Individual vs. group language sessions: Does it matter?

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The only way that most school SLPs can even hope to schedule their caseloads is to see children in groups. Unfortunately, we don’t have much evidence on how grouping affects children’s progress. Groups might be distracting—or, children may actually benefit from hearing the teaching directed toward their peers.

Eidsvåg and colleagues treated a group of preschoolers with developmental language disorder (DLD) and morphological errors either individually or in pairs. The researchers selected a target and a control morpheme for each child. For children in the group condition, they also tracked a third “ambient” morpheme—the one that their peer was learning. The children received enhanced conversational recast treatment, where clinicians get children’s attention before recasting their errors using a variety of verbs. Each child heard 24 recasts of their target morpheme per session, which means that children in the group condition also heard 24 recasts of their partner’s target morpheme.  

Confirming earlier studies, the researchers found that the treatment was effective. Children in both conditions were better at using their targeted morpheme (but not their control morpheme) after 5 weeks of sessions. Gains in the individual vs. group conditions were similar, but children in the group condition did not improve on their peers’ target morphemes (meaning kids aren’t necessarily learning from instruction directed to their fellow group members).

So, it looks like group treatment for morphology is as effective as individual treatment, at least when the groups are small and when the dosage* of teaching episodes is the same. We can’t stress this point enough, though—kids got the exact same amount of teaching in each condition. In a mixed group of 4 kids, that probably won’t happen, and these results might not hold.

Psst! Check out Elena Plante’s advice for SLPs on keeping track of variability and dose during enhanced conversational recast sessions in a note on this review.

*Want to think more on dosage? Scan down to Schmitt et al., here, and also read here.

 

Eidsvåg, S. S., Plante, E., Oglivie, T., Privette, C., & Mailend, M.-L. (2019). Individual versus small group treatment of morphological errors for children with developmental language disorder. Language, Speech, and Hearing Services in Schools. doi:10.1044/2018_LSHSS-18-0033

Starting with the hard stuff: Complexity for morphology

We’ve talked about the complexity approach to speech and grammar treatment before. The idea is that if we work on the hard stuff, we can get easier skills that weren’t targeted directly. In speech treatment, this means working on later-developing sounds or clusters to get earlier-developing sounds or singletons. In grammar treatment, we might target a morpheme in a more difficult context to get the same morpheme in an easier one.

De Anda and colleagues wanted to know whether the complexity approach would help with copula and auxiliary BE* production.  They point out that auxiliaries might be harder than copulas because they also require the –ing verb ending. Also, copulas and auxiliaries are harder in question forms because you have to switch the word order (e.g., “Is the dog tired?” or “Is the dog running?”).

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The study included a single child, a 3-year-old boy with average overall language scores but difficulty with grammatical morpheme production. Researchers used scenes, puppets, and a prompting hierarchy to elicit singular and plural auxiliary questions (e.g., “Is the dog eating” or “Are the dogs eating?”—see the article Appendix for example scripts). Each treatment session included 30 trials, which took place during ten 20–45-minute sessions over 2.5 weeks. Probes and a language sample were repeated after the final treatment.

As treatment went on, the child needed fewer prompts to produce auxiliaries in questions. In probes after treatment, he had higher accuracy on copula BE in statements. (Language sample results were more mixed, though.) Of course, this is a single case study with a pre-post design, so, not the strongest evidence. However, the study did show that it was feasible to elicit auxiliary BE in questions even for a child who wasn’t yet attempting that structure. If you’re already working on auxiliary and copula BE with a child, it might be more efficient to target BE in questions first.

 

*Quick grammar reminder: forms of BE include am, is, are, was, and were. Copula BE is a linking verb, like in “The dog is tired.” Auxiliary BE is a helping verb, as in “The dog is running.”

De Anda, S., Blossom, M., & Abel, A. D. (2019) A complexity approach to treatment of tense and agreement deficits: A case study. Communication Disorders Quarterly. doi:10.1177/1525740118822477

The ins and outs of variability for teaching prepositions

Studies have shown that variability (using a mix of different examples) can improve vocabulary and grammar learning for preschoolers with Developmental Language Disorder (DLD). In this study, Nicholas and colleagues wanted to find out if variability also helped children learn prepositions.

Two prepositions, above and beside, were targeted in the study; the children didn’t know those words before the training began. The researchers controlled the variability of both (1) the objects presented to the children to demonstrate the meaning of the prepositions, and (2) the labels the clinicians used for those objects:

 
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There were 3 groups. In each group, one morpheme was taught with low variability and the other was taught with high variability over three short sessions:

  1. Typically developing children, high/low object and label variability

  2. Typically developing children, high/low object variability only

  3. Children with DLD, high/low object variability only 

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This was an early, exploratory study using a series of cases, so the results are a little tricky to interpret. In the first group, half of the typically developing children showed a benefit for low object and label variability (e.g., This is above that, demonstrated with similar objects). In the second group, 4 of 6 typically developing children showed a benefit for high object variability (e.g., This is above that, demonstrated with different objects). Results for children with DLD in the third group were more mixed. Four children did better when objects had low variability, but two children did better with high object variability. Overall, children with higher language skills seemed to benefit more from label variability, and children with higher receptive vocabulary seemed to benefit more from object variability.

So what does this mean for practice? If you’re working with a child who has low overall language or receptive vocabulary skills, trying to show the meaning of a preposition with a bunch of different words and objects might be confusing or distracting. Instead, you might limit the variety of the objects you use to show what it means, as well as what you call them.

 

Nicholas, K., Alt, M., & Hauwiller, E. (2019). Variability of input in preposition learning by preschoolers with developmental language disorder and typically-developing language. Child Language Teaching and Therapy. doi:10.1177/0265659019830455

Survivor: Home-based early literacy edition

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Early literacy skills are crucial to set the stage for learning to read. We know that kids with Developmental Language Disorder (DLD) are likely to struggle with skills like print knowledge. There are only so many hours in the (preschool) day, so some early literacy programs are designed to be completed by caregivers at home. However, experience tells us that not all caregivers will complete home literacy activities. In this study, Justice and colleagues wanted to find out which caregivers might finish or not finish a home program. 

The researchers used a technique called survival analysis, which sounds dramatic, but “survival” in this case just means finishing the book reading program (phew). They looked at results from a previous study on the effect of different incentives on caregivers’ participation. Caregivers of 4- to 5-year-old children with DLD were asked to complete the (free!) Sit Together and Read (STAR) program. The program includes 15 books paired with print-focused activities that are completed in 4 sessions per week over 15 weeks. Caregivers recorded their reading sessions and reported back to the researchers regularly. The main findings included:

  • Only 55% of caregivers completed the program

  • Of families who dropped out, a third never started the program at all

  • Families were less likely to drop out early if they received incentives of money ($.50 per session) or encouragement (positive text messages)

  • Higher-SES caregivers were more likely to complete the program than lower-SES caregivers

  • Caregivers of children with higher print knowledge skills were more likely to complete the program than caregivers of children with lower print knowledge skills. 

So what can we do with these findings? When asking caregivers to complete home literacy activities, we need to have realistic expectations for their participation. The biggest barrier seems to be getting started, so we can focus our efforts on supporting caregivers early in the program. While most of us probably can’t pay families for completing a program, sending encouraging texts or notes to remind them how important reading is might help increase participation. And lower-SES caregivers or caregivers of children with low print knowledge skills are likely to need the most support of all.

 

Justice, L. M., Chen, J., Jiang, H., Tambyraja, S., & Logan, J. (2019). Early-literacy intervention conducted by caregivers of children with language impairment: Implementation patterns using survival analysis. Journal of Autism and Developmental Disorders. doi:10.1007/s10803-019-03925-1

Mistakes preschoolers make in multi-symbol utterances using AAC

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Preschoolers learning to communicate via AAC systems typically start by using one symbol at a time. Many go on to construct 2–3 symbol utterances, but make mistakes along the way. In this study, the researchers looked back at data from a prior study to explore 10 three–four-year-olds’ errors when producing multi-symbol utterances. In total, they made errors on 45% of their utterances!

We’ll get to those errors, but first, some background. All the preschoolers had a speech sound disorder/delay diagnosis, although one child also had a secondary ASD diagnosis and another was diagnosed with cerebral palsy. During the intervention sessions, the kids used an AAC device (an iPad with Proloquo2Go) to describe videos, then the clinician briefly modeled the targets and facilitated play-based therapy for 20 minutes. Keep in mind that the preschoolers didn’t have access to the device outside of the study, and 8 of the 10 participants actually had no prior experience with AAC before the intervention.  

Because AAC literature has focused heavily on inversions (word order reversals), the researchers checked for other error patterns.

 
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The main takeaway? Inversions and omissions were more common than substitutions and additions overall, but there were differences across targets and—business as usual for AAC studies—there were differences across the children in the study.

So, what can we do with this information? For starters, when you collect data, think beyond the number of words in the utterance. Instead, try classifying the types of errors the students are making. Are they inversions, substitutions, omissions, or additions? We’d wager that you’d approach instruction just a little bit differently depending on the error type—and that type of modification to your instruction could make all the difference!

FYI: As we mentioned, data analyzed here was originally collected for a different study. Although the data set isn’t perfect, this is the first study we have that conceptualizes the errors these children might be making. Also, keep in mind these targets were chosen specifically for speakers of English, which has a Subject + Verb  + Object syntax structure.

 

Binger, C., Richter, K., Taylor, A., Williams, E. K., & Willman, A. (2019). Error patterns and revisions in the graphic symbol utterances of 3- and 4- year old children who need augmentative and alternative communication. Augmentative and Alternative Communication. doi:10.1080/07434618.2019.1576224

AAC carryover: Buy-in is only the beginning

One of the biggest frustrations for clinicians who support AAC are the devices that don’t get used. You know, the ones that sit in the cabinet unless you’re in the room, or the ones that parents ask you not to send home. There are a lot of factors that contribute to this kind of device abandonment (can’t you just picture a lonely device feeling sorry for itself?). We need to understand these factors, so we can focus our work on the key ingredients that will promote AAC device use and help students—and their support teams—be successful.  

You won’t be surprised by two of the most common caregiver-related barriers to device success: 

1)    The adults don’t know how to use the device (or, they lack operational competency).

This includes finding words, programming, troubleshooting, and navigating the device settings. Parents and teachers often report that they don’t get enough training in this stuff.

2)    The adults don’t have positive attitudes about the device (or, they lack buy-in).  

Specific aspects of buy-in can include considering the device the child’s voice and believing that it should be available at all times.

These two barriers are important, for sure, but how important? And what else are we missing? This study delved into this issue, focusing on the operational competency and buy-in of parents and teachers of school-aged (3–16 years) children with autism, and whether they related to how frequently the children’s AAC devices were used. The 33 children in the study all used a personally-owned PRC device or the related LAMP Words for Life app as their main method of communication at both home and school. To measure how much devices were used, the researchers analyzed data from PRC’s Realize Language feature across three school days and one weekend. Parent and teacher surveys were used to measure operational competency and buy-in.

The good news? Overall, buy-in and operational competency was high for everyone. The bad news? No one was using devices that much. In this group, teachers reported greater buy-in (or at least answered their surveys that way, but that’s a whole different topic...), but parents and teachers were equally comfortable operating the devices. The devices were used more frequently at school vs. home (over half of the kids didn’t use the devices at home at all). 

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A big grain of salt here: the study looked at really a pretty small window in time (Is one weekend at your house representative of how your family works?), and only one device company—that uses a relatively complex language system—was in the mix. We also don’t know if looking at students with diagnoses other than autism would make a difference. Even so, it’s clear that something’s going on here. We can see that good intentions, valuing the device, and being trained in its use just isn’t enough. It looks like we need a broader conversation about barriers, including the practicalities of incorporating a device into daily activities and routines, especially at home. We definitely need to address operational competency and buy-in, but our families and other stakeholders are likely to need more support than that. The authors remind us to keep communication at the center of the conversation, rather than the technology. After all, the device is only the tool—communication is the point.

 

DeCarlo, J., Bean, A., Lyle, S., & Cargill, L. P. M. (2019). The Relationship Between Operational Competency, Buy-In, and Augmentative and Alternative Communication Use in School-Age Children With Autism. American Journal of Speech-Language Pathology. doi:10.1044/2018_AJSLP-17-0175

And more...

  • Accardo and colleagues provide an overview of effective writing interventions for school-age children with ASD. Most interventions took place in the classroom and used mixed approaches, combining “ingredients” like graphic organizers, video modeling, and constant time delay—a prompting strategy borrowed from ABA. Within the review, Tables 1 and 2 give an idea of what each one looked like, so check that out.

  • Baker & Blacher assessed behavior and social skills in 187 13-year-olds with ASD, intellectual disabilities (ID), or both. They found that having ID along with ASD was not associated with more behavior problems or less developed social skills as compared with ASD only.

  • Cerdán et al. found that eighth graders who had poor comprehension skills correctly answered reading comprehension questions more often when the question was followed by a rephrased, simplified statement telling them exactly what they needed to do.

  • Curran et al. found that preschool-aged children who are DHH and receive remote microphones systems in their homes have significantly better discourse skills (but no better vocabulary or syntax skills) than otherwise-matched children who don’t get those systems.

  • Facon & Magis found that language development, particularly vocabulary and syntax comprehension, does not plateau prematurely in people with Down Syndrome relative to people with other forms of intellectual disability. Language skills continue to show growth in both populations into early adulthood. (We’ve previously reviewed specific interventions that have resulted in language gains among older children and teens with Down Syndrome. )

  • Hu et al. suggest that computer-assisted instruction (CAI) can improve matching skills in school-age children with autism and other developmental disabilities. Although techy and exciting, CAI on its own isn’t enough—evidence-based instructional strategies like prompting and reinforcement have to be programmed in, too. This CAI used discrete trial training, and was more efficient (fewer prompts and less therapy time were needed for mastery!) than a traditional, teacher-implemented approach with flashcards.

  • Lim et al. found that the literacy instruction program MULTILIT was effective with school-age children with Down syndrome. MULTILIT combines phonics and sight word recognition instruction, geared toward children with students who are “Making Up Lost Time in Literacy” (MULTILIT; get it?). The program was implemented 1:1 for 12 weeks, and the students made gains in phonological awareness, word reading and spelling. MULTILIT has been investigated by the developers, but this is the first time it’s been studied by other researchers—and with kids with Down syndrome in particular.  Note: This article wasn’t fully reviewed because the training (provided only in Australia) is not available to the majority of our readers.

  • Muncy et al. surveyed SLPs and school psychologists and found that, in general, these professionals are underprepared to assess and treat children with hearing loss and other, co-occurring disabilities, and that they lack confidence in this area. Participants reported many barriers to valuable collaboration with other professionals, like audiologists (hint: there aren’t enough of them!), and that they want more training in this area.

  • Schlosser et al. found that 3–7 year old children with ASD accurately identified more animated symbols than static symbols. The animated symbols represented verbs; for example, depicting a person turning around versus a still line drawing of “turn around.” It makes sense to see action verbs—well—in action; however, researchers acknowledge we can’t make grid displays full of animated symbols since that could be overstimulating. The next step is to test the effects of animation on symbol identification with other more well-known symbols sets like PCS.

  • Scott et al. used science books and a signed dialogic reading program with an 11-year-old Deaf student, and found increases in the student’s ability to answer comprehension questions.

  • St John et al. found that 92% of their sample of children and adolescents with Klinefelter syndrome also had a communication impairment. Pragmatic, language, and literacy impairments were common, and the researchers described some speech impairments as well. Establishing a comprehensive communication profile for this group is important because we’re still learning about Klinefelter syndrome, which is caused by one or more extra X chromosomes.

  • Updates on PEERS, a structured social skills program for adolescents and young adults we’ve discussed before! Wyman & Claro used the school-based version of PEERS both with adolescents with ASD (the target audience) and those with intellectual disabilities (ID; an overlooked group in social skills research who may benefit nonetheless). Both groups of students improved their social knowledge, and the ID group (but not the ASD group) increased social interactions with friends outside of school. Meanwhile, Matthews et al. found that speeding up the traditional, clinic-based PEERS program, by offering it in 7 weeks (twice weekly sessions) instead of 14, didn’t reduce its effectiveness.

Accardo, A. L., Finnegan, E. G., Kuder, S. J., & Bomgardner, E. M. (2019). Writing Interventions for Individuals with Autism Spectrum Disorder: A Research Synthesis. Journal of autism and developmental disorders, 1-19. doi:10.1007/s10803-019-03955-9

Baker, B. L., & Blacher, J. (2019). Brief Report: Behavior Disorders and Social Skills in Adolescents with Autism Spectrum Disorder: Does IQ Matter? Journal of Autism and Developmental Disorders. doi:10.1007/s10803-019-03954-w

Cerdán, R., Pérez, A., Vidal-Abarca, E., & Rouet, J. F. (2019). To answer questions from text, one has to understand what the question is asking: Differential effects of question aids as a function of comprehension skill. Reading and Writing. doi:10.1007/s11145-019-09943-w

Curran, M., Walker, E. A., Roush, P., & Spratford, M. (2019). Using Propensity Score Matching to Address Clinical Questions: The Impact of Remote Microphone Systems on Language Outcomes in Children Who Are Hard of Hearing. Journal of Speech, Language, and Hearing Research. doi:10.1044/2018_JSLHR-L-ASTM-18-0238

Facon, B., & Magis, D. (2019). Does the development of syntax comprehension show a premature asymptote among persons with Down Syndrome? A cross-sectional analysis. American Journal on Intellectual and Developmental Disabilities. doi: 10.1352/1944-7558-124.2.131

Hu, X., Lee, G. T., Tsai, Y, Yang, Y., & Cai, S. (2019). Comparing computer-assisted and teacher-implemented visual matching instruction for children with ASD and/or other DD. Journal of Autism and Developmental Disorders. doi:10.1007/s10803-019-03978-2

Lim, L., Arciuli, J., Munro, N., & Cupples, L. (2019). Using the MULTILIT literacy instruction program with children who have Down syndrome. Reading and Writing. doi:10.1007/s11145-019-09945-8

Matthews, N. L., Laflin, J., Orr, B. C., Warriner, K., DeCarlo, M., & Smith, C. J. (2019). Brief Report: Effectiveness of an Accelerated Version of the PEERS® Social Skills Intervention for Adolescents. Journal of Autism and Developmental Disorders. doi:10.1007/s10803-019-03939-9

Muncy, M. P., Yoho, S. E., & McClain, M. B. (2019). Confidence of School-Based Speech-Language Pathologists and School Psychologists in Assessing Students With Hearing Loss and Other Co-Occurring Disabilities. Language, Speech, and Hearing Services in Schools. doi:10.1044/2018_LSHSS-18-0091

Schlosser, R. W., Brock, K. L., Koul, R., Shane, H., & Flynn, S. (2019). Does animation facilitate understanding of graphic symbols representing verbs in children with autism spectrum disorder? Journal of Speech, Language, and Hearing Research. doi:10.1044/2018_JSLHR-L-18-0243

Scott, J. A., & Hansen, S. G. (2019). Comprehending science writing: The promise of dialogic reading for supporting upper elementary deaf students. Communication Disorders Quarterly. doi:10.1177/1525740119838253

St John, M., Ponchard, C., van Reyk, O., Mei, C., Pigdon, L., Amor, D. J., & Morgan, A. T. (2019). Speech and language in children with Klinefelter syndrome. Journal of Communication Disorders. doi:10.1016/j.jcomdis.2019.02.003 

Wyman, J., & Claro, A. (2019). The UCLA PEERS School-Based Program: Treatment Outcomes for Improving Social Functioning in Adolescents and Young Adults with Autism Spectrum Disorder and Those with Cognitive Deficits. Journal of Autism and Developmental Disorders. doi:10.1007/s10803-019-03943-z

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’!”)

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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

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