“Try this at home” isn’t enough

The effects of coaching on teaching parents reciprocal imitation training

4.png

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.

Long-term outcomes of Hanen’s Target Word program

How much of a long-term impact does parent-implemented speech–language therapy have on late talkers? That’s an important question. Most studies have focused on short- or medium-term outcomes and have not looked into long-term follow-up results.

5.png

These researchers wanted to know the medium- and long-term effects of a low-dosage parent program for late talkers. To do this, they provided the Hanen’s Target Word program to 30 parents of 24-month-old late talkers, and followed a different set of 30 parents–child pairs that did not receive the program. The program included five group sessions and two individual video-feedback sessions over the span of three months. They then tested parents’ use of the strategies at 36 months, and language skills at 36 and 48 months.

They found that the program accelerated the vocabulary growth for the late talkers, but by age 4, there were no longer any differences between the two groups’ expressive vocabularies and both had reached age-appropriate scores. Both groups, however, continued to fall behind their peers in syntax and grammar.

The parents who participated in the study followed their child’s lead more and put less communicative pressure on their child; however, the parents did not significantly improve in how often they responded to their child’s communication or in how much linguistic stimulation they provided their child. Through analysis, the researchers found the strategy of reducing communicative pressure to be specifically associated with children’s language growth.

Here are some important considerations and takeaways from the study:

  • Null long-term results don’t mean that the intervention wasn’t worthwhile. As we know, increasing two year olds’ vocabularies can help ease the frustration of not being able to communicate which is an important goal of early intervention.

  • Dosage and coaching style play an important role in treatment outcomes. The authors discuss how the parent results of this study differed sharply from the Roberts and Kaiser (2015) study in which the researchers taught parents Enhanced Milieu Teaching (EMT) strategies, and parents were able to learn all of them. One of the reasons why is that the intervention dosage was much higher for the EMT study (four workshops and 24 hour-long sessions, compared to two), giving parents more opportunity for practice and feedback. Adjusting the dosage or coaching style of the Target Word program may be one option for increasing its long-term effectiveness.

  • Reducing communicative pressure may be an especially important strategy for parents. This is a simple strategy to teach parents, and these results demonstrate how powerful it can be for supporting language growth in toddlers.

  • Ongoing monitoring is important for late-talkers. Nearly one third of the children who participated still had language scores below the normal range at four years of age, but fewer than half of those children received speech–language therapy after the study. Monitoring is important to ensure that these children don’t fall through the cracks when language demands as they grow older.

One final note: this isn’t a replication study of Hanen’s Target Word program, but rather it’s a study that tested its effectiveness in real-world contexts. That’s awesome for two reasons: (1) authors aren’t tied to Hanen, which helps eliminate bias, and (2) real-world contexts = more like what we SLPs face = more clinically applicable! 

Want more? These authors also published a study of Hanen’s Target Word program (so popular!) This retrospective study (looking back at client charts) similarly showed gains in communicative participation and vocabulary for children who participated in the program.

 

Kruythoff-Broekman, A., Wiefferink, C., Rieffe, C., Uilenburg, N. (2019). Parent-implemented early language intervention programme for late talkers: parental communicative behaviour change and child language outcomes at 3 and 4 years of age. International Journal of Language & Communication Disorders. doi: 10.1111/1460-6984.12451

Go long! Go deep! Storybook reading intervention to target breadth and depth of word knowledge in preschool-age children

One of the most fun and, quite honestly, easiest contexts that we can use in therapy with toddlers and preschoolers is shared book reading. And, it’s kind of a no brainer that we can and should be using interactive read alouds to target one of the key areas of language development that’s lacking in our 2-, 3-, and 4-year-old clients: receptive and expressive vocabulary*.

In this intervention study of 226 preschoolers, they found that:

  • Kids who had a high initial level of vocabulary knowledge were able to increase their understanding and use of words through exposure alone.

  • However, for kids with the weakest initial vocabulary levels, exposure and repetition isn’t enough.

6.png

So what helps? Explicit instruction. Their explicit intervention activities included: pictures, clear child-friendly definitions, and being encouraged to act out, use, and explain target words. They found that in order to go beyond breadth (the number of words that you know) to depth (how much you know about a word), explicit instruction of word meaning and interactive activities that extend understanding beyond how the words are depicted in the book, helped. Ultimately, going long and going deep is key if we want to have a long-term impact on vocabulary development.

*This isn’t the first time we’ve discussed the topic of word learning during shared book reading. See this review, too.

 

Dickinson, D. K., Nesbitt, K. T., Collins, M. F., Hadley, E. B., Newman, K., Riveria, B. L., …Hirsh-Pasek, K. (2019). Teaching for breadth and depth of vocabulary knowledge: Learning from explicit and implicit instruction and the storybook texts. Early Childhood Research Quarterly. doi:10.1016/j.ecresq.2018.07.012

Understanding Mexican culture to inform clinical practice

7.png

Understanding the culture of the clients we serve is always crucial to implementing effective evidence-based practice. This article is a great one for learning about the impact of Mexican culture on language and learning.

This study of 35 Mexican mothers of toddlers is one of the most well-done and dense (in a good way) descriptions of the associations between culture, language, and learning we’ve seen in a while. There is a lot in here; so, honestly, if you have a large proportion of Mexican children on your caseload, this study warrants a full read!

But, of course, we’ll give you a couple big take-aways, to give you something to consider right away! Two primary ones from this article were:

  1. Consider the developmental relevance of activities other than play. When coaching a parent on how to stimulate language naturally, you must know what activities that adult participates in most with the child. For Mexican mothers, this is often mealtime and caregiving routines, and less often things like pretend play.

  2. Consider communication partners other than the mother. Mexican families tend to value the roles of everyone in the family—older siblings, dad, extended family members— in teaching and raising the child. Perhaps most notable is the role of older siblings, who not only play a lot with the younger siblings but also teach them how to behave and participate productively in the family. Basically, if you’re only looking at coaching mom, you’re likely not looking broadly enough, and need to consider the diverse and integral roles of all family members.

Cycyk, L.M., & Hammer, C. (2019). Beliefs, values, and practices of Mexican immigrant families towards language and learning in toddlerhood: Setting the foundation for early childhood education. Early Childhood Research Quarterly. doi:10.1016/j.ecresq.2018.09.009

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.

2.png

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.

Language delay and behavior problems: How can we help?

It’s not much of a surprise to EI SLPs that language problems and behavior problems can be pretty intertwined (e.g., here), and parenting style can be associated with both behavior and language outcomes. We also know that well-designed parent-implemented interventions can be wonderfully effective (they had better be if entire states are re-vamping their early intervention programs to promote the coaching model). So—can we support these things simultaneously?

5.png

Garcia et al. implemented the Infant Behavior Program (IBP) with a group of mother–child pairs. The Infant Behavior Program was adapted from the Child-Directed Interaction (CDI) component of Parent-Child Interaction Therapy (PCIT). Programs like PCIT and Triple P- Positive Parenting Program have been shown to help children reduce negative behaviors, but no one has really studied what how (or if) those parent implemented behavior interventions affect language development. While PCIT training and certification is geared toward mental health professionals, the components of CDI and IBP will sound familiar to EI SLPs. The intervention guides parents to interact with their children using positive parenting skills, avoiding negative parenting skills, and ignoring unwanted behavior, and consisted of 5–7 weekly visits of 60–90 minutes. Parents were then asked to continue using the taught parenting skills in 5-minute increments throughout the day.

“Do” (Positive parenting skills)

  • Imitating

  • Describing

  • Reflecting

“Don’t” (Negative parenting skills)

  • Negative talk

  • Questions

  • Commands

Researchers found that change in parenting style was associated with an increase in the children’s total number of utterances. (Note: this effect was seen at six months after the intervention ended; the kids didn’t show a difference in total number of utterances at three months, or number of different utterances at either time they were tested). But the authors cautioned that presence of negative parenting skills did not change the toddlers’ number of utterances for better or for worse, so definitely don’t interpret this to mean we should throw out questions and commands.

So if an EI SLP is called in on a case where both language and behavior are concerns, but parent priority is behavior, maybe we start with those “positive” responsive techniques (labeling, imitating, and reflecting) before we jump in with questions and commands, because it looks like these positive behavior strategies can also help with language development!

 

Garcia, D., Hungerford, G. M., Hills, R. M., Barroso, N. E., & Bagner, D. M. (2019). Infant language production and parenting skills: A randomized controlled trial. Behavior Therapy. Advance online publication. doi:10.1016/j.beth.2018.09.003

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…

3.png

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.

Want to increase generalization? Try matrix training

Let’s talk about matrix training. It’s a language intervention that’s been around for a while (e.g., Goldstein, 1983), and there’s quite a bit of evidence to demonstrate that it can be used as a framework to teach vocabulary and functional language skills. But, probably more importantly, kids can learn new and untrained language targets by participating in matrix training. Tell me more, right?

Well, the way that it works is that language targets (for instance, adjectives and nouns) are written on the vertical and horizontal axes of a table—aka: matrix. The targets can be either all unknown words or a combination of known and unknown depending on the client. Then, those targets are used to create various combinations. So, if you’re focusing on increasing your client’s understanding of adjectives and nouns, your matrix could look like this:

December graphics (1).png

Matrix training is based on the idea of recombinative generalization (Goldstein, 1983)—which basically means that if we teach a word combination {brown + bear} and then expose the child to one of the same words again but in a new combination {brown + bird}, the child can generalize their understanding or use of untrained, related targets {brown + horse}.

So, the matrix essentially serves as a visual guide that can be used to identify the sequence for instruction by making it easy for you to see which treatment targets are related. For instance, if you choose targets that are in the yellow diagonal cells (brown bear, red bird, blue horse, yellow duck, green fish) as well as the teal cells just above them (brown bird, red horse, blue duck, yellow fish), many of the same adjectives and nouns will be repeated in your intervention. By doing this, your client can then generalize their understanding to related, untrained targets (such as, brown horse, brown duck, red duck, brown fish, red fish, blue fish).

In this study, matrix training was used as a framework for intervention with three children between the ages of 22 and 35 months with severe language delays and/or ASD. The training focused on teaching the toddlers simple, one-step directions (e.g., shake) that included animals (e.g., dog). Three individual matrices were created based on each child’s knowledge of the target actions and animals before the training began. The intervention targeted six (or, 30%) of the one step action–object instructions with each child, and included components of discrete trial training (antecedent, responses, and consequences) as well as verbal and physical prompts and reinforcement. After training, the other 70% of the action-object combinations that weren’t directly taught were probed, and each of the three children demonstrated some level of generalization to these unknown targets (and, one of the toddlers demonstrated understanding of all of the untrained action-object combos!). 

Talk about more getting a little more bang for your buck, am I right?!

Although this study only included 3 participants, the findings suggest that matrix training is a simple framework to implement that has the potential to cut down on time spent on teaching language targets in intervention. This is particularly exciting news for our youngest clients who demonstrate the most significant language delays.

Curiel, E.S.L., D. M., Sainato, D. M., & Goldstein, H. (2018). Matrix training for toddlers with Autism Spectrum Disorder and other language delays. Journal of Early Intervention40(3), 268–284.

Throwback (2011): Increasing sound production through imitation therapy

4.png

Imitation is the sincerest form of flattery. However, every SLP has worked with a child who simply doesn’t imitate. No matter how many times we blow raspberries, make animal noises, or wave our arms wildly, we are met with blank stares. Yet imitation during early development is a crucial building block to successful communication. 

This study looked at a systematic method for teaching nonverbal toddlers the skill of imitation. All children in the study were 18–19 months old, showed minimal babbling, did not imitate sounds, and did not produce any phonetically consistent forms. All of the children scored lower than the 2nd percentile on the PLS-3 or PLS-4 scores. Sounds like your typical El late talker, right?

Back in 1972, Zedler developed a therapeutic technique referred to as Technique Imitation Therapy (IT) for use with young children who did not develop language as expected. He believed that a child’s language development is dependent on the child’s awareness that his or her own behavior can affect others. The idea is that providing opportunities for the child to direct an adult’s attention and actions, the child will realize that their own actions can influence others. With reinforcement (as always), the child should eventually be able to learn how to imitate.  

In the present-day study, clinicians implemented Imitation Therapy with 18–19-month-old toddlers 2–4 times per week in 50 minute sessions, until the child spontaneously imitated verbalizations at least eight times in two consecutive sessions. This took between 16–18 sessions for the group of children, or approximately 8 weeks.

Imitation Therapy consists of four steps, starting with the adult serving as the sole imitator of everything the child does and says, until the child realizes that the adult is imitating him/her. Next, when the child begins to do some basic imitation of the adult, he is positively reinforced. Then, the adult begins to only imitate the child’s oral movements or sounds produced. At the final stage, the adult and child imitate each other reciprocally, with the goal of the child imitating sounds consistently. At the end of the study, all children showed a significant increase in their sound production and repertoire of phonemes. Specifically, all children had at least 13 phonemes and produced 100+ sound productions per session. Talk about measureable progress! This article describes the procedure in great detail, so that any SLP could recreate IT at their next home visit.  

The authors do mention that small sample size and lack of a control group are limitations of this study. However, each of the children missed a week of therapy due to fall/spring break. During this break, they experienced a decrease in sound production, which subsequently increased when therapy was again initiated. This observation reinforces the evidence that IT may have been a factor in the children’s progress. At a minimum, imitation therapy appears to be a promising technique to try with nonverbal toddlers who struggle to imitate.   

 

Gill, C., Mehta, J., Fredenburg, K., Bartlett, K. (2011). Imitation therapy for non-verbal toddlers. Child Language Teaching and Therapy, 27(1), 97–108.