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.

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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

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

Throwback Pub (2017): Treating CAS in the under-three crowd

Childhood Apraxia of Speech. Where to begin? If you’ve tried searching for treatment strategies in very young children, like here or here, or read ASHA’s Technical Report (though that one’s now a decade old…), you know it’s slim pickings. There are good treatment strategies for older children. But, ah, hellooo, what do we do before age four?

This study describes the Speech Motor Learning (SML) approach and tested its effect on a 33-month-old boy with CAS. SML is based on the Four Level Framework (FLF) of speech sensorimotor control. The basic idea in the FLF is that there are four phases in processing speech: linguistic-symbolic planning, speech motor planning, speech motor programming, and execution. The motor and sensory systems communicate to develop motor plans and adjust motor programs. See the article for a synopsis of the FLF.

SML uses principles of motor learning to train sound sets of gradually increasing difficulty. The (very basic) idea is to build “core motor plans” for each speech sound, and then build the flexibility to execute those motor plans in varying phonetic contexts. Nonword targets are based on stimulability, accuracy of production, and developmental appropriateness, and are introduced in a series of stages. The SLP trains a small set of stimulable consonants and vowels, and targets CVCV non-words in five levels of increasing difficulty as the child masters each level. For example, the first level might include nonwords like /bɪbu/, /bɪbi/, /bɪba/ and then slowly increase complexity to nonwords like /bɪdu/, /bɪmu/, /bɪgu/.

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Does it work? Well, maybe. The boy in this single case study had been involved in an early intervention program using the Hanen program for over a year with minimal improvement in his articulation. He had normal hearing as screened by an audiologist, and scored within normal range on the Rossetti Infant-Toddler Language Scale. Treatment was provided for 9 weeks, and the authors examined whether the treated sounds could be correctly produced in words or nonwords. The child decreased his total number of errors per word and non-word, and improved his production in the first set of targets and some of the second set, but the authors hesitated to attribute all of his progress to the treatment alone because his baseline scores were variable.

For more on the SML approach and FREE software for creating CVCV and CVC stimuli, see the lead author’s website here.

 

van der Merwe, A., & Steyn, M. (2017). Model-driven treatment of childhood apraxia of speech: Positive effects of the speech motor learning approach. American Journal of Speech-Language Pathology, 1-15.

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.