CHAPTER IV - Intervention Methods for Young Children with Communication Disorders - continued

Specific Techniques for Speech/Language Interventions

Speech and language interventions for young children with communication disorders include a variety of specific techniques. The specific intervention techniques reviewed in this section reflect the available scientific literature that met criteria for adequate evidence about efficacy. There are other techniques used in clinical practice that are not presented in this guideline.

There are several ways to classify these techniques and an intervention for an individual child usually incorporates a number of specific techniques. One of the major distinctions between techniques is the extent to which they are based on a directive or a naturalistic focus. In techniques with a more directive focus, the professional providing the intervention controls or directs the intervention. In techniques with a more naturalistic or non-directive focus, the professional providing the intervention attempts to create learning opportunities for the child in a less structured environment.

Directive interventions

Directive interventions tend to include the following characteristics:

• providing massed blocks of trials

• having the professional control the antecedents (stimuli) and consequences (reinforcers)

• using consequences such as verbal praise or tokens that are not related to the child's current activities

In directive interventions, the professional providing the intervention controls the antecedents and consequences presented to the child. Directive approaches use specific techniques such as modeling and prompting to elicit targeted language structures from the child. An example of modeling is having the professional name an object shown to the child and then prompting the child to name the object. Prompting involves the professional presenting a verbal command or question, or some nonverbal cue, to the child to elicit a desired verbal response. Directive interventions frequently use blocks of discrete trials or drills in a controlled environment.

Naturalistic interventions

Naturalistic approaches commonly include the following characteristics:

• providing distributed learning opportunities rather than massed blocks of trials

• following the child's focus of attention or interest

• using antecedent and consequent stimuli naturally associated with a particular communication response

Naturalistic interventions use specific techniques that create opportunities for the child to use targeted language structures. This approach utilizes aspects of adult-child interaction that promote language acquisition. Deciding which techniques to use for an individual child requires the professional to draw upon knowledge about normal language acquisition and to be cognizant of the needs of the particular child. A critical aspect of naturalistic interventions is the professional's ability to read, interpret, and respond appropriately to the child's cues.

Naturalistic and enhanced or modified milieu methods (also called incidental teaching) involve the professional arranging materials in the environment in a way designed to elicit targeted responses from the child.

Directive versus Naturalistic Intervention>

Evidence Ratings : [A] = Strong [B] = Moderate [C] = Limited [D1] = Opinion/Studies do not meet criteria [D2] = Literature not reviewed

Recommendations

Selecting a specific speech/language therapy technique

1. It is important to recognize that no one specific speech/language therapy technique or approach is best for all young children. [B]

2. When selecting an intervention technique or approach, it is important for the professional providing the intervention to consider the individual characteristics of the child, and the child's stage of language development. [B]

3. It is often useful to consider the child's conversational skills and verbal style in deciding whether to use a more directive or a more naturalistic intervention. [D1]

Using a continuum of techniques as the child progresses

4. For some children, more directive interventions may be appropriate, particularly at the beginning stages of treatment. Directive interventions can be very effective in eliciting initial structures of speech or gesture. [B]

5. Naturalistic interventions may be more useful than directive interventions in increasing spontaneous language and generalization to non-treatment settings. [C]

6. It is recommended that intervention methods progress from a more directive towards a more naturalistic focus. This progression is important as some functional aspects of language (such as social context and conversational turn-taking) cannot be established through directive intervention and need to be learned using more naturalistic approaches. [B]

7. It is important to recognize that a naturalistic approach may help to facilitate long-term goals for speech/language interventions such as:

   • expressing basic needs

   • establishing functional use of language

   • interacting socially

   • acquiring knowledge [D1]

Evaluating the Effectiveness of Specific Techniques for an Individual Child<

Recommendations

Using specific intervention techniques

1. It is important to recognize that:

• Many different specific intervention techniques have been shown to be effective in improving speech/ language skills in children with communication disorders.

• Specific techniques that will prove to be most effective for an individual child will depend upon many factors including the type of communication disorder, the child's personality characteristics, and the presence of other developmental problems. [A]

Identifying intervention targets

2. It is recommended that the intervention targets for each child be clearly identified and defined with clear criteria for mastery. [A]

Monitoring treatment progress

3. It is strongly recommended that the degree of effectiveness of a particular speech/language intervention be assessed on a regular basis for each child. [A]

4. When a child is receiving discrete speech/language therapy sessions, it is recommended that the child's progress be periodically evaluated and documented during the course of the intervention. Specifically, it is important to:

• assess and document behaviors and communication skills at baseline

• document progress at the end of each intervention session [A]

5. When a child is receiving a speech/language intervention that is integrated within the child's daily activities (rather than in discrete sessions), it is still important to periodically monitor and document the child's progress. [A]

6. It is important to assess the extent to which the speech/language skills acquired with specific intervention techniques are generalized to non-treatment settings. [A]

7. It is recommended that the professional providing the intervention use information gathered regularly about the child's progress to assist in choosing and modifying:

• intervention strategies

• intensity, frequency, and duration of intervention [A]

Using information about the child's progress to modify the intervention

8. Elements of single-subject design methodology, when adapted to clinical settings (see Appendix A, Table A-7) can be useful for documenting the child's progress and the effectiveness of specific intervention techniques. [A]

Single-subject design studies provide information about the efficacy of specific techniques as they are used for an individual child. These studies can also provide information about the efficacy of broad general intervention approaches as well as about the efficacy of more narrow specific elements and variations of these interventions.

Interventions for Children with Speech/Language Problems and Other Developmental Disorders

For children who have both speech/language and other developmental problems, additional considerations may apply in planning and carrying out interventions. This section provides specific recommendations on how intervention may be modified for children with general developmental delays, hearing problems and oral-motor or feeding problems. Recommendations are also given for children needing augmentative communication.

Children with general developmental delays or disorders

Children whose communication disorder is only one part of a more general developmental disorder may require multiple services to address multiple needs. Since the communication disorder is only one aspect of the overall needs of the child, there are additional intervention considerations for those children who have a language delay but no other apparent developmental problems.

Often, similar speech and language intervention strategies are effective for children with communication disorders regardless of whether these children are affected only in the communication domain or in other developmental domains as well. In fact, many of the treatment efficacy studies that were evaluated included subjects whose communication disorders were embedded in more general developmental disabilities. Some studies comparing specific treatment approaches found an association between the child's pre-treatment developmental level and the intervention method. Such an association indicates that the most effective intervention method differs according to the child's pre-treatment developmental level.

Children with hearing impairments

When hearing loss occurs at birth or within the first few months of life ("prelingual" onset), the impact on communication development is usually significant because the loss occurs during the time considered critical for language development. The effect of even mild hearing loss can delay speech and language development in a young child. There is strong evidence that early intervention for an infant or young child with hearing loss or an infant or young child who is deaf results in optimal development of communication skills (Moeller and Carney, 1998).

Many children experience temporary and fluctuating hearing loss associated with otitis media with effusion (OME), particularly during the first three years of life (AHCPR, 1994). Children with sensory hearing loss may also have OME resulting in a mixed hearing impairment. OME is treated medically or, in some cases, surgically. While persistent OME is considered by most to be a risk factor for a communication disorder, there is controversy as to whether OME in early life results in long-term communication sequelae.

Children with oral-motor and feeding deficits

Meeting the nutritional needs of an infant or young child is an integral part of caring for their growth and development. To meet these needs, factors related to the child's oral-motor mechanisms need to be considered. Oral-motor mechanisms are involved in the feeding, overall health of the child (including respiratory, gastrointestinal, and neurological systems), sensory integration, and postural tone.

In children with oral-motor deficits, one of the primary goals of oral-motor treatment is efficient and safe oral feeding for nutrition and the prevention of aspiration. An additional important goal of oral-motor treatment is the development of coordinated movements of the respiratory and phonatory systems and the mouth for communication.

Children needing augmentative communication

Some children may require augmentative communication, especially when speech is not an effective mode of communication for the child. In some children, the need for augmentative communication may be transitional or temporary.

Augmentative communication involves using various methods and/or equipment to assist in the child's communication. An augmentative communication system may be a composite of communication components, which may include communication strategies, manual signs, and communication devices, such as a manual communication board, computer, or dedicated electronic device.

Many of the general intervention recommendations for children who have only a communication disorder also apply to children who have a communication disorder associated with other developmental problems.

Interventions for Children Who Have a Communication Disorder Associated with Other Developmental Problems

Evidence Ratings : [A] = Strong [B] = Moderate [C] = Limited [D1] = Opinion/Studies do not meet criteria [D2] = Literature not reviewed

Recommendations

Addressing all areas of concern

1. For children whose communication disorder is combined with disabilities in other areas of development, it is recommended that interventions address all affected areas rather than just focusing on communication in isolation. [D2]

Timing of assessment and intervention

2. For children with a developmental disorder diagnosed at birth, it is recommended that intervention for communication begin at birth. [D2]

3. For newborns with genetic syndromes or conditions with a high probability of developmental delay (including hearing loss and certain neurological conditions), it is recommended that communication intervention begin immediately. For example:

• As early as birth to 3 months of age, there may be a need to initiate oral-motor or feeding therapy or intervention for a hearing impairment.

• As early as 4 to 6 months of age, it is recommended that behavioral techniques be used to increase the frequency and variety of vocalizations. In addition, it is important to start training parents and other caregivers for such procedures. [D2]

Modifying intervention strategies when children have additional disabilities

4. It is important to be aware that particular communication treatment strategies may have to be modified when the child's communication disorder is combined with other disabilities. Reciprocity, responsivity, joint attention, and rhythm may be more difficult to establish and maintain with a child whose communication is impacted by other areas of development or medical issues. [D2]

5. It is important to be aware that the expected rate of progress in communication may be different for a child who has additional areas of impairment. [D2]

6. Strategies which might help in setting up the communication environment for children with a communication disorder and other developmental problems include the following:

• adapting materials, equipment, and lessons to the developmental level of the child

• adapting the home and/or therapy environment so the child has to solve problems or reinforce skills to do what he or she wants to do

• gearing the level of stimulation in the environment to the individual learning style of the child

• using preparatory physical or sensory stimulation or alerting activities prior to or during language stimulation

• presenting learning material in small increments (through the use of task analysis) and providing sensory, emotional, or physical supports

• presenting language-related concepts concretely, repetitiously, and/or with multi-sensory input through the use of sensory cues, which may need to be dramatic or exaggerated (such as large visual pictures, tactile or auditory cues)

• setting up predictable schedules to help a child transition from one activity to another

• including parent and peer interactions as part of the communication environment in order to help foster generalization of communication skills [D2]

Coordination of care among professionals and parents

7. Because children whose development is affected in multiple areas require multiple services, it is important to:

• use an interdisciplinary team approach, involving those professionals with expertise in the child's specific developmental problems as well as the child's primary health care provider if appropriate

• coordinate services so interventions are not fragmented and parents are not put in the role of coordinating their child's services (for example, if services are provided by more than one professional, have joint planning for intervention goals, methods, and schedules as well as regular communication about progress) [D2]

Interventions for Children Who Have a Speech/ Language Problem Associated with a Hearing Loss

Evidence Ratings : [A] = Strong [B] = Moderate [C] = Limited [D1] = Opinion/Studies do not meet criteria [D2] = Literature not reviewed

Recommendations

1. It is recommended that communication intervention for young children with hearing loss follow a developmental approach with a goal of maximizing age-appropriate communication skills. [D2]

2. Communication intervention goals specifically directed at infants and children with hearing loss who are learning language through or partly through the auditory channel, may need to emphasize specific aspects of language (such as phonologic and syntactic) that often are less salient (less audible, less visible). [D2]

Selecting hearing amplification devices

3. It is recommended that use of personal hearing amplification devices (such as hearing aids, FM system) be considered a prerequisite for optimal communication intervention for the children with hearing loss. [D2]

4. It is recommended that hearing amplification devices be individually selected and fitted for each child's specific type, degree, and configuration of hearing loss. Prescriptive hearing aid fitting procedures and real-ear measurement are particularly effective for individualizing the fitting of amplification devices to infants and young children. [D2]

5. It is recommended that there be regular monitoring of the child's hearing loss as well as effectiveness of the child's hearing amplification devices. [D2]

6. It is recommended that in some cases of profound sensory hearing loss, cochlear implants be considered an option. [D2]

Interventions for Children with Oral-Motor Deficits or Feeding Problems

Evidence Ratings : [A] = Strong [B] = Moderate [C] = Limited [D1] = Opinion/Studies do not meet criteria [D2] = Literature not reviewed

Recommendations

1. Because of the implications for future oral functions such as speech, it is important to initiate treatment when there are oral-motor deficits or feeding problems. Oral-motor function is important for the development of coordinated movements of the mouth and for the respiratory and phonatory systems that are necessary for communication. [D2]

2. When speech intelligibility is significantly reduced related to oral-motor deficits, it is recommended that intervention address these concerns. [D2]

3. It is recommended that a comprehensive oral-motor therapy program be initiated for a child who is receiving non-oral feedings to facilitate the transition to oral feedings. [D2]

Planning oral-motor and feeding interventions

4. Before initiating a feeding program, it is extremely important to rule out possible medical complications that may be affecting feeding. When aspiration or gastrointestinal reflux is suspected, it is recommended that more extensive medical testing be considered. [D2]

5. It is recommended that the goals of a feeding and swallowing treatment plan include consideration of the following:

   • safety and support of the child's health

   • maintenance of optimal nutrition

   • implications for future feeding

   • implications for future oral functions such as speech

   • a positive feeding environment and a positive interaction between the child and the parent or caregiver [D2]

6. It is recommended that feeding and oral-motor therapy plans involve the parents and other caregivers as much as possible for optimal results and maintenance. [D2]

Selecting oral-motor and feeding intervention techniques

7. Since it is uncommon that an infant or young child's feeding problem will be resolved using only one technique or approach, it is recommended that feeding and oral-motor intervention methods be combined. Feeding and oral-motor intervention methods may include:

• preparatory methods which are implemented prior to feeding sessions (such as alerting or calming techniques, handling, or positioning changes)

• compensation or facilitation (such as strategies that impose alteration in behavior, bolus characteristics, prostheses, and orthodontic appliances)

• behavioral methods (such as oral-facial desensitization, tolerance for eating situation, alterations of sensory environments, or advancing eating behaviors to more mature skills)

• medical or surgical management (such as diagnostic testing, tube feeding, repair of anatomical anomalies, or anti-reflux medications) [D2]

8. It is important to revise techniques and strategies as appropriate to meet the child's changing needs. [D2]

Qualifications of professionals

9. Because of the high risk for aspiration and other complications in infants and young children who have feeding or swallowing disorders, it is strongly recommended that professionals working with these children have adequate knowledge, training, and experience specific to these conditions. [D2]

10. It is recommended that feeding and oral-motor interventions involve expertise from varied medical and behavioral disciplines because it is important that a feeding management program also provide health, developmental, and psychosocial supports. [D2]

Interventions for Children Needing Augmentative Communication

Evidence Ratings : [A] = Strong [B] = Moderate [C] = Limited [D1] = Opinion/Studies do not meet criteria [D2] = Literature not reviewed

Recommendations

1. When choosing an augmentative communication system for intervention, it is important to consider the following factors:

• the child's vision, hearing, and cognitive abilities

• the intended audience

• access, portability, adaptability, possibilities for expansion, and maintenance [D2]

2. It is recommended that augmentative communication interventions focus on training with a system that:

• is easy to use

• enables the child to be understood by a wide variety of communication partners

• provides motivation to use the system in response to natural cues in everyday contexts [D2]

3. It is important to focus on the child's communication skills rather than the child's skill in using the system. [D2]

Developing vocabulary

4. When developing the vocabulary for an augmentative communication system, it is important to provide the child with vocabulary items that are appropriate both for the child's developmental and chronological age. [D2]

5. It is recommended that the vocabulary items include words from a variety of semantic/syntactic classes so the child will have opportunities to learn and use language. [D2]

Strategies for supporting the development of natural speech

6. It is recommended that strategies for supporting the development of natural speech always be included in augmentative communication intervention strategies for infants and young children. [D2]

References

General

1. Carney AE, Moeller MP. Treatment efficacy: Hearing loss in children. Journal of Speech Language and Hearing Research 1998; 41: 61-84.

2. Conture EG. Treatment efficacy: Stuttering. Journal of Speech and Hearing Research 1996; 39 (Supplement): S18-S21.

3. Holland AL, Fromm DS, DeRuyter F, Stein M. Treatment efficacy: Aphasia. Journal of Speech and Hearing Research 1996; 39 (Supplement): S27-S36.

4. Ingham J, Riley G. Guidelines for documentation of treatment efficacy for young children who stutter. Journal of Speech, Language and Hearing Research 1998; 41: 753-770.

5. McLean LK, Cripe JW. The effectiveness of early intervention for children with communication disorders. In The Effectiveness of Early Intervention. Guralnick MJ (ed.). Baltimore, MD: Paul H. Brookes Publishing Co., 1997.

6. Olswang LB. Treatment efficacy: The breadth of research. In Treatment Efficacy Research in Communication Disorders. Olswang LB, Warren SF, Minghetti NJ (eds.). Rockville, MD: American Speech-Language-Hearing Foundation, 1990.

7. Pediatric Working Group. Bess FH, Chase P, Gravel JS, Seewald RS, Stelmachowicz P, Tharpe AM, Williams A. Amplification for infants and children with hearing loss. American Journal of Audiology 1996; 5: 53-68.

8. Stool SE, Berg AO, Berman S, Carney CJ, Cooley JR, Culpepper L, Eavey RD, Feagans LV, Finitzo T, Friedman E, Goertz JA, Goldstein AJ, Grundfast KM, Long DG, Macconi LL, Melton L, Roberts JE, Sherrod JL, Sisk JE. Otitis Media with Effusion in Young Children. Clinical Practice Guideline No. 12. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services, 1994. (AHCPR Publication No. 94-0622)

Articles Cited as Evidence - Group Studies

1. Barnett WS, Escobar CM, Ravsten MT. Parent and clinic early intervention for children with language handicaps: A cost-effectiveness analysis. Journal of Division for Early Childhood 1988; 12: 290-298.

2. Best W, Melvin D, Williams S. The effectiveness of communication groups in day nurseries. European Journal of Disorders in Communication 1993; 28: 187-212.

3. Broen PA, Westman MJ. Project parent: A preschool speech program implemented through parents. Journal of Speech and Hearing Disorders 1990; 55: 495-502.

4. 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: 1414-1423.

5. Cole KN, Dale PS. Direct language instruction and interactive language instruction with language delayed preschool children: A comparison study. Journal of Speech and Hearing Research 1986; 29: 206-217.

6. Cole KN, Dale PS, Mills PE. Individual differences in language delayed children's responses to direct and interactive preschool instruction. Topics in Early Childhood Special Education 1991; 11: 99-124.

7. Eiserman WD, McCoun M, Escobar CM. A cost-effectiveness analysis of two alternative program models for serving speech-disordered preschoolers. Journal of Early Intervention 1990; 14: 297-317.

8. Eiserman WD, Weber C, McCoun M. Two alternative program models for serving speech-disordered preschoolers: A second year follow-up. Journal of Communication Disorders 1992; 25: 77-106.

9. 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: 141-157.

10. Fey ME, Cleave PL, Ravida AI, Long SH, Dejmal AE, Easton DL. Effects of grammar facilitation on the phonological performance of children with speech and language impairments. Journal of Speech and Hearing Research 1994; 37: 594-607.

11. Girolametto L, Pearce PS, Weitzman E. Interactive focused stimulation for toddlers with expressive vocabulary delays. Journal of Speech and Hearing Research 1996; 39: 1274-1283.

12. Girolametto L, Pearce PS, Weitzman E. Effects of lexical intervention on the phonology of late talkers. Journal of Speech and Hearing Research 1997; 40: 338-348.

13. Girolametto L, Verbey M, Tannock R. Improving joint engagement in parent-child interaction: An intervention study. Journal of Early Intervention 1994; 18: 155-167.

14. Haley KL, Camarata SM, Nelson KE. Social valence in children with specific language impairment during imitation-based and conversation-based language intervention. Journal of Speech and Hearing Research 1994; 37: 378-388.

15. Pearce PS, Girolametto L, Weitzman E. The effects of focused stimulation intervention on mothers of late-talking toddlers. Infant-Toddler Intervention 1996; 6: 213-227.

16. Robertson SB, Weismer SE. The influence of peer models on the play scripts of children with specific language impairment. Journal of Speech and Hearing Research 1997; 40: 49-61.

17. Tannock R, Girolametto L, Siegel LS. Language intervention with children who have developmental delays: Effects of an interactive approach. American Journal of Mental Retardation 1992; 97: 145-160.

18. Wilcox MJ, Kouri T, Caswell S. Early language intervention: A comparison of classroom and individual treatment. American Journal of Speech Language Pathology 1991; 49-62.

19. Yoder PJ, Kaiser AP, Alpert CL. An exploratory study of the interaction between language teaching methods and child characteristics. Journal of Speech and Hearing Research 1991; 34: 155-167.

20. Yoder PJ, Kaiser AP, Goldstein H, et al. An exploratory comparison of milieu teaching and responsive interaction in class-room applications. Journal of Early Intervention 1995; 19: 218-242.

Articles Cited as Evidence - Single-Subject Design Studies

1. Alpert CL, Kaiser AP. Training parents as milieu language teachers. Journal of Early Intervention 1992; 16: 31-52.

2. Connell PJ. Teaching subjecthood to language-disordered children. Journal of Speech and Hearing Research 1986; 29: 481-492.

3. Gierut JA. The conditions and course of clinically induced phonological change. Journal of Speech and Hearing Research 1992; 35: 1049-1063.

4. Gierut JA, Morrisette ML, Hughes MT, Rowland S. Phonological treatment efficacy and developmental norms. Language, Speech, and Hearing Services in Schools 1996; 27: 215-230.

5. Goldstein H, English K, Shafer K, Kaczmarek L. Interaction among preschoolers with and without disabilities: Effects of across-the-day peer intervention. Journal of Speech and Hearing Research 1997; 40: 33-48.

6. Hemmeter ML, Kaiser AP. Enhanced milieu teaching: Effects of parent-implemented language intervention. Journal of Early Intervention 1994; 18: 269-289.

7. Kaiser AP, Hester PP. Generalized effects of enhanced Milieu teaching. Journal of Speech and Hearing Research 1994; 37: 1320-1340.

8. Kaiser AP, Ostrosky M, Alpert CL. Training teachers to use environmental arrangement and Milieu teaching with nonvocal preschool children. Journal of The Association for the Severely Handicapped 1993; 18: 188-1993.

9. Losardo A, Bricker D. Activity-based intervention and direct instruction: A comparison study. Journal of Mental Retardation 1994; 98: 744-765.

10. Pinder GL, Olswang LB. Development of Communicative Intent in Young Children with Cerebral Palsy: A Treatment Efficacy Study. Infant-Toddler Intervention 1995; 5: 51-70.

11. Venn M, Wolery M, Fleming L, DeCesare L, Morris A, Cuffs M. Effects of teaching preschool peers to use the mand-model procedure during snack activities. American Journal of Speech Language Pathology 1993; 38-46.

12. Warren SF, Bambara LM. An experimental analysis of milieu language intervention: teaching the action-object form. Journal of Speech and Hearing Disorders 1989; 54: 448-461.

13. Warren SF. Facilitating basic vocabulary acquisition with milieu teaching procedures. Journal of Early Intervention 1992; 16: 235-251.

14. Warren SF, Yoder PJ, Gazdag GE, Kim K, Jones HA. Facilitating prelinguistic communication skills in young children with developmental delay. Journal of Speech and Hearing Research 1993; 36: 83-97.

15. Weismer SE, Murray BJ, Miller JF. Comparison of two methods for promoting productive vocabulary in late talkers. Journal of Speech and Hearing Research 1993; 36: 1037-1050.

16. Yoder PJ, Kaiser AP, Alpert CL, Fischer R. Following the child's lead when teaching nouns to preschoolers with mental retardation. Journal of Speech and Hearing Research 1993; 36: 158-167.

17. Yoder PJ, Warren SF, Kim K, Gazdag GE. Facilitating prelinguistic communication skills in young children with developmental delay II: Systematic replication and extension. Journal of Speech and Hearing Research 1994; 37: 841-851.

Appendix A

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