Teaching grammar to kids with ASD—How explicit should we be?

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We know that the language skills of children with autism spectrum disorder (ASD) vary… a lot. While some children are impaired across all language domains, others have weaknesses in just a few. For example, one subgroup of children with ASD have a relative weakness in grammar compared to the other domains. For kids with impairments in grammar, it is common practice to use an implicit intervention approach.

Perhaps you use implicit strategies with your clients? Do you show them pictures, model, and provide corrective feedback and recasts (e.g., “That’s right! The dog is running!”)? These are all implicit (you’re basically bombarding the child with correct productions and hoping that it sticks). Sometimes, though, you might feel that implicit isn’t enough. With some of your clients, do you ever find it helpful to explicitly provide the grammatical rule that you’re working on (e.g., we add -ing because it’s an action word)?

The authors of this study wanted to see whether adding an explicit component to intervention would be advantageous for children with ASD*. Seventeen children with ASD (ages 4–10) were taught two novel grammatical forms by either a combined explicit–implicit approach or an implicit-only approach. The combined approach differed in one way—the rule was described to the kids during intervention, which ended up being advantageous. More children learned the rules and used the novel forms during the combined explicit–implicit approach compared to the implicit-only approach.  

So if you’re working with kids with ASD with grammatical weaknesses, should you present the rules during intervention? At this point, it’s worth a try. The authors did question the generalizability of the results because the sample in the study was not very diverse (all subjects were verbal with mild-moderate ASD); so while the explicit component could be helpful for some of your students, it’s important to keep this limitation in mind.

*Got deja vu? We’ve reviewed another study from this lab on explicit grammar intervention before, but that one looked at children with developmental language disorders (DLD).  This study extends those findings to a new population!

 

Bangert, K. J., Halverson, D. M., & Finestack, L. H. (2019). Evaluation of an explicit instructional approach to teach grammatical forms to children with low-symptom severity Autism Spectrum Disorder. American Journal of Speech–Language Pathology. doi:10.1044/2018_AJSLP-18-0016

Training natural communication partners how to model AAC

Model, model, model! We all know how important and effective AAC modeling can be (see here and here, for example)—however, modeling is only as good as the partners who are implementing it. If you’re working with kids who use AAC, chances are there are communication partners who need guidance in how to model, and that’s no simple task. If you’re thinking “I agree, but HOW do I teach the partners?”, this review is for you!

The authors of this study gathered 29 studies in which more than 250 communication partners (including peers, teachers, paraprofessionals, parents, and other adults) implemented modeling strategies across various settings. Although they looked at a handful of research questions, the most clinically relevant questions were: How were the communication partners trained and what did they have to say about the training they received?

The most common training strategies were:

  • orally sharing information

  • modeling the strategies, and

  • allowing the partners to practice in controlled settings (role plays), or with a child, while providing feedback

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Overall, partners rated instruction as worth the time, easy to understand, practical, and transferable to other children. Some additionally offered the suggestion to provide more direction on how to model during a child’s regularly occurring activities (something to consider when you are providing training).

Seems pretty straightforward, right? We train the partners using those strategies and then off they go? Not so fast. The authors found that most communication partners also benefited from simultaneous support while learning to model. So after you train the partners, it’s important that you stick around to offer coaching and consultation as necessary.

If this seems daunting (how can I possibly fit this into my already jam-packed day!?), it’s important to remember that teaching communication partners can drastically improve the reach of our interventions—the amount of time we spend with our students is so limited compared to their interactions with natural communication partners.

If partner instruction is something you’d like to improve, be sure to check out the full article (specifically Table 2) for a list of the included studies and the training strategies used in each.

 

Biggs, E. E., Carter, E. W., & Gilson, C. B. (2019). A scoping review of the involvement of children's communication partners in aided augmentative and alternative communication modeling interventions. American Journal of Speech–Language Pathology. doi: 10.1044/2018_AJSLP-18-0024

Language deficits in preschoolers born premature: How should we assess?

By now, it’s fairly well known that prematurity is a major risk factor for language delays in toddlerhood and beyond. But what do those language deficits look like and how can we assess them adequately?

This study examines these questions by comparing preschoolers born preterm* with their typically developing, full term counterparts. They examined both groups’ expressive language skills, nonverbal IQ, and attention skills, as well as parental reports of hyperactivity and attention problems.

A standardized language assessment (CELF-Preschool 2) and language sample analysis were used to assess expressive language skills, with some interesting results. The only significant difference in CELF-P2 results was the Recalling Sentences subtest, but every measure of semantic and grammatical skills was significantly lower in the language samples of the preterm group. Attentional difficulties partially explained these skill differences, but not hyperactivity or nonverbal IQ. Keep in mind that these results don’t necessarily match those of previous studies of children born preterm, but the authors of this study do a thorough job of explaining possible reasons for this in the discussion section.

What are the takeaways for evaluating preschoolers born preterm?

  1. Don’t forget the value of standardized sentence recall tasks as an indicator of language disorder.

  2. Language sample analysis is worth taking the time to complete. Structured, standardized language assessments don’t always adequately measure deficits in conversational language skills.

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Check out our previous reviews (there are so many of them!) if you’re feeling stuck on where to begin with language sample analysis. But if you’re involved in research or just curious about the details, be sure to click over to the article for an interesting discussion of which measures the authors chose to use and why.

*before 36 weeks gestation; also, the researchers excluded children with diagnoses that further increased their risk of delays (issues such as chromosomal abnormalities, meningitis, or grade III/IV intraventricular hemorrhage)

 

Imgrund, C. M., Loeb, D. F., & Barlow, S. M. (2019). Expressive Language in Preschoolers Born Preterm: Results of Language Sample Analysis and Standardized Assessment. Journal of Speech, Language, and Hearing Research. doi:10.1044/2018_jslhr-l-18-0224

“I wish…I think…I wonder…”: Improving parents’ shared book readings

Shared book reading can be a sweet moment between parent and child—while also serving to improve a child’s literacy skills. The trick is figuring out how to help parents make the most of these interactions. This pilot study examined the effects of a short training on parent–child storybook readings. While this study focused on Deaf/Hard-of-Hearing preschoolers, most outcomes focused on the changes in the parents’ skills—meaning you can apply this across many populations.

Researchers recorded multiple shared book readings at each of three stages in the experiment: before training parents, in the “intervention period” (the two weeks following the parent training), and eight weeks after training. The training was only twenty minutes long (very do-able for real world clinicians!) and included a very short power point, a two-minute video model, and discussion with the parents. The authors focused on these topics for parent training:

  • Switching mindset from “education” to gaining insight into the child’s thoughts

  • No such thing as right or wrong

  • Increasing use of wait time

  • Increasing conversational turns

  • Making phonemic awareness fun and silly (like making up nonsense words by taking words in the text and changing one phoneme)

  • Using open ended prompts: “I wish…”  “I think…” “I wonder…” “What do you think?”

Parents were also given two booklets from the National Institute for Literacy and a few wordless picture books to add to their home collection.

When measuring parent interaction types, the authors split prompts into two categories:

Open-Ended Prompts

Questions that encourage open-ended discussion: “What do you think…

Indirect prompts such as “I think…” or “I hope…” paired with wait time

Closed-Ended or Right/Wrong Prompts

WH questions about the story text: “What is that?” “Where is her bone?

Questions about the story text that encourage one word answers

Yes/no questions or “how many” questions

For only spending twenty minutes on parent training, researchers saw some encouraging changes! Both the total number of parent–child exchanges and the percentage of open-ended prompts increased from baseline, through the intervention and retention stages. The percentage of words spoken by the child was also higher in the intervention and retention stages (though only the intervention stage showed a statistically significant difference from baseline levels). Because a dip was shown in all outcomes during the retention stage, eight weeks after training, it looks like clinicians will probably need to follow-up with parents periodically.

For more along these lines, check out our reviews about supporting parents to complete literacy programs, teaching vocabulary via shared readings, and improving the narrative comprehension of children with ASD.

Nelson, L. H., Stoddard, S. M., Fryer, S. L., & Muñoz, K. (2019). Increasing Engagement of Children Who Are DHH During Parent–Child Storybook Reading. Communication Disorders Quarterly. doi:10.1177/1525740118819662

Rhetorical competence: Anaphors, organizational signals, and refutation cues. Oh my!

If you’re an SLP who works with older elementary children and above, you’re probably already targeting strategies to improve reading comprehension. And you likely already know the differences between narrative texts and expository (informational) texts. But are you targeting rhetorical competence to improve expository text comprehension? Have you... even heard of rhetorical competence (RC)? Don’t panic if this is foreign to you—we’ve got a handy breakdown of some common rhetorical devices, based on this new article.

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Anaphors/Connectives:

  • Direct readers to think about an earlier referent in the text

  • e.g. Students are getting hurt because of unsafe playground equipment. A potential solution for this problem

Organizational Signals:

  • Help readers create a mental representation of the main ideas and text structure

  • e.g. “A second issue to consider is…” or “The first reason…

Refutation Cues:

  • Signal to readers that an incorrect belief is being asserted and then refuted

  • Many people think that ____, but actually ____

Now that you’re up to speed, on to the study*. The authors examined (1) how RC develops between 3rd and 6th grades, (2) how RC contributes to comprehension of expository texts, even beyond skills such as decoding and inferencing, and (3) if the relationship between RC and comprehension is moderated by grade level and other reader characteristics. The findings are detailed and dense, so here are the results that you, the practicing SLP, should focus on:

  • All measures of RC were correlated with improved comprehension of expository text. (Strong RC and strong text comprehension tended to go together.)

  • RC contributes to a student’s expository comprehension above and beyond that student’s inferencing skills, decoding ability, prior knowledge, and working memory. This means that the ability to use rhetorical devices makes a unique contribution to comprehension.

  • RC develops slowly over time and was not even complete in the 6th graders included in this study, meaning it is a skill you can target across several grade levels.

Sadly, this study didn’t tackle how to target rhetorical devices. But as the communication expert, you are uniquely positioned to explicitly draw attention to rhetorical devices in text, especially with readers who may already struggle with comprehension. Keep your eyes open for these features in the texts you’re already using, giving you the perfect opportunity to build rhetorical competence!

*Keep in mind, this sample featured typically-developing Spanish students, but there are enough similarities in text structure that the findings apply to English-speaking students as well.

García, J. R., Sánchez, E., Cain, K., & Montoya, J. M. (2019). Cross-sectional study of the contribution of rhetorical competence to children’s expository texts comprehension between third- and sixth-grade. Learning and Individual Differences. doi:10.1016/j.lindif.2019.03.005

What’s driving our clinical decision-making?

We know a lot about what types of assessment tools SLPs tend to use (see here, here, and here, for example), but we don’t know much about how we synthesize and prioritize the information we gather in those assessments to come up with a diagnosis (or lack thereof). How do we reconcile inconsistent results? What factors tend to carry the most weight? How much do outside influences (i.e. policies and caseload issues) affect our decisions? Two different studies this month dive into the minds of SLPs to begin answering these questions.

Fulcher-Rood et al. begin by pointing out that school-based SLPs receive conflicting information on how to assess and diagnose language disorders from our textbooks, our federal/state/local guidelines and policies, and the research. So how do we actually approach this problem in real life? To learn more, they used a pretty cool case study method, where lots of assessment results were available for each of five, real 4–6-year-olds (cognitive and hearing screenings, parent/teacher questionnaires, three different standardized tests and two different language samples, transcribed and analyzed against SALT norms), but the 14 experienced SLPs who participated only saw the results they specifically asked for to help them make their diagnoses. This better reflects actual practice than just giving the SLPs everything upfront, because in school settings you’re for sure not going to have SPELT-3 scores or LSA stats to consider unless you’re purposefully making that happen. The case studies were chosen so that some showed a match between formal and informal results (all within or all below normal limits), whereas some showed a mismatch between formal and informal testing, or overall borderline results. Importantly, SLPs were instructed not to consider the “rules” of where they work when making a diagnosis.

Here were some major findings:

  • Unsurprisingly, when all data pointed in the same direction, SLPs were unanimous in determining that a disorder was or wasn’t present.

  • When there was conflicting information (standard scores pointed one direction, informal measures the other), almost all the SLPs made decisions aligning with the standardized test results.

  • Across cases, almost all the SLPs looked at CELF-P2 and/or PLS-5 scores to help them make a diagnosis, and in most cases they asked for parent/teacher concerns and language sample transcripts as well. A third of the SLPs didn’t ask for LSA at all.

  • Only a few SLPs used SPELT-3 scores, and no one asked for language sample analyses that compared performance to developmental norms.

These results reinforce what we learned in the survey studies linked above: SLPs use a lot of standardized tests, combined with informal measures like parent/teacher reports, and not so much language sampling. What’s troubling here is the under-utilization of tools that have a really good track record at diagnosis language disorders accurately (like the SPELT-3 and LSA measures), as well as over-reliance on standardized test scores that we know can be problematic—even when there’s tons of other information available and time/workplace policies aren’t a factor.

The second study, from Selin et al., tapped into a much bigger group of SLPs (over 500!), to ask a slightly different question:

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Under ideal conditions, where logistical/workplace barriers are removed, how are SLPs approaching clinical decision-making? And what about the children, or the SLPs themselves, influences those decisions? 

Their method was a little different from the first study. SLPs read a paragraph about each case, including standard scores (TOLD-P:4 or CELF-4, PPVT-4, GFTA-2, and nonverbal IQ) and information about symptoms and functional impairments (use of finiteness, MLU, pragmatic issues, etc.). Rather than giving a diagnosis, the SLPs made eligibility decisions—should the child continue to receive services, and if so, in what area(s) and what type of service (direct, consultation, monitoring, etc.)?

The survey method this team used yielded a TON of information, but we’ll share a few highlights:

  • Freed from the constraints of caseloads and time, SLPs recommended continued service more often than we do in real life. We know that workplace policies and huge caseloads can prevent us from using best practices, but it’s helpful to see that play out in the research. It’s not just you!

  • Six cases were specifically set up to reflect the clinical profile of Specific Language Impairment*, but when determining services and goal areas, SLPs choices didn’t consistently align with that profile. So, even when a case was consistent with SLI, services weren’t always recommended, and when they were, the goals didn’t necessarily correspond with the underlying deficits of that disorder. So as a group, our operational knowledge of EBP for language disorders has a lot of room for improvement. Unlike with speech sound disorders, SLPs were not sensitive to clinical symptoms of SLI (tense/agreement errors, decreased MLU) when making eligibility decisions.

  • Yet again, SLPs relied heavily on standardized scores, even when other evidence of impairments was present.  

So what can you do with all this information? First of all, think about what YOU do in your language assessments. What tools do you lean on to guide your decisions, and why? Are you confident that those choices are evidence-based? Second, keep doing what you’re doing right now—learning the research! There is tons of work being done on assessment and diagnosis of language disorders, use of standardized tests, and LSA (hit the links to take a wander through our archives!). Taking a little time here and there to read up can add up to a whole new mindset before you know it.  

*SLI, or developmental language disorder (DLD) with average nonverbal intelligence.

 

Fulcher-Rood, K., Castilla-Earls, A., & Higginbotham, J. (2019). Diagnostic Decisions in Child Language Assessment: Findings From a Case Review Assessment Task. Language, Speech, and Hearing Services in Schools. doi:10.1044/2019_LSHSS-18-0044

Selin, C. M., Rice, M. L., Girolamo, T., & Wang, C. J. (2019). Speech-Language Pathologists’ Clinical Decision Making for Children With Specific Language Impairment. Language, Speech, and Hearing Services in Schools. doi:10.1044/2018_LSHSS-18-0017

Better word learning through repeated retrieval

With vocabulary, there’s a tendency to talk about “teaching” and “probing” as two separate things, with too much of the latter getting in the way of the former. But as it turns out, asking your students to recall words you’ve recently taught them can be an important part of teaching. Depending on where you got your SLP training, concepts like “spaced retrieval” may have been part of your curriculum in adult cognitive therapy, but we can apply those same ideas to working with our preschool-aged friends with developmental language disorder (DLD) as well! We know our young clients with DLD struggle to learn new words, and vocabulary deficits can snowball over time, with negative effects on literacy and language, so anything we can do to improve that process is definitely worth knowing about.

In the first of a pair of studies from Leonard, Haebig, and colleagues, the authors taught novel (meaning, invented) words to a group of preschoolers (about age 5) with and without DLD. Half the words were taught with a procedure called repeated retrieval with contextual reinstatement (RRCR), that worked like this:

  1. Learn a new target word (see a picture paired with 3 exposures to the word and a simple definition)

  2. Prompt to recall (retrieve) that word, then hear the name/definition again (study the word)

  3. Learn 3 more words

  4. Retrieve the target word again, then study the word

  5. Learn 3 more words

  6. Retrieve the target word a third time, then study the word

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The “contextual reinstatement” part of RRCR comes from the fact that the attempts to retrieve the word are broken up by exposures to different words (in steps 3 and 5 above). The other half of the words were taught with the same procedure, but without the prompts to recall the word, so at steps 2, 4, and 6, the children just got the additional chances to study the target word.

For children with and without DLD, the repeated retrieval condition resulted in better word learning (about 2.5 more word forms recalled out of 8 in a labeling task, and 1 more definition) both 5 minutes and 1 week after teaching. Note that the same advantage didn’t hold if they were tested using a multiple-choice format (think the PPVT), which is an easier task than naming pictures. An even cooler part of the results? The children with DLD did just as well as the typically-developing kids, with the same number of exposures to the target words.

And how important is that “contextual reinstatement” piece, anyway? That’s the question the second of the two studies examined. They compared the RRCR protocol with immediate retrieval, where kids needed to recall taught words right after learning them, without other words being presented in between. Similar to the previous results, the kids were much better at remembering words learned via RRCR. So it’s not just the retrieval aspect that’s important, but needing to retrieve information after thinking about something else in between. So while there’s still more to learn (How many words can you teach at a time via this method? What’s the best retrieval schedule to use?), this is a powerful concept that you can bring to your own intervention.

 

Leonard, L. B., Karpicke, J., Deevy, P., Weber, C., Christ, S., Haebig, E., … Krok, W. (2019). Retrieval-Based Word Learning in Young Typically Developing Children and Children With Developmental Language Disorder I: The Benefits of Repeated Retrieval. Journal of Speech, Language, and Hearing Research. doi:10.1044/2018_JSLHR-L-18-0070

Haebig, E., Leonard, L. B., Deevy, P., Karpicke, J., Christ, S. L., Usler, E., … Weber, C. (2019). Retrieval-Based Word Learning in Young Typically Developing Children and Children With Development Language Disorder II: A Comparison of Retrieval Schedules. Journal of Speech, Language, and Hearing Research. doi:10.1044/2018_JSLHR-L-18-0071

Speech homework: The parents’ perspective

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If you are an SLP who works with children with speech sound disorders (SSD), you are aware of: (1) how important home practice is, and (2) how difficult it is to ensure it happens. You send home cute activities and worksheets only to find out they’re never being done. You email parents with suggestions but wonder how much parents actually use them.

Some researchers decided to interview parents about their experiences with home practice in order to better understand their perspective. They wanted to hear from parents how SLPs could better support and encourage their attempts!

The researchers interviewed six parents of children aged 3–6 who had participated in speech–language therapy for an SSD. Several themes emerged throughout the conversations. They boiled them down these: 

Evolution over time

Parents expressed that their experiences with home practice changed over time. At the beginning, parents often felt confused, overwhelmed, and unsure of how to complete the activities. Over time, parents felt increasingly confident in the activities and what was expected of them.

Different roles

Parents saw the SLP as the expert who could provide materials and instruction, but saw themselves as ultimately responsible for supporting their child’s speech and language.

Importance

Parents stressed the importance of several things to them: their child’s speech and communication growth, their own role and involvement in therapy, consistent home practice, and rapport with the SLP. They felt that when there was rapport, they and their child were more motivated to do home practice and they saw more progress.

Managing the practicalities of home practice

Parents expressed difficulty with the logistics of home practice. All parents reported that it was challenging to find the time to do the activities and most admitted that they did not complete the full amount of time suggested by the SLP. Parents described receiving activities that were not motivating to their child or did not suit them as a family. They were often also unsure of how to complete the activities or how to do the technical components of therapy.

Taken together, these findings leave us SLPs with some helpful takeaways. First, it’s important for parents and SLPs to have a clear discussion about both of their expectations at the beginning of therapy. These parents spoke about how their expectations did not always match the realities of what therapy looked like and it took a while for them to adjust and figure out the ropes. Second, it may be beneficial to regularly share data about the child’s progress, as parents found that when their child made progress, they were more motivated to continue home practice. Last, SLPs should work with the family to provide family-appropriate materials as well as sufficient training and clear instructions for how to complete them.

 

Sugden, E., Munro, N., Trivette, C.M., Baker, E., Williams, A.L. (2019) Parents’ experiences of completing home practice for speech sound disorders. Journal of Early Intervention. doi: 10.1177/1053815119828409.

Perspectives & Tutorials

Five overarching factors central to grammatical learning and treatment in children with developmental language disorder

Want to take your therapy up a notch, by thinking like a linguist? Check out this review paper, based in theory, that uses a cross-linguistic perspective to discuss ways to improve grammar therapy for children with developmental language disorders (DLD). In the piece, the authors address a few questions:

What do English-speaking children with DLD struggle with, more than children with DLD who speak other languages?

What features of English could explain those particular difficulties?

Most importantly—how could we use this knowledge to potentially improve our therapy?

There are five main points, summarized in Table 1. Keep in mind that this isn’t empirical research, so we don’t know for certain how implementing the authors’ suggestions would affect our clients’ progress. But in the absence of enough clinical evidence (the unfortunate position we too often find ourselves in), approaching a challenge with a well-informed theory is the best place to start. Ideally, before we figure out whether something works, we should already have a good idea of why it should.

Interprofessional Education: Application of Interprofessional Education Collaborative Core Competencies to School Settings

The Impact of Social Media on Communication Sciences and Disorders: A Need for Examination and Research

This one is aimed towards researchers—calling on them to look into the effects that social media (the good, the bad, and the ugly) are having on our profession and clients. It’s worth checking out just for the list of possible ways that the social media scene could be helping—and hurting—SLP practice.

Linking Cognitive Processing, Psychosocial Development, and Social Competency to Intervention for Adolescents With Autism Spectrum Disorder Level 1 Severity