Programs Supporting Young Children's Language Development
Kathy Thiemann, PhD, Steven F. Warren, PhD
University of Kansas, USA
In this paper we document recent evidence of effective language approaches for children with severe language delays, secondary to autism or other developmental disabilities (DD). Following a discussion of some current challenges in the field, we describe an early language intervention model, and the need to foster and measure success in implementation of such approaches by caregivers, early interventionists and other adults. The paper concludes with a discussion of two research priorities necessary to move the field forward in developing optimal language interventions – further longitudinal analyses of the efficacy of different treatment approaches based on specific treatment and child variables, and the potential impact of differential treatment intensity.
We know that children with delayed or disordered language are at increased risk for social, emotional and behavioural problems.1,2,3,4 Early intervention programs that utilize the most effective language intervention approaches will likely impact children’s later communication performance and social relationships.
Fortunately, achievements have been reported in the early detection of language delays and disorders,5,6 and in our knowledge of settings, programs and approaches that enhance optimal language development. Critical components of comprehensive early language intervention programs and recommended language teaching strategies include:
- prelinguistic milieu teaching (PMT);7,8
- milieu teaching, which consists of incidental teaching9 and mand-model procedures;10
- responsive interaction approaches,11including growth recasts;12,13
- direct teaching of specific language targets using adult directed strategies.14
A brief overview of each of these strategies is provided below. The references above provide more detailed descriptions for interested readers.
Language intervention programs require ideal situations and contexts for language learning that support the use of effective approaches. For example, enabling contexts15 that set the stage for language learning within caregiver-child interactions, include:
- creating communication opportunities (e.g., keeping toys out of reach, violating expected routines);
- following the child’s lead by providing activities of interest to child; and
- building and establishing social routines (e.g., rituals such as peek-a-boo or pat-a-cake).
Similarly, routine-based interventions provide an ideal scaffold and context for teaching.16,17 Within enabling contexts and routines, one can use any of the milieu teaching, responsive interaction, direct instruction or direct language teaching approaches described below to promote language learning in natural environments.
Once the social interaction environment is arranged, the adult can then provide specific teaching techniques to prompt, model and acknowledge or reinforce clear, intentional communication attempts within child-centered play routines. These strategies are called “prelinguistic milieu teaching techniques,” and are used to help children who are not yet speaking to transition from preintentional to intentional communication.
Milieu teaching approaches consist of specific teaching techniques embedded within a child’s ongoing activities, interactions and social routines. Two such techniques are called mand-model and incidental teaching procedures. Mands are typically adult questions, commands or directives. Using this strategy, an adult would initiate the teaching episode by asking a question that would require a specific response from the child (e.g., a ball is up on the shelf and the adult says, “What do you want?”). In an incidental teaching episode, the adult waits for the child to initiate and then prompts for a more complex response (e.g., the child reaches for the ball, and the adult says, “Can you say ball?”). Common features of both techniques include:
- following the child’s lead;
- arranging the environment to indirectly or directly prompt child productions with more explicit mands;
- natural social consequences; and
- targeting specific gestures, vocabulary or language structures.
Responsive interaction includes teaching caregivers to be highly responsive to the child’s communication attempts by following the child’s lead, waiting for the child to initiate, responding by commenting on actions or toys of interest and modeling language.
Direct teaching is characterized by prompting, reinforcing, and giving immediate feedback on grammatical or vocabulary targets in structured and scripted sessions. Recasting and direct teaching approaches are particularly suited for children at risk or with minor speech and language delays. A recast occurs when the adult expands or modifies a child’s utterance by adding new syntactic or semantic information.18 Recasts may help children make comparisons and distinguish differences between their own utterance and the adult’s recast of that utterance, which may facilitate acquisition of new grammatical or semantic structures.11
Over 70% of children ages 3–5 years identified with a disability have delayed communication and language development,19 and this is the single most common reason for special education referral.20 One of the primary challenges will be to move research findings into everyday practice. To remediate these deficits early on, widespread training is needed for early interventionists and parents, on how to use responsive interaction styles and other effective interventions in early intervention and home settings.21,22
Empirical data are emerging on the effectiveness of language intervention procedures following larger scale comparative, longitudinal intervention studies that (in some recent cases) employ true experimental designs with random assignment of subjects to contrasting treatment conditions.7,23-29 Findings provide support for a developmental model of early communication and language development. This model views the amount and quality of language input a child receives as crucially important, and encourages the use of distinctive approaches at different stages in development.30
Recent Research Results
Research suggests that if a child’s average Mean Length of Utterance (MLU) is greater than 2.5, responsive interaction approaches are more effective than milieu teaching; milieu teaching strategies are more effective for children with an MLU below 2.0.28,29 Yoder and Warren29 reported that children with highly responsive and more educated mothers benefited the most from prelinguistic milieu teaching (e.g., parents taught to prompt, model and reinforce intentional communication). Children with less responsive, less educated mothers benefited more from approaches focusing on following the child’s lead and responding to communication attempts.
For children not yet speaking or with limited expressive vocabulary, treatment approaches have been developed to target intentional non-symbolic skills thought to be critical for the later emergence of intentional symbolic (expressive language) skills.31,32 For example, the intervention might focus on intentional communication by facilitating coordinated joint attention to direct an adults’ attention to an object using unconventional or conventional gestures, vocalizations or words. Over the past few years, several randomized controlled studies have been published examining differential effects of specific language intervention approaches on improving intentional communication of young children with DD. One such approach, responsive education/prelinguistic milieu teaching (RE/PMT), includes both direct, regular intervention sessions with the child and parent training to ensure high levels of responsiveness. The premise of this combined approach is that a higher level of responsivity is by itself not adequate to substantially improve the communication of young children with developmental disabilities.33 In one of the first studies to support this argument, Yoder and Warren34 successfully trained paraprofessionals to implement a combined RE/PMT intervention, and found modest effects on communication behaviours of young children with limited language at the start of the study.
In a replication of this study, Fey et al.23 trained speech-language pathologists to implement RE/PMT to 51 toddlers with DD. Although they reported significantly more intentional communicative acts after six months of treatment for children receiving RE/PMT, compared to children not receiving treatment, Warren et al.26 found that the effect was not maintained six months later. Therefore, Warren et al.26 recommended that clinicians implement RE/PMT longer than six months and at a higher frequency; with the caveat that we still need empirical data to show effects of lengthier treatment periods and/or more intensive treatment sessions as a supplement to community-based interventions. Treatment intensity is also an important variable in the effectiveness of treatments for language impairment secondary to autism.35
The developmental model is also relevant for the treatment of children with autism, Yoder and Stone24,25 conducted two studies to compare RE/PMT and the Pictures Exchange Communication System (PECS) on spoken words and joint attention of 36 preschoolers with autism. Treatment was provided for 24 hours over a six-month period. Results revealed that children who received PECS treatment expressed more spontaneous words compared to those in RE/PMT. Six months later, however, PECS treatment effects were maintained only for children who initially explored a higher number of different toys in play. Furthermore, RE/PMT was of greater benefit to children with higher rates of joint attention, possibly due to the ability to imitate adult models and stronger motivation by the social consequences of their acts.
A developmental model of early language intervention has been proposed, which assumes that no one approach is appropriate to remediate the range of communication skills children need as they progress from prelinguistic to linguistic communication. Recent treatment comparison studies are reporting differential treatment outcomes based on initial child characteristics. Research is demonstrating the importance of attending to child abilities (e.g., play skills, joint attention, MLU), family characteristics (e.g., parent education and responsivity), and the need to train early interventionists (e.g., parents, paraprofessionals, speech language pathologists) so as to tailor treatment programs based on these factors. More recent longitudinal intervention studies have provided a stronger foundation for RE/PMT language approaches to improve communication skills in young children with autism and DD, with severe language delays.
The next phase of research necessitates additional studies that examine varying levels of intensities for different treatments, agree on common definitions for ‘intensity,’ and governmental funding of differential treatment intensity research. Collectively, future research should be aimed at:
- continuing to refine this developmental model based on additional longitudinal, comparative analysis of the relative efficacy of different treatments in relation to specific treatment and learner characteristics, treatment goals and instructional contexts,
- examination of intensity dose and/or length of treatment necessary to maintain communication progress and enhance later language outcomes.35,36
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- Tomblin JB, Zhang XY, Buckwalter P, Catts H. The association of reading disability, behavioral disorders, and language impairment among second-grade children. Journal of Child Psychology and Psychiatryand Allied Disciplines 2000;41(4):473-482.
- Gertner BL. Influence of communicative competence on peer preferences in a preschool classroom. Journal of Speech and Hearing Research 1994;37(4):913-923.
- Wetherby AM. Communicative profiles of preschool children with handicaps: Implications for early identification. Journal of Speech and Hearing Research 1989;54(2):148-158.
- Woods JJ, Wetherby, AM. Early identification of and intervention for infants and toddlers who are at risk for autism spectrum disorder. Language, Speech, and Hearing Services in Schools 2003;34(3):180-193.
- Yoder PJ, Warren SF. Maternal responsivity predicts the prelinguistic communication intervention that facilitates generalized intentional communication. Journal of Speech, Language, and Hearing Research 1998;41(5):1207-1219.
- Yoder P, Warren SF. Maternal responsivity mediates the relationship between prelinguistic intentional communication and later language. Journal of Early Intervention 1999;22(2):126-136.
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- Warren SF, McQuarter RJ, Rogers-Warren AK. The effects of mands and models on the speech of unresponsive language-delayed preschool children. Journal of Speech and Hearing Disorders 1984;49(1):43-52.
- Wilcox MJ, Shannon MS. Facilitating the transition from prelinguistic to linguistic communication. In: Wetherby AM, Warren SF, Reichle J, eds. Transitions in prelinguistic communication. Baltimore, Md: P.H. Brookes Pub.; 1998:385-416.
- Camarata SM, Nelson KE, Camarata MN. Comparison of conversational-recasting and imitative procedures for training grammatical structures in children with specific language impairment. Journal of Speech and Hearing Research 1994;37(6):1414-1423.
- Fey ME, Cleave PL, Long SH, Hughes DL. Two approaches to the facilitation of grammar in children with language impairment: An experimental evaluation. Journal of Speech and Hearing Research 1993;36(1):141-157.
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- Warren SF, Yoder PJ, Leew SV. Promoting social-communicative development in infants and toddlers. In: Goldstein H, Kaczmarek LA, English K, eds. Promoting social communication: Children with developmental disabilities from birth to adolescence. Baltimore, Md: P.H. Brookes Pub.; 2002:121-149. Communication and language intervention series; vol. 10.
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- Warren SF, Walker D. Fostering early communication and language development. In: Teti DM, ed. Handbook of research methods in developmental psychology. Malden, Mass: Blackwell Publishers; 2005:249-270.
- Wetherby AM, Prizant BM. Profiling young children’s communicative competence. In: Warren SF, Reichle JE, eds. Causes and effects in communication and language intervention. Baltimore, Md: P.H. Brookes Pub.; 1992:217-253. Communication and language intervention series; vol. 1.
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- Warren SF. The future of early communication and language intervention. Topics in Early Childhood Special Education 2000;20(1):33-37.
- Wolery M, Bailey DB. Early childhood special education research. Journal of Early Intervention 2002;25(2):88-99.
- Fey ME, Warren SF, Brady N, Finestack LH, Bredin-Oja SL, Fairchild M, Sokol S, Yoder PJ. Early effects of responsivity education/prelinguistic milieu teaching for children with developmental delays and their parents. Journal of Speech, Language, and Hearing Research 2006;49(3):526-547.
- Yoder PJ, Stone W. A randomized comparison of the effect of two prelinguistic communication interventions on the acquisition of spoken communication in preschoolers with ASD. Journal of Speech, Language, and Hearing Research 2006;49(4):698-711.
- Yoder PJ, Stone W. Randomized comparison of two communication interventions for preschoolers with Autism Spectrum Disorders. Journal of Consulting and Clinical Psychology 2006;74(3):426-435.
- Warren SF, Fey ME, Finestack LH, Brady NC, Bredin-Oja SL, Fleming KK. A randomized trial of longitudinal effects of low-intensity responsivity education/prelinguistic milieu teaching. Journal of Speech, Language, and Hearing Research 2008;51(2):451-470.
- Schwartz IS, Carta JJ, Grant S. Examining the use of recommended language intervention practices in early childhood special education classrooms. Topics in Early Childhood Special Education 1996;16(2):251-272.
- Yoder PJ, Kaiser AP, Goldstein H, Alper C, Mousetis L, Kaczmarek L, Fischer R. An exploratory comparison of milieu teaching and responsive interaction in classroom applications. Journal of Early Intervention 1995;19(3):218-242.
- Yoder PJ, Warren SF. Relative treatment effects of two prelinguistic communication interventions on language development in toddlers with developmental delays vary by maternal characteristics. Journal of Speech, Language, and Hearing Research 2001;44(1):224-237.
- Warren SF, Yoder PJ. Emerging model of communication and language intervention. Mental Retardation and Developmental Disabilities Research Reviews 1997;3(4):358-362.
- Warren SF, Yoder PJ, Gazdag GE, Kim KG, Jones HA. Facilitating prelinguistic communication skills in young children with developmental delay. Journal of Speech and Hearing Research 1993;36(1):83-97.
- Yoder PJ, Kaiser AP, Alpert C, Fischer R. Following the child’s lead when teaching nouns to preschoolers with mental retardation. Journal of Speech and Hearing Research 1993;36(1):158-167.
- Warren SF, Brady N. The role of maternal responsivity in the development of children with intellectual disabilities. Mental Retardation and Developmental Disabilities 2007;13(4):330-338.
- Yoder PJ,Warren SF. Effects of prelinguistic milieu teaching and parent responsivity education on dyads involving children with intellectual disabilities. Journal of Speech, Language, and Hearing Research 2002;45(6):297-1310.
- Dawson G, Rogers S, Munson J, Smith M, Winter J, Greenson J, Donaldson A, Varley J.Randomized, controlled trial of an intervention for toddlers with autism: The Early Start Denver Model. Pediatrics 2010;125(1):e17-e23.
- Warren SF, Fey ME, Yoder PJ. Differential Treatment Intensity Research: A missing link to creating optimally effective communication interventions. Mental Retardation and Developmental Disabilities 2007;13(1):70-77.