Developmental, naturalistic options for preschoolers with autism

There are many, many options for teaching pragmatic skills to children with autism, varying from structured discrete trial training (DTT) to more naturalistic, child-led interventions. Often we think of behavioral and naturalistic approaches to therapy as an either/or. In reality, though, the majority of the interventions available for young children with autism use a naturalistic approach, based on developmental principles, while also pulling in elements of behavioral theory (recently, autism researchers coined the term “naturalistic developmental behavioral intervention,” or NBDI, to reflect these nuances).

This systematic review focuses on developmental social pragmatic (DSP) interventions (similar to NBDIs, but not including any explicit prompting, which is a more behavioral strategy). The researchers carefully defined DSP interventions using a core set of criteria to make sure they pulled just the right group of studies. DSP interventions:

  • Are based on developmental principles (hence the name!)

  • Use natural/play-based settings in therapy

  • Follow the child’s lead

  • Emphasize environmental arrangement and natural communication opportunities, and

  • Avoid explicit prompting (“Say ‘More Blocks’!”)


Although DSP interventions (like NDBIs) incorporate some behavioral principles, they are not DTT—we’re talking about less structured learning opportunities here. Need examples? Think SCERTS (social communication, emotional regulation, transactional support intervention), DIR (developmental, individual difference, relationship-based intervention), PACT (parent-mediated communication-focused treatment), and More Than Words.

There are a few ways you might use a review like this. Have an intervention in mind and want to see if it made the list? Want to learn more about the evidence base for the intervention your school or clinic is already using? Or maybe you want to look into a new and different intervention for preschoolers with ASD? Whatever your purposes, keep in mind that (as with many systematic reviews and meta analyses) it’s a bit apple-and-oranges to compare the kids’ language outcomes across studies— we need more research to be able to say which DSP interventions lead to the biggest language gains. The results show us, though, that these interventions in general had positive effects on attention, engagement in social interactions, and initiations for preschoolers with ASD. Parent interaction styles improved, too, becoming less directive and more responsive. We love seeing outcomes like that! Overall, this article is a nice place to start organizing your thoughts on the many developmental social pragmatic options available for treating preschoolers with autism. 

Binns, A. V., & Oram Cardy, J. (2019). Developmental social pragmatic interventions for preschoolers with autism spectrum disorder: A systematic review. Autism and Developmental Language Impairments. doi:10.1177/2396941518824497

SUGAR update: can it diagnose DLD?

Remember SUGAR? It’s the new, alternative language sample analysis protocol meant to work within the realities of a busy SLP’s workload. It’s been a while, so here’s a quick recap: SUGAR involves calculating four metrics on a 50-utterance sample where you only transcribe child utterances:  

  1. Mean length of utteranceSUGAR (MLUS)*

  2. Total number of words (TNW)

  3. Clauses per sentence (CPS)

  4. Words per sentence (WPS) 

For specifics and examples, check out the complete procedures (including videos) on their website.

While the creators of SUGAR have provided some support for its validity, the diagnostic accuracy of the four measures hasn’t been tested—until now! In this new study, the authors recruited 36 3- to 7-year-old children with DLD (currently receiving or referred to services) and 206 with typical language, and used the SUGAR protocol to sample their language. All four measures showed acceptable sensitivity and specificity (above 80%), using research-based cutoff scores (see the paper for specifics on cutoffs for each measure). The most accurate classification, according to the authors, was achieved with a combination of MLUS and CPS.


One of SUGAR’s big selling points is that it’s quick (like, 20 minutes quick), at least for kids with typical language. Did that still hold for the children with DLD? Actually, in this study they took less time to provide a 50-utterance sample than their typical peers. Bonus!

Language sampling can be daunting for the full-caseload SLP, but we love that research like this is identifying promising LSA measures that have high diagnostic accuracy (higher, we might add, than many commercially-available tests), while addressing our time and resource barriers.

An important note: there are many methodological differences between SUGAR and other LSA procedures, and SUGAR has not been uncontroversial. We’ll be on the lookout for more research on SUGAR’s diagnostic potential or comparing SUGAR to more traditional protocols to help us really understand the pros and cons of the different LSA methods.

*When calculating MLUS, derivational morphemes (-tion) are counted separately and catenatives (hafta, wanna) count as two morphemes.


Pavelko, S. L., & Owens Jr, R. E. (2019). Diagnostic Accuracy of the Sampling Utterances and Grammatical Analysis Revised (SUGAR) Measures for Identifying Children With Language Impairment. Language, Speech, and Hearing Services in Schools. doi:10.1044/2018_LSHSS-18-0050

Ultrasound visual biofeedback: a new tool for treating SSD?

Have a student (...or 50?) on your caseload with articulation goals? Have some of them been there for a long time? While some of our kids with speech sound disorders (SSD) make quick progress with traditional methods, what can we try with those whose errors persist despite treatment? One new—and cool— option is ultrasound visual biofeedback (u-VBF).

“Wait, what? Ultrasound??”

Yes, it’s actually been an active area of research for both assessment and intervention for many years, with positive or mixed outcomes reported. Ultrasound is non-invasive and uses high-frequency sound waves to make an image of the tongue, which clients can see as they speak, in real-time. This technology is most helpful for place errors involving the tongue, since labial sounds can be seen using a mirror. And while it sounds super-expensive, ultrasound units have actually become so affordable that we’re starting to see clinics and even school districts jump on board!

This newest study from Cleland et al. used u-VBF to treat a diverse range of children who presented with a range of SSDs, comorbid conditions like DLD or ASD, and different speech targets. (Note: /r/ was excluded as a possible target in this particular study.) The authors conducted a thorough assessment for each child to determine errors and stimulability, which guided the target selection for each child (check out the article for a cool flow chart illustrating this). After an initial baseline phase, 10–12 treatment sessions were conducted, following procedures you can find in this resource manual from the same authors.


Most children made some improvement toward their speech sound, although those without a co-occurring diagnosis made the most improvements, which the authors took to mean that children with comorbidities might benefit from higher dosage. These results show us that ultrasound can be used to treat lingual articulation errors in a wide range of SSDs. Given the design and sample size, we can’t say much about treatment of specific targets or client subtypes at this point. And since this paper didn’t address the dreaded /r/, see here, here, and here for more on that.

Cleland, J., Scobbie, J. M., Roxburgh, Z., Heyde, C., & Wrench, A. (2019). Enabling new articulatory gestures in children with persistent speech sound disorders using ultrasound visual biofeedback. Journal of Speech, Language, and Hearing Research. doi:10.1044/2018_JSLHR-S-17-0360

Mixing language with science to target "because" and "so" in preschoolers with DLD

As SLPs, we all love the intricacies of grammar… right? No?

Well, we at least love ourselves some good ol’ adverbial clauses, right? Anyone? Just me?

Ok, so maybe we don’t all share the same nerdy love of all things grammar, but we can probably all agree that complex sentences are essential for both conversation and academics, and that children with developmental language disorder (DLD)—who struggle to use and understand these sentences—need effective language intervention to learn them. Also, even for us grammar enthusiasts, complex syntactic constructions can be difficult to teach. So what do we do?

That’s where this single-case study* from Curran and Van Horne comes in. They hypothesized that recast strategies—which have been researched extensively for teaching morphology—would improve preschool children’s use of causal adverbials, specifically because (“I ate because I was hungry”) and so clauses (I was hungry, so I ate). Critically, the authors distinguish between kids being able to use the word “because” in their speech (which happens pretty early) and actually acquiring multi-clause sentences that express a cause–effect relationship; and we’re interested in that second, more complex skill.  

What’s great about this study’s approach is that it looked at causal adverbials in the context of science instruction, which relies heavily on understanding of cause and effect. After some baseline probes and some standard science lessons, the researchers provided 20 sessions of science instruction combined with language intervention, using visuals, recasts, and prompting for those so and because clauses. A typical recast might sound like this: 

Child: “The kite goed up. Wind pushed it.”

Adult: “The kite went up because the wind pushed it.” 

Wondering how they got the kids to produce these structures in the first place? They used prompts like this one for because: “She pushed air in. The plunger popped out. Why did the plunger pop out? Start with ‘The plunger...’”

So did it work? Well, six of the seven children improved in their use of because clauses, showing strong positive trends during the intervention phase, compared to control structures. So clauses did not improve significantly, maybe because they were less frequent or as the result of a possible “competition effect” between because and so. Finally, while the kids did learn the science content over time, it didn’t seem to be the result of language skills gained.

The authors sum it up nicely: “Multiclause adverbials can be effectively addressed in clinical intervention, even for children who do not yet possess significant written language or metalinguistic skills.” Larger studies could help to clarify some of these findings, but using recasts as a way to teach complex syntactic structures is a promising strategy for children with DLD.


*Single case designs have their own special place in research and are valuable tools for treatment studies. They can highlight individual differences (because group designs only look at mean differences), and because it’s pretty comparable to what SLPs are doing in the real world, they have high social validity. We still would love to see similar results come from a larger study design, but these smaller studies teach us a lot in the meantime.


Curran, M., & Van Horne, A. O. (2019). Use of Recast Intervention to Teach Causal Adverbials to Young Children With Developmental Language Disorder Within a Science Curriculum: A Single Case Design Study. American Journal of Speech-Language Pathology. doi:10.1044/2018_AJSLP-17-0164

On intelligibility: why use it, and options for measurement

It’s been suggested that we use intelligibility as part of comprehensive speech assessment, and measurement of treatment outcomes. Why? Well, because intelligibility is kind of the point of speech therapy in the first place, right? Also, intelligibility can pick up on phonological changes that other measures (like percent consonants correct, PCC) can’t.

So which intelligibility measures are we supposed to be using, exactly? Or, more appropriately—what are our options?

First, there are many ways to measure intelligibility. We can use rating scales, single word measures, or connected speech; and raters may include the clinician, family, peers, or unfamiliar listeners. Each of these have their own pros and cons in terms of reliability, validity, and compatibility with clinical practice. But the gold standard has been to calculate the percent of words understood, by unfamiliar listeners, in a connected speech sample (Gordan-Brannan & Hodson, 2010).

And while speech samples + few unfamiliar listeners as raters may be ideal, that carries a time burden for clinicians. Further, we also really want data on how the child is functioning in his or her everyday life. These considerations are what make the Intelligibility in Context Scale (ICS) particularly enticing—developed and measured over the past several years from (ongoing) research by McLeod and colleagues.

What is the ICS? It’s a brief, 7-item rating scale, completed by the parents of preschool and school-aged children. It can supplement other clinical measures for a nice look at functional speech. The scale can be found here (also on the last page of this article). Additional things to know about it:


Multilingual populations: It’s been translated into 60 languages (free, online!), and being multilingual doesn’t affect the scores (McLeod et al., 2015). It’s recommended that you use a separate sheet for each language the child speaks.

Screening: Use for preschool screening would be appropriate, especially as additional normative data is collected by future research. For now, this article can help you identify appropriate scores for your environment. You’ll extrapolate to your clinical population by looking at the scores they found in their sample of 4- and 5-year-olds (see Table 3 of the study). Do keep in mind the limitations of their study (read Limitations section). But basically, the scores in this study are relatively conservative, so children are generally likely to require further speech evaluation if their scores are lower than that 2015 study.

Psychometric properties: You can find this data throughout several of their articles; in particular, this one, which provides support for the ICS as a valid and reliable measurement of preschool children’s intelligibility.

Though we started by looking at the McLeod et al., 2015 paper, research for this Throwback review ended up sending us toward several papers on intelligibility, linked out above. Enjoy!

Perspectives & Tutorials

On SSDs and Eligibility (required reading!)

Remember last month, when we promised to point you towards any really good stuff coming out of ASHA’s revamped Perspectives journal? Yeah, we didn’t have to wait very long. We (and others) have been shouting from the social media rooftops about this new Clinical Forum since it first hit the web a couple weeks ago, but consider this your official notice to get clicking!  

There’s an introduction and four articles that dive into all the thorniest issues about qualifying students for articulation services in schools: standardized testing, use of developmental norms (relevant for the recent hoopla around the new/not-new speech sound norms—see this blog post), single sound errors, and the social impact of speech sound disorder (SSD) as a basis for qualification. We’re giving you some highlights and don’t-misses below, but seriously: if you diagnose and treat a lot of SSDs, especially in the schools, read it all. These articles are all open-access, so no barriers there! This would also be a great issue for school-based SLPs to grab for a professional development session with your co-workers! The discussion will be so good, you won’t even need the coffee and donuts. Probably. Maybe. Better bring them just to be safe...

Clinical Forum Prologue: Speech Sound Disorders in Schools: Who Qualifies?

Standardized Tests and the Diagnosis of Speech Sound Disorders

If you’re in a big hurry, read this quote... 

“Unfortunately, because the majority of standardized tests of articulation and phonology currently did not meet basic psychometric requirements (Kirk & Vigeland, 2014), it is essential that they do not act as the cornerstone of speech sound assessment.”

...and jump to the section called “Evidence-Based Evaluations of SSDs,” which starts on page 61 of the PDF. It lays out the 10(!) elements that would comprise a best-practice evaluation plan. They do suggest school SLPs not be “discouraged” by their recommendations, but to use them as a basis for advocating for more time to complete your assessments in the manner our field’s best evidence supports.

And before you go, print out page 62 (Table 1, a summary of criterion references for phonology) and laminate it for your next round of eval write-ups.  

Using Developmental Norms for Speech Sounds as a Means of Determining Treatment Eligibility in Schools

“Developmental norms for phonological error patterns or speech sounds can be a useful tool in determining eligibility, but some guidelines seem to overemphasize the use of norms, particularly single age cutoffs, and, in some cases, even advocate for use that is inappropriate.”

If the powers-that-be have given you eligibility guidelines that hinge on developmental norms, there may be an issue, so don’t skip this article. The gist of it all? Age of acquisition needs to be viewed as a range, not a single age, and developmental norms should not be your only data point. The case studies in this article are especially helpful in considering this issue—they walk you through the process of integrating standardized test results with developmental norms to make clinical decisions.  

It Might Not Be “Just Artic”: The Case for the Single Sound Error

Does your school/district/state support serving students with single sound errors? There’s a lot of variability in whether, when, and how these kids get therapy in school, and many reasons offered for why they perhaps don’t need to. This article asks you to reconsider some of those reasons, given evidence of the effects on literacy and other areas of functioning. Make sure you check out the appendix, for a bulleted list of recommendations on assessment, treatment, and advocacy—and we’re not just saying that because she links to a TISLP piece!

Eligibility and Speech Sound Disorders: Assessment of Social Impact

The jury is in, whether or not your district is on board: we need to consider social impact when assessing the “academic” impact of SSDs on our students. Here, you’ll find several methods you can use to evaluate social impact, and reading through the case studies will help you consider which methods are best for which situations.   

Final note—if you just can’t right now with the reading, try a podcast episode instead. A bit easier to fit into a busy schedule, and may even get you excited about checking out the full articles! Try here and here.


More Perspectives & Tutorials

Building capacity in AAC: A person-centered approach to supporting participation by people with complex communication needs

Challenges and opportunities in augmentative and alternative communication: Research and technology development to enhance communication and participation for individuals with complex communication needs

Cognitive predictors of sentence comprehension in children with and without developmental language disorder: Implications for assessment and treatment

Innovative Service Delivery Models for Serving Children with Speech Sound Disorders

New and emerging AAC technology supports for children with complex communication needs and their communication partners: State of the science and future research directions

The Sequential Unfolding of First Phase Syntax: Tutorial and Applications to Development

Speech-Language Pathology and the Youth Offender: Epidemiological Overview and Roadmap for Future Speech-Language Pathology Research and Scope of Practice          

This open-access article is your advocacy pick of the month! See a previous review on this important topic here.

Supporting Children With Traumatic Brain Injury in the Schools


And more

Hwa-Froelich & Matsuo found that children who were adopted internationally had pragmatic skills within the average range, yet their scores were lower than their non-adopted, typically-developing peers. Understanding the language skill profiles of children adopted internationally is important so that we don’t over-refer or misdiagnose these kids. P.S. We’ve reviewed this team’s research with this same population before here.

In the largest study of its kind to date, Potter, Nievergelt, & VanDam found that children with speech sound disorders have similar tongue strength as their typically-developing peers. This study adds to the evidence base that disputes the use of non-speech oral motor exercises in speech therapy.

Rivera Pérez et al. wondered whether monolingual SLPs could use audio prompting (i.e., pre-recorded stimuli in the home language) to facilitate vocabulary learning in Spanish–English bilingual preschoolers with typical language abilities. Children were taught vocabulary in either English only or in both English and audio prompt-delivered Spanish. All children learned English vocabulary, and only the group receiving audio prompting improved on Spanish vocabulary measures, suggesting audio prompting may help improvement in the home language. We should note that their design didn’t compare the English-only and English-plus-audio-prompting conditions and participants were typically developing children taught by SLPs. Still, more research like this could help identify ways SLPs can better serve their bilingual students. Exciting! 

Roberts et al. found positive effects of teaching preschoolers (including some dual language learners) letter name and letter–sound correspondence. No surprise there—we know how important that skill is! It is interesting that they found no advantage for teaching letter names before letter sounds: the jury’s still out on whether one should be taught before the other.

A study by Sue et al. reminds us to consider generalization not only across contexts but across receptive–expressive language modalities. In a single case design on vocabulary training in children with ASD, where children were taught a set of words either receptively or expressively, they found that some but not all of those words taught were acquired in the untrained modality. More expressive-to-receptive transfer was noted—which makes a lot of sense. There are still open questions about the optimal teaching order (if there is one) and what the implications are for dosage.


Hwa-Froelich, D. A., & Matsuo, H. (2019). Pragmatic language performance of children adopted internationally. American Journal of Speech–Language Pathology. doi:10.1044/2018_AJSLP-18-0075

Potter, N. L., Nievergelt, Y., & VanDam, M. (2019). Tongue strength in children with and without speech sound disorders. American Journal of Speech–Language Pathology. doi:10.1044/2018_AJSLP-18-0023

Rivera Pérez, J. F., Creaghead, N. A., Washington, K., Guo, Y., Raisor-Becker, L., & Combs, S. (2019). Using Audio Prompting to Assist Monolingual Speech–Language Pathologists to Teach English–Spanish Vocabulary to English Learners. Communication Disorders Quarterly. doi:10.1177/2F1525740118819659

Roberts, T. A., Vadasy, P. F., & Sanders, E. A. (2019). Preschoolers’ alphabet learning: Cognitive, teaching sequence, and English proficiency influences. Reading Research Quarterly. doi:10.1002/rrq.242

Su, P. L., Castle, G., & Camarata, S. (2019). Cross-modal generalization of receptive and expressive vocabulary in children with autism spectrum disorder. Autism & Developmental Language Impairments. doi:10.1177/2F2396941518824495

Traveling SLP Magic: How to be in two places at once

Where are my itinerant clinician friends—those SLPs who pack up their therapy room in a weird rolling suitcase thing, make nice with administrative assistants all over town, eat in their cars, and find themselves constantly thwarted by conflicting building schedules? Yes, hello there! Let’s talk about how things could be different.

In a word… telepractice. As much as we value being physically present for our students and colleagues, we’re living in the age of Facetime, video conferencing, and working remotely. The whole realm of using technology to be a place that you’re not is now mainstream, and easier for people to accept and accommodate than even a few years ago. And after all, a 15-minute drive can easily mean 30 or 40 minutes of lost productivity, once you factor in packing/unpacking, parking, check-in, and everything else involved with a transition between buildings. This article takes the perspective that it’s not whether SLPs should be using telepractice, but how. There’s been plenty of research showing that telepractice can work (see our reviews on the topic), we just need to be smart about:

What job tasks we target for telepractice, and

How we go about it

The article lays out two case studies of SLP using telepractice for (1) direct service to high school students, (2) remote supervision of an SLPA, and (3) remote observations and consultations by a district AAC specialist. They include a lot of really helpful details about how they set these systems up, so definitely check out the article if you’re thinking about trying something similar. The authors studied the effectiveness of telepractice in these cases through a survey. The participants reported that:

  • Telepractice was effective and generally easy to implement for both direct and indirect services/supervision

  • The dreaded technical issues could be dealt with

  • It could be motivating to students, and

  • The SLPs had increased flexibility and decreased travel time

The downsides? Tech troubles did happen, and there were also some issues communicating and coordinating with sites. Choosing the right partners and laying down the groundwork is critical to making it work!


The last part of the article lays out some very practical pro tips for other SLPs. For example, they recommend holding a team meeting upfront to demonstrate the systems you’ll use, answer questions, and secure buy-in from everyone involved. Also consider small but impactful steps like scheduling email reminders (with backup contact information and links to video sessions), or using two separate computers on the clinician end of thingsone for the audio/video, and one for all your other therapy “stuff.”  And if your admin needs any convincing? Remind them that you’ll be saving them time (from travel) and potentially money (from mileage reimbursements)!

Note: Not all states allow Medicaid billing of telesessions quite yet. So if you’re in the schools, that is an important thing to check first.


Boisvert, M. K., & Hall, N. (2019). Telepractice for School-Based Speech and Language Services: A Workload Management Strategy. Perspectives of the ASHA Special Interest Groups. doi:10.1044/2018_PERS-SIG18-2018-0004

Who needs extra time in fluency therapy?

A lot of what we know about evidence-based practice is how things work (or don’t) in general, for groups of similar clients, on average. But as we’ve all seen, even the best approaches don’t work for everyone, or don’t work to the same degree, at the same speed, or in exactly the same way in every case. Knowing how to factor individual differences into our assessment and intervention process is a huge research question (or ten thousand small ones), and it’ll take time for our field to get there. This new study is one link in that chain, addressing how self-regulation abilities relate to therapy outcomes and duration for young children who stutter.


Children who stutter often struggle with self-regulation, in a similar way to kids with ADHD. (We mentioned a study last month that addressed the importance of “effortful control” in predicting stuttering severity.) Basically, self-regulation is the ability to control your reactions (emotions AND behaviors) to changes in your environment. Kids who have a hard time self-regulating will have really big emotions, both positive and negative, and struggle to calm down when they're upset or excited. They'll also have more trouble focusing and shifting attention than other kids. Here, Druker et al. looked at 185 children between 2 and 6 years old, all of whom had been discharged or discontinued from stuttering therapy within the last three months. About half of these kids displayed “elevated” ADHD symptoms (subclinical, so not actually receiving a diagnosis), as determined by a parent-report measure. Refer back to the article for more details on how this was measured.

Now that in itself is worth knowing, but even more useful is this: the children with more ADHD symptoms needed about 24% more time in therapy (here corresponding to about 3 sessions), to meet the criteria for discharge. If you know right off the bat that your new little client struggles with attention and self-regulation (consider adding a questionnaire to your evaluation protocol or intake process so you know this!), you can take that into account in your treatment plan and expectations for progress.

What other implications do we see for practice? The authors suggestjust like the authors from the piece last month—that SLPs directly address self-regulation skills within fluency therapy. We can’t say from the current research how to do that, or how it might affect outcomes, but it’s a logical step to consider.


Druker, K., Hennessey, N., Mazzucchelli, T., & Beilby, J. (2019). Elevated attention deficit hyperactivity disorder symptoms in children who stutter. Journal of Fluency Disorders, 59, 80–90.