look at the process of teaching parents to use naturalistic language strategies during book reading. To do this, they taught two mothers, one with a three-year-old with ASD and one with a 5-year-old with cerebral palsy, two sets of strategies.

The first set of strategies was engagement strategies for parents to use before, during, and after reading books.

  • Before book reading:

    • Say the title and author (e.g. “This book is called ____ and is written by ____.”)

    • Ask a question to build interest (e.g. “What do you think this book is about?”)

  • During book reading:

    • Make encouraging statements (e.g. “I like how you’re sitting so nicely with me!” “Good job turning the page.”)

    • Use nonverbal and verbal means to focus the child’s attention (e.g. point to a picture and say, “Look! It’s a gorilla!”)

  • After book reading:

    • Ask a closing question to maintain interest, or relate the book to the child’s life (e.g. “Which animal makes a funny sound, a cow or a sheep? Why? What sound does our dog make?”)

The second set of strategies was components of the intervention program Parent-Implemented Communication Strategies (PiCS) (Meadan et al. 2014).

  • Modeling: demonstrate a word, phrase, or gesture with the expectation that the child will imitate (e.g. “Turn the page”)

  • Mand–model: in addition to the model, use a verbal prompt in the form of a question (e.g. “What do you want?”), a choice (e.g. “Should we read the cat book or the tractor book?”), or a command (e.g. “Say ‘turn the page”).

  • Time delay: pause within an established routine to give the child an opportunity to initiate communication (e.g. label all of the pictures on a page except for one, point to the last picture, and look expectantly at the child for five seconds).

They taught parents these strategies via two initial teaching sessions followed by 12 weeks of twice-a-week coaching sessions. The two initial teaching sessions included reviewing the material, watching example videos, role-playing, and feedback. The coaching sessions used the following format:

  • The researcher reviewed the target strategy

  • The researcher provided feedback on the previous session using a video clip, giving direct positive and constructive feedback

  • The mother and child engaged together in shared storybook reading while the researcher observed

  • The mother reflected on her own use of the strategies, and the researcher provided suggestions and feedback. Together, they problem-solved any concerns or issues

The researchers found a connection between the mothers’ use of the PiCS strategies and the child’s communication, providing support for teaching parents to use the PiCS strategies during shared book reading. They also found that the hands-on practice/coaching component was key for the mothers to use the PiCS strategies successfully. Because we EI SLPs are already familiar with the strategies that were taught to the parents in this study, this is definitely something we can use in our sessions!

 

Akamoglu, Y., & Meadan, H. (2019). Parent-implemented communication strategies during storybook reading. Journal of Early Intervention. doi: 10.1177/1053815119855007.

A quick course on cerebral palsy

Join me in my rabbit hole for a moment, SLP friends. Bring coffee. Last month, Developmental Medicine & Child Neurology had a whole issue on cerebral palsy (CP).

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Our search takes us back to 2017, when a HUGE group of researchers lead by Iona Novak described diagnosis and treatment options based on their systematic review (note: this research team also included SLPs and people with CP/parents of people with CP as authors, so we have the FULL EBP triangle going on here!). Cerebral palsy is a huge umbrella diagnosis; but in general, CP is defined as a non-progressive disorder of posture and movement related to an injury or some problem in the developing brain. It can be diagnosed between 1 and 2 years, and sometimes a provisional diagnosis is given until CP can be confirmed or ruled-out after a period of development, around 5 years. For a diagnosis of CP, a child has to demonstrate motor dysfunction and either abnormal neuroimaging or a risky clinical history (genetics, stroke, maternal health risks, etc.). Table 1 in Novak et al. will give you a thorough overview of identification and diagnosis.

Last month, Msall published a commentary on a recent paper by Boychuck et al., who surveyed international experts on CP to compile a list of red flags clinicians should keep in mind (see Table 3 or read the Msall’s one-page commentary for more information):

  • Children should be referred for evaluation if they demonstrate things like:

    • Holding hands in fists, asymmetry, or head lag after 4 months

    • Tightness in legs between 6–12 months

    • Requiring support to sit after 9 months

    • Hand preference before 12 months

  • Children should be referred for monitoring if they demonstrate:

    • A persistent startle after 6 months

    • Consistent toe-walking or asymmetric walking after 12 months

  • Children should be referred to SLPs any time there are feeding or communication delays or concerns

    • Speyer et al. reported a high prevalence of feeding (53.5%), drooling (44%), and swallowing (50.3%) problems in children with CP.

Thinking about the diagnostic process and transition to treatment, EI SLPs should be pretty well-versed in interacting with parents, but it’s always nice to have a reminder of parent priorities as they begin to plan for their child’s interventions. Byrne et al. conducted focus groups of parents and providers and found that overall, parents of children with CP want:

  • Honesty and directness from providers, with information specific to their child (not just a general prognosis)

  • Explanations of the assessments and tools used to make the diagnosis (including the names of the assessments)

  • Written material (it helps to be able to refer back)

  • Support from providers and assistance in securing services 

In terms of treatment in CP, EI is critical for development. We have to help build those brain connections and take advantage of early neuroplasticity. While CP is a motor disorder (so you will probably need involvement from PT and OT in some capacity), many children with CP have feeding and communication difficulties, so SLPs are likely to be involved on intervention teams. For communication, Novak et al. recommended supporting parent–child interaction, and considering AAC. If feeding is a concern, the team should assess swallowing safety because pneumonia is particularly risky for people with CP. For those of you providing family-centered services in natural environments, you’re already on the right track for service delivery for this population. McCoy et al. measured gross motor outcomes in children with CP, but their message is powerful for all EI providers. The number of therapy visits (including PT, OT, AND Speech) did not predict outcomes, but family-centered services and the focus of sessions (e.g., incorporating overall health and well-being and engaging in structured play activities) did. So keep coaching those parents on how to implement interventions in enjoyable and contextualized settings.

 

Boychuck, Z., Andersen, J., Bussieres, A., Fehlings, D., Kirton, A., Li, P., …, & Majnemer, A. (2019). International expert recommendations of clinical features to prompt referral for diagnostic assessment of cerebral palsy. Developmental Medicine & Child Neurology. doi: 10.1111/dmcn.14252.

Byrne, R., Duncan, A., Pickar, T., Burkhardt, S., Boyd, R., Neel, M. L., & Maitre, N. L. (2019). Comparing parent and provider priorities in discussions of early detection and intervention for infants with and at risk of cerebral palsy. Child: Care, Health, and Development. doi: 10.1111/cch.12707.

McCoy, S. W., Palisano, R., Avery, L., Jeffries, L., Fiss, A. L., Chiarello, L., & Hanna, S. (2019). Physical, occupational, and speech therapy for children with cerebral palsy. Developmental Medicine & Child Neurology. doi: 10.1111/dmcn.14325.

Msall, M. E. (2019). Establishing community pathways for the early recognition of cerebral palsy: Red flags, enablement, and family support. Developmental Medicine & Child Neurology. doi: 10.1111/dmcn.14314.

Novak, I., Morgan, C., Adde, L., Blackman, J., Boyd, R. N., Hernandez-Brunstrom, J., …, & Badawi, N. (2017). Early, accurate diagnosis and early intervention in cerebral palsy: Advances in diagnosis and treatment. JAMA Pediatrics. doi:10.1001/jamapediatrics.2017.1689.

Speyer, R., Cordier, R., Kim, J., Cocks, N., Michou, E., Wilkes-Gillan, S. (2019). Prevalence of drooling, swallowing, and feeding problems in cerebral palsy across the lifespan: A systematic review and meta-analyses. Developmental Medicine & Child Neurology. doi: 10.1111/dmcn.14316.

Throwback (2017): Not just more talk, but Toy Talk

We know that the language input children receive matters. But telling parents to “talk more” might not cut it, especially as you approach the twos and threes! So how can we instead make sure the input supports the child’s grammatical growth?

Consider Toy Talk. It’s a strategy parents are taught to use (in this study, via three parent coaching sessions right before the child’s second birthday), where they’re told to respond to the child’s interests in play, and importantly:

“Talk about the toys” and “Give the object its name” 

Simple, huh? But the effects are substantial. It will basically: force adults’ use of nouns instead of pronouns in the subject position, which pulls the subject and verb away from one another, rather than allowing contractions that may be learned by the child as one unit instead of two morphemes. So it looks like this:

Without toy talk:

It’s soft.

He’s running. 

With toy talk:

The kitten is soft.

The horse is running.

It also makes learning verb tense and agreement easier by forcing marking and helping kids notice these morphemes in the parents’ input:

Without toy talk:

Hop onto the horse.

Drink some water. 

With toy talk:

The cowboy hops onto the horse.

The horse drinks water. 

Toy Talk has been found to be fairly easy for adults to learn and use, and improves the growth trajectories of the children’s unique combinations of subjects and verbs and tense-agreement morphemes.

We don’t yet know how big of an impact strategies like this could make for kids with DLD, but so far it looks promising, and certainly worth trying! Learn more, and grab a parent-friendly handout here.

 

Hadley, P.A., Rispoli, M., Holt, J.K. (2017). Input Subject Diversity Accelerates the Growth of Tense and Agreement: Indirect Benefits From a Parent-Implemented Intervention. Journal of Speech, Language, and Hearing Research. doi: 10.1044/2017_JSLHR-L-17-0008

Hadley, P.A., Rispoli, M., Holt, J.K., Papastratakos, T., Hsu, N., Kubalanza, M., McKenna, M.M. (2017). Input Subject Diversity Enhances Early Grammatical Growth: Evidence from a Parent-Implemented Intervention. Language Learning and Development. doi: 10.1080/15475441.2016.1193020.

Babble Boot Camp: Yes, it’s a thing

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Pretty much all therapy we do is reactive, as in response to a diagnosed speech or language delay. But what about preventative therapy? As early interventionists, we often see young children who have diagnosed conditions that will almost certainly lead to speech and language delays. What is the best way to work with families in this particular situation? Peter et al. studied a preventative intervention they coined “Babble Boot Camp.” Aside from the adorable name, this parent-implemented program actually had some pretty neat results.

The children in this study had been diagnosed with Classic Galactosemia (CG), which is a genetic disorder that can be diagnosed at birth. Children with CG have a very high rate of speech and language disorders, but, as is typical with EI, often don’t receive intervention until the speech and language delays become apparent. Instead of waiting for the inevitable, these researchers started young—at two months, to be exact.

Babble Boot Camp is a program of activities and routines specifically developed for children in the pre-speech or very early speech and language stages of development. Parents met with an SLP via telepractice for 10 minutes per week to receive training and consultation. Examples of activities included reinforcing and stimulating coos and babbles, joint book reading, naming objects, imitation, and expanding children’s utterances. The SLP provided ideas for incorporating these techniques into routines and daily activities.

All children who participated in this study showed greater babbling complexity and increased complexity of meaningful speech compared to the control child (who also had CG). The majority of the children also demonstrated age-appropriate expressive vocabulary and communication skills at 24 months, which is pretty impressive for children with such a high chance of delay. Although this study used a small sample size, it does provide preliminary evidence that a proactive approach to speech/language intervention may be effective in the long-term; so get those families enlisted!

 

Peter, B., Potter, N., Davis, J., Donenfeld-Peled, I., Finestack, L., Stoel-Gammon, C., . . . VanDam, M. (2019). Toward a paradigm shift from deficit-based to proactive speech and language treatment: Randomized pilot trial of the Babble Boot Camp in infants with classic galactosemia. F1000Research. doi:10.12688/f1000research.18062.1

“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.