Section 2: What works? (only) Downloaded from

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1 Language Problems Practice Resource Section 2: What works? (only) Downloaded from

2 Practice Resource: Language Problems Table of Contents Overview... 2 Glossary... 6 Session 1: Introduction Setting the scene... 7 Stages of development in language... 9 Infants (9 12 months)... 9 Toddlers (13 months 3 years)... 9 Preschool aged children (3 5 years) About language delay and language disorder What is language delay? Prevalence and impact of language delay Early indicators of language delay What is language disorder? Section 2: What works? Asking about language concerns Parent report Testing children Introduction to language development strategies Understanding parent administered language interventions Understanding group interventions What you can do Information for parents Key Messages for Professionals Key Messages for Managers Section 3: What the research shows Summary of the evidence on language interventions Key research findings on language delay Interventions for language Research on language delay interventions Research on parentadministered language interventions Annotated summary of intervention studies Summary of intervention studies Language intervention studies References Appendix 1: Centre for Community Child Health Appendix 2: Telstra Foundation Appendix 3: Criteria for selecting topics Appendix 4: NHMRC Guidelines for Levels of Evidence Appendix 5: Glossary of Terms Research Methodology Centre for Community Child Health

3 Glossary Childcentred approach A perspective that emphasises the importance of fostering a child s language development by following the child s lead in conversation. Didactic approach An approach involving an adult modelling a desired response and then attempting to get the child to give this response. Expressive language Hybrid approach Parentadministered Intervention Prelinguistic stage Receptive language Semantics Language produced by the child. A combination of childcentred and didactic approaches, in which the child is encouraged to learn a specific lesson or complete a specific task in his or her natural environment. An approach to language development that usually occurs in the child s natural environment in which a parent or carer takes the lead in supporting language development. The stage before a child uses words to communicate. Understanding what spoken words mean. The meaning of words. Syntax The grammatical arrangement of words in sentences. Vocabulary The total number of words a person knows and uses. Refer to Appendix 5 for a glossary of terms related to research methodology terminology. Centre for Community Child Health

4 Asking about language concerns In Section 1: Introduction the developmental aspects of language delay and suggested behaviours that might indicate language delay or disorder were outlined. There are also more formal screening tools to detect language delay and disorder (known as communication disorders) in children aged one to five years. The goal of screening tests is not to arrive at a formal diagnosis, but rather to identify children who have an increased likelihood of a communication disorder and therefore need further indepth assessment to establish the diagnosis. The four screening tools summarised in this section were selected to cover different styles of screening (parent report and formal testing) as well as different levels of detail produced by the procedure (quick and simple or long and detailed). It should be noted, however, that no standard screening tool exists. This is largely because no single tool on its own has been shown to have strong validity in identifying children who require further assessment. Where possible, it is recommended that a combination of tools be used to provide a comprehensive assessment of a child s language development. Parent report 1. Parent Evaluation of Development Status (PEDS) PEDS, designed to detect developmental and behavioural problems in children from birth to eight years of age, includes questions specific to language development. PEDS relies on asking parents to complete a tenitem questionnaire which takes only a few minutes. The PEDS tool was developed in the United States but has since been trialled successfully in Australia. PEDS can be used in any setting and has been used in Australia in child care centres, preschools and kindergartens, maternal and child health centres, general medical and paediatric practices and schools. More information about the PEDS can be found at the website: 2. MacArthur Communicative Developmental Inventories The MacArthur Communicative Developmental Inventories are normreferenced tests of language development in children and are based on parent reports on a standardised questionnaire. They are intended to describe typical language development in children from 8 to 30 months of age. There are two formats, one for children aged 8 to 16 months old and another for children aged 16 to 30 months. Parents complete a standardised questionnaire about various aspects of nonverbal and verbal communication. More information can be found at: Centre for Community Child Health

5 Testing children 1. Peabody Picture Vocabulary Test (PPVT) The PPVT is a normreferenced test that measures receptive vocabulary for standard English and screens for verbal ability. The test contains a number of black and white linedrawn pictures and does not require the child to read or write. The test can be used by educators, counsellors, psychologists and clinicians, takes 1015 minutes to administer and is appropriate for children two years and older. More information about the PPVT can be found at: 2. Communication and Symbolic Behaviour Scales (CSBS) The CSBS is a standardised instrument used to assess infants, toddlers, and preschoolaged children at risk for communication delays and impairments. The CSBS is used during natural play routines and other adultchild interactions. It is a 22item survey of children's language skills and symbolic development. Symbolic development refers to a child s tendency to use one thing to represent another and is demonstrated in gestures, facial expressions and play behaviours (for example, using a block as a cup, and pretending to drive a car with a Frisbee as a steering wheel). The CSBS should be administered by a health professional trained to assess the development of young children. The assessment takes about 5075 minutes. More information about the CSBS can be found at: Further information about different screening tools available for children one to three years old can be found at the following site: New York Department of Health: Screening Tests for Communication Disorders U.S. Preventive Services Task Force (USPSTF): Screening for Speech and Language Delay: Centre for Community Child Health

6 Introduction to language development strategies Language problems in children from birth to three years can be categorised into four groups: 1. Expressive language delay 2. Receptive language delay 3. Expressive language disorder 4. Receptive language disorder A language problem, whether a delay or a disorder, can include a combination of expressive and receptive difficulties. The recommendations about the approaches and strategies that are included in this section focus on language delay only rather than disorder and pertain to either expressive or receptive delay. It is important to note that the term delay is used to describe language problems in children three years and younger. Children with a suspected language disorder should be referred to a speech pathologist for more detailed assessment and management. The evidence suggests that there are three main approaches to children with expressive or receptive language delay: 1. Parentadministered language intervention (indirect) 2. Group intervention program 3. Direct treatment by clinician This resource will focus on parentadministered language interventions and group interventions (which may also be provided by clinicians). A language problem, whether a delay or a disorder can include a combination of expressive and receptive difficulties. the term delay is used to describe language problems in children three years and younger Centre for Community Child Health

7 Understanding parent administered language interventions Key points Parents can be taught a childcentred approach to assist their child if he or she is at risk of a language delay or has one. Training is provided by a language practitioner, such as a speech pathologist. Parental responses to children s communication are particularly likely to facilitate later language development. Indirect parentadministered treatment in the areas of expressive (particularly) and receptive language is at least as effective as direct clinicianadministered treatment. The strongest evidence for this is from expressive language studies in which more children were involved and the results of which are more easily generalised to the wider population than in studies looking at receptive language. Research results suggest that natural approaches to encouraging children s language development, approaches such as showing a picture of a car and asking the child what it is, are more effective than approaches that use structured training to advance a child s development. For optimal results parents need to be highly motivated and committed to work with their child. Parents can be taught a childcentred approach to assist their child if he or she is at risk of a language delay or has one. Centre for Community Child Health

8 What are the main features of parentadministered language intervention? A parent or carer is the main facilitator of language development. The intervention usually occurs in the child s own natural environment and uses modelling and responding to what the child is paying attention to. The parent or carer, rather than the child, receives direct instruction from a professional. Types of parental responses include: 1. Compliance: The adult responds to the presumed meaning of the child s communication. 2. Imitative responses: The adult imitates vocally or physically the child s communication behaviour. 3. Linguistic mapping: The adult says what the child s nonverbal communication appears to convey, for example when the child points to a book that he wants to read the adult says something like Hugo says read the book. Parentadministered treatment is at least as effective as clinicianadministered, especially if parents learn to: be more sensitive to the child s communication follow the child s lead change the environment to promote language Is parent administered language intervention the same as parent involvement? Parentadministered language interventions are different from parent involvement. Parent involvement happens when the child receives direct intervention from the speech pathologist and parents act as a support for their child by being present, observing sessions and carrying out suggestions made by the speech pathologist for facilitating language at home. Parentadministered interventions require more than parental involvement. Centre for Community Child Health

9 Understanding group interventions Limited research suggests that group interventions for children with language delay may be effective. Group interventions involve small numbers of children with language delays coming together on a regular basis to advance their language development. While such approaches may be less naturalistic than parentadministered programs, they have the advantage of providing a supportive environment in which to learn. Further, group sessions can still be based on a nondirective approach to learning. The inclusion of children without a language delay in such programs provides a valuable model for children with delays to witness ageappropriate language. Typical features of a group intervention Sessions extending over several months (usually four to six) Small groups of children (perhaps three or four) Children working in pairs One theme per week Nondirective child initiates action Children with normal language development taking part Positive peer interactions modelled Children s social interaction praised Facetoface interactions encouraged Parentadministered language interventions usually occur in the child s own natural environment and uses modelling and responding Group interventions involve small numbers of children with delay coming together on a regular basis Centre for Community Child Health

10 What you can do Language delay strategies The following strategies can be used by parents of children with receptive or expressive language delay to help with their children s language development. Training in these strategies is typically provided by a language practitioner such as a speech pathologist, however the principles below can be useful starting points for parents. For optimal results parents need to be highly motivated and committed to working with their child. Childcentred approaches: The adult chooses the materials but does not direct the activity. Rather he or she follows the child s lead, providing followup on a child s utterance with other language that is appropriate to the context and the child s level of understanding. No specific actions are prescribed, as the focus is on general communication. For example: The child s utterance is: Daddy car. The adult s options for responding include: Copying: Daddy car. Expanding: Yes, Daddy s driving the car. Extending: It s a red car. Recasting: Is it daddy s car? The following are some examples of parent specific language strategies: Naturalistic Example: Wait for the child to show interest, get down to the child s physical level and initiate communication. Interaction promoting strategies Example: Encourage the child to take turns in a conversation. Ask questions and wait for a response. Language modelling strategies Example: Label objects and actions, expand utterances, and extend topics. Centre for Community Child Health

11 Hybrid approaches These are a combination of childcentred approaches and structured training and require a child to learn specific lessons or complete specific tasks as directed by the adult. Two examples of hybrid approaches follow. 1. Responsive Interaction Technique: These techniques aim to facilitate the transition from prelinguistic to linguistic communication and prompt the child to make a response. The parent is taught to use target words, to avoid directly prompting child, to keep using the word within the context of situation and to encourage child to produce an utterance but not insist on it. For example, during a play session involving bathing a doll, the parent uses such words as baby and bath in a focused way at least five times. 2. Prelinguistic Milieu Teaching: This type of teaching involves the parent reacting to a child showing natural interest in an activity or object and asking the child questions about it. The parent is taught to wait until the child shows interest in the activity or object, then to name the activity or object and ask the child to imitate what has been said. The adult uses questions such as What s this? to elicit a response before giving child the desired object. For example, the child points to an object out of reach, such as a ball, and the adult asks What? to prompt the child to use the word ball. Another example would be if a child looks in the direction of the ball and the adult asks What do you want? For optimal results parents need to be highly motivated and committed to working with their child. Centre for Community Child Health

12 Language promotion strategies Language promotion strategies differ from language interventions in that they are ways to enhance the language development of a normally developing child rather than ways to address delay that has already occurred. Language promotion strategies are proactive, while language interventions are reactive. Outlined below are ways parents can promote language development in children at different ages. 1 With your fourmonth old: Talk Copy and exaggerate the sounds your baby makes. Talk about what you are doing and the things around you. Sing songs, tell rhymes. Interact Look your baby in the eyes. Cuddle and hold your baby close. Get down and play at your baby s level. Use books Show your baby bright, colourful pictures. Talk about pictures in books. With your eightmonth old: Talk Name things around you, lots of times each day. When your baby makes a sound like a word, say the word. Talk about things your baby shows you or looks at. Talk about what you and your baby are doing. Interact Get down and play at your baby s level. Play games like peekaboo and action nursery rhymes like twinkle, twinkle. Point to and name body parts for example ask Where is your nose? 1 These suggestions were successfully employed as part of the Universal Promotion Language Strategy developed by Centre for Community Child Health, the Department of Human Services and The Royal Children s Hospital Speech Pathology Department. The initiative involved maternal child health nurses advising parents at 12 and 18 month visits about ways to enhance their children s language skills. Centre for Community Child Health

13 Use books Provide small, sturdy books with textures and colours. Point to and name the pictures over and over together. Read aloud. With your twelvemonth old: Talk Name things around you, lots of times each day. Repeat the sounds and words your baby makes. Talk about: o things your baby shows you or looks at even if they don t seem interesting to you! o what you and your baby are doing. Use action words to describe things you do or see for example, dropping, dancing, washing, walking. Interact Play social games for example wave goodbye, play peekaboo. Point to and name body parts for example ask Where is your nose? Watch television together and enjoy the songs and actions. Play together with toys such as blocks, stacking toys, and dolls. Use books Show pictures of babies. Repeat lots of rhymes and songs. Read a book at bedtime. Point to and name the pictures over and over together. With your eighteenmonth old: Talk Add to what the child says for example, saying Yes, it s a big blue truck. Use lots of action words for example, cooking, jumping. Describe things using words such as hot, big, small, wet. Talk about feelings for example, happy, sad, cross. Ask questions for example, What is that? Reward the child s use of any words, even if they are not quite right! Centre for Community Child Health

14 Interact Encourage pretend play for example, feeding the teddy. Play together with such materials as play dough, paint, sand, and talk to the child as you play. Watch television together, choosing programs with repetition, actions and adults and children talking together. Use books Show books with animals, trucks, food and other children. Give sturdy small books with pictures and some words. Read books over and over together, especially at bedtime. With your twoyear old: Talk Interact Use lots of action words for example, laughing, clapping. Describe colours, textures, tastes. Talk about feelings using words such as happy, sad, cross. Ask questions such as What are you doing?, Where s teddy? Repeat what your child says, adding a few words for example, Yes, it s a big furry cat. Respond positively to any sentences, even if they re not quite right! Play the same games over and over. Play together with play dough, paints, and colours, and talk about them as you go. Encourage pretend play using materials such as zoo animals and dressups. Sort objects by shape and colour and use stacking toys. Count things, such as blocks, fingers and toes. Watch television together and talk about what is happening. Use books Retell the same stories often. Encourage your child to: o choose which books to read o turn the pages o point to and name pictures in the book o fill in the words of the story or rhyme o use numbers Centre for Community Child Health

15 With your three and a halfyear old: Talk Interact Use books Talk about trips you ve been on for example asking What did you like best at the zoo? Add new words and information during conversations with your child. Describe the order and position of things use words such as first, last, under, behind. Talk about feelings, using words such as excited, surprised. Ask what, where, who, why questions. Encourage questions from your child. Listen to and encourage attempts to tell stories. Make things together with boxes, play dough, and blocks. Do lots of drawing and colouring. Play matching and sorting games with colours and shapes. Use simple board games and bigpiece picture puzzles. Count things for example, One for you and one for me. Have a dressup box with animal tails, fabric, hats. Retell the same stories often, especially at bedtime. Let your child tell the story in her or his own words. Ask questions about the story What happens next?, How does he feel? Start reading alphabet and counting books. Point to letters, especially the ones in your child s name. Language promotion strategies are proactive, while language interventions are reactive. Centre for Community Child Health

16 Information for parents Parents can be directed to the following sites for additional tip sheets and information on language development and language promotion: Child and Youth Health: Communication difficulties p=114&np=306&id=1877 ASHA: Activities to Encourage Speech and Language Development Activities.htm Speech Pathology Australia: Helping your baby to talk pdf The Raising Children website is a onestop resource for parenting information with all the basics on raising children 08 years, qualityassured by Australian experts, and supported by the Australian Government. Centre for Community Child Health

17 Key Messages for Professionals Language is a particularly important form of human communication and is defined as the set of symbols, usually words or signs that are organised by convention to communicate ideas. Language is made up of expressive language produced by the speaker and receptive language heard and understood by the listener. Key principles of language Communication begins at birth. Early language development is only one element of the communication process. Communication includes a range of prelinguistic behaviours including making eye contact, shared smiling and laughter between infant and another person, attending to the same thing as another person, babbling and cooing, imitating and showing understanding. All children acquire language in the same developmental sequence without requiring direct teaching or effort. All children acquire language in the same developmental sequence, as they are biologically programmed to acquire it without direct teaching or effort. For this to occur children must be exposed to language and exposed to normal social communication and interaction. Language is influenced by the complex interaction of both genetic and environmental influences. Genetic factors influence the way a child makes use of interactions and experiences in the environment. Environmental influences include child rearing practices and patterns of parentchild interaction. Language delay At least 20 per cent of infants and toddlers across all socioeconomic ranges have early language and communication delays. Up to 60 per cent of language delays in these children resolve without formal treatment between the ages of two and three years. Language problems can be secondary to another condition (such as autism, hearing impairment, or developmental disorder) or primary (that is, not accounted for by another condition). Problems can involve expressive difficulties, receptive difficulties or both and can be persistent or temporary. Centre for Community Child Health

18 Evidencebased strategies for expressive or receptive language delay Parents can be taught strategies successfully to address delay and facilitate their child s language development. For motivated parents this is at least as effective as direct clinician (for example, speech therapist) administered treatment and can be achieved by: ensuring the parent is committed to working with his or her child. Encourage a childcentred approach where the parent becomes sensitive to a child s typical communication and lessons are tailored to a child s natural activities and focus. teaching the parent specific strategies, such as: naturalistic: Wait for the child to show interest in an object or activity, get down to child s physical level and initiate communication. interactionpromoting: Encourage the child to take turns in conversation. Ask questions and wait for a response. language modelling: Label objects and actions, expand utterances and extend topics. Note: Where parents are unmotivated or are unlikely to be effective facilitators, a clinicianadministered approach is recommended. Centre for Community Child Health

19 Key Messages for Managers Language is a particularly important form of human communication and is defined as the set of symbols, usually words or signs that are organised by convention to communicate ideas. Language is made up of expressive language produced by the speaker and receptive language heard and understood by the listener. Key principles of language Communication begins at birth. Early language development is only one element of the communication process. Communication includes a range of prelinguistic behaviours including making eye contact, shared smiling and laughter between infant and another person, attending to the same thing as another person, babbling and cooing, imitating and showing understanding. All children acquire language in the same developmental sequence without requiring direct teaching or effort. All children acquire language in the same developmental sequence, as they are biologically programmed to acquire it without direct teaching or effort. For this to occur children must be exposed to language and exposed to normal social communication and interaction. Language is influenced by the complex interaction of both genetic and environmental influences. Genetic factors influence the way a child makes use of interactions and experiences in the environment. Environmental influences include child rearing practices and patterns of parentchild interaction. Language delay At least 20 per cent of infants and toddlers across all socioeconomic ranges have early language and communication delays. Up to 60 per cent of language delays in these children resolve without formal treatment between the ages of two and three years. Language problems can be secondary to another condition (such as autism, hearing impairment, or developmental disorder) or primary (that is, not accounted for by another condition). Problems can involve expressive difficulties, receptive difficulties or both and can be persistent or temporary. Centre for Community Child Health

20 Evidencebased strategies for language delay Managers of services for young children have a number of options available to them for providing assistance to parents of children with expressive and receptive language delays. 1. Teaching parents strategies to facilitate their child s language development has been a particularly successful method for addressing language delay. Providers of services could support parentadministered interventions. Services would need to reinforce to parents the importance of being highly committed to working with their child, as well as teaching them specific strategies to use. 2. Group programs specifically designed for children have also been effective in addressing expressive language delay in children. Such programs have the advantage of providing a supportive social environment in which to learn. These programs could be run easily in early childhood program facilities. A speech pathologist could facilitate each session. Programs are often operated successfully with both typicallydeveloping and languagedelayed children participating together. The groups are largely social in nature and would function as a play group for some children. 3. If parents require more specialised assistance for their child for any reason, a referral for a speech pathologist will be required. Centre for Community Child Health