evidence-based practice: children’s language disorders...

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Evidence-Based Practice: Children’s Language Disorders

Marc E. Fey, PhDUniversity of Kansas Medical Center

Intercampus Program in Communicative DisordersEmail: [email protected]

• U.S. Department of Education grant #H324C990091 from the Office of Special Education Programs

• Center grant P30 HD002528 from NICHD

• Center grant P30 DC005803 from NIDCD

• Grant #1 R01 DC007660 from NIDCD

• Steve Warren, Shelley Bredin-Oja, University of Kansas

• Paul Yoder, Vanderbilt University

Important Acknowledgments

• Introduction: 10 min

• An example demonstrating the importance of EBP: 30 min

• Levels and quality of evidence: Appraising individual studies and meta-analyses: 30 min

• Focused Question 1: Does telegraphic input (I) to preschoolers with developmental language impairment (P) result in better uptake and faster and better use of expressive syntax and morphology outcomes (O) than fully grammatical input (C)? 20 min

Plan for the Morning

• BREAK

• EBP decision-making for FQ1: 30 min

• Focused Question 2: Do recasts of the platform utterances (I) of preschoolers with developmental language impairment (P) result in better expressive syntax and morphology outcomes (O) than non-contingent models of txtargets(C)? 20 min

• EBP decision-making for FQ2: 40 min

Plan for the Morning

• Introduction and clean up morning loose ends (30 min)

• A model of speech/language intervention intensity, or dosage (15 min).

• A description of RE/MCT for infants and preschoolers with little expressive language (45 min).

• BREAK

Plan for the Afternoon

• A review of studies evaluating the efficacy of RE/PMT (30 min).

• Recommendations for use and discontinuation of RE/PMT (30 min)

• Questions

Plan for the Afternoon

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Do We Really Need EBP?A Hypothetical Example

• Consider a 2nd grade child with receptive and expressive vocabulary, grammar, narrative, and reading/writing/spelling problems, all measured as more than -2 SD.

• All of these problems are documented by the teacher, who made the referral to me.

A Demonstration of the Need for EBP in SLP


• The child’s parents have just attended a seminar on a new technique for grammar facilitation; a body contortion treatment that “relaxes muscles, frees the brain of interfering stimuli, and increases blood flow to the language cortex.”


– Children are assisted into “facilitative positions” and when posed listen to audio-taped productions of their specific language targets.

– The tx is inexpensive, only $50 per 30 min session, and it is recommended 3 sessions/week for 3 months.

– The presenter tried this tx on 10 children.

– For 7 out of 10, standardized language test scores increased 3-5 points in only 3 months.

• Audience reaction?

A Demonstration of the Need for EBP in SLP The Three Components of EBP

1. (External) evidence from the best available research

2. The clinician’s expertise and experience with the intervention(s)

3. Known characteristics of the child’s (family’s) communication status; The child’s family’s preferences

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Five Steps in Evidence-Based Practice

• Develop a question (PICO)

• Search for relevant research

• Evaluate the evidence

• Make the decision

• Evaluate the outcome of the evidence-based approach

Levels of External Evidence: Control of Bias and Subjectivity

Ia Meta-Analysis or Systematic Review of RCTs

Ib Strong Randomized Controlled Study (RCT)

IIa Systematic Review of Quasi-Experiments

IIb Strong Quasi-Experimental or Single Subject or Weaker RCT

III Non-experimental (Correlational/Case) or weaker Quasi-Experiment or Single Subject Experiment

IV Basic Research, Committee Report, Consensus Conference

Intervention-Relevant Research: Five Phases of Research Development

Pre-trial Research

Early Efficacy Studies

Feasibility Studies

Effectiveness Studies

Later Efficacy Studies

Strength of External Evidence

• In general, studies that fall lower on this continuum provide stronger external evidence for making intervention decisions.• Studies involve tests of interventions using

increasingly stronger study designs and increasing more tx-like outcome measures and contexts.

• A practice receiving support from studies from increasingly lower phases in this hierarchy can be applied with greater confidence than those with support from lower levels.

Pre- trial Research

• The basic question addressed:– What factors are associated with faster, more efficient

language development?

• These are not clinical trials because they do not represent efforts to control intervention variables to improve language performance among children with language delay.

• They usually involve children with typical language.

• They may be experimental, but are more often observational and correlational.

Feasibility Studies

• These studies are designed to evaluate the clinical feasibility of an untested intervention component or package.

• Basic questions addressed:– Do the hypothesized intervention mechanisms

appear to have the predicted clinical effects?

– Can clinicians carry out the intervention efficiently with children with language impairments in clinical contexts under planned time constraints?

– What outcome measures are most useful clinically and/or most sensitive to the intervention?

– Do children enjoy the therapy materials?

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Feasibility Studies

• Often, they do not involve a control group.

• They are usually pre-post, small group studies, or even case studies.

Early Efficacy Studies

• The main question addressed:– Is there a cause-effect relationship between the treatment

variable and the target outcome?

• These may be fully experimental, using group designs, with subjects assigned to groups at random.

• Experiments may use single-subject designs.

• Outcome measures are limited to the specific goals of the intervention; they may not reflect fully functional uses in highly meaningful contexts (e.g., use of a target form in response to pictures instead of in conversation).

Later Efficacy Studies

• These studies have outcome measures that are not tied to the specific goals of the intervention.– Has learning generalized to other types of content,

form, and use not targeted directly in treatment?

– Strongest designs compare a new treatment with a standard practice.

• Outcome measures should be more meaningful than those used in early efficacy studies.– They should not be only standardized tests or contrived

probes.

Effectiveness Studies

• The main question:– Are the effects of efficacy trials still observable when

the intervention is tested under everyday-like conditions?

• with non-project staff in the same context within which the interventionist fulfills her typical roles and responsibilities.

• with different (sub)populations?

• using different service delivery options?

• with variations in the protocol, such as with less intensity, less parent cooperation, more child absences?

• when other interventions are added?

1. Was the evidence from an RCT, quasi-experiment, or single-subject experiment?

2. Were groups the same on key variables before the tx was applied?

3. Was the intervention described well and implemented accordingly?

4. Were examiners/coders/raters blind as to the participants’ experimental groups?

5. Was inter-rater reliability acceptable?

6. Were the findings statistically significant with effect size boundaries that didn’t include zero?

7. Were the findings clinically important?

Limiting Bias and Subjectivity in Individual Studies –

Dollaghan’s (2007) CATE

Are the results of the reviewed studies compelling, suggestive, or equivocal? A decision that the evidence is compelling indicates that

the clinician should make an effort to implement the target intervention.

Limiting Bias and Subjectivity in Treatment Studies –

Dollaghan’s (2007) CATE

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1. Was the method for searching for relevant studies clearly described?

2. Was inter-judge reliability acceptable?

3. Were the individual studies appraised independently?

4. Was an average effect size that corrected for sample size calculated?

5. Was the average effect statistically and clinically significant?

6. Was a forest plot used to suggest homogeneity of outcomes across studies?

7. Were the results relevant to my clients and my FQ?

Limiting Bias and Subjectivity in Systematic Reviews and Meta-Analyses – Dollaghan (2007)

Are the results of the reviewed studies compelling, suggestive, or equivocal? A decision that the evidence is compelling indicates that

the clinician should make an effort to implement the target intervention.

Limiting Bias and Subjectivity in Treatment Studies –

Dollaghan’s (2007) CASM

Grammar Facilitation Principle Number 9 (Fey, Long, &

Finestack, 2003)

Avoid telegraphic speech, always presenting grammatical models in well-formed phrases and sentences, (including appropriate function words and bound morphemes).

Examples of Telegraphic Models

Context: Child watches mom feed a baby from a bottle.

Adult 1: “(I/Mommy) feed (baby).”

Adult 2: “(Baby) drink (milk).”

Adult 3: “(Baby) guzzle (milk).”

Examples of Telegraphic Requests for Imitation


Adult 1: “Say, (I/Mommy) feed (baby).”

Adult 2: “Say, (Baby) drink (milk).”

Adult 3: “Say, (Baby) guzzle (milk).”

Modifying a Current Clinician or Parent Practice:

Alternatives to Telegraphic Input

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Adult 1: “(I’m) feeding the baby.”

Adult 2: “(The baby is) drinking (the milk).”

Adult 3: “(The baby is) guzzling (the milk).

Examples of Non-Telegraphic Models

Grammatical or Telegraphic Input -Does it matter?

• I assume that the reduction in complexity provides appropriately simplified input for the child who is in the early stages of language learning….

• Key to this second assumption is the notion that the purpose of providing simplified input is to make it easier for the child to imitate the utterance in his or her own production….

Assumptions Underlying Use of Telegraphic Input (Kaiser, p. 4, 2010)

• Minimally, we know that production of morphosyntactic form is the most difficult aspect of language for many if not most English-speaking children with language learning problems.

Some Problems with Telegraphic Models and Requests for Imitation

• Telegraphic models remove access to these difficult forms and may indicate to children that they are unimportant when they are often keys to comprehension.


dack

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dack

Verb (kick)

Noun (ball)

Adjective (brown)

a dack

a dack*Verb(*kick)

Noun (ball)

*Adjective (*brown)

tooz dack

tooz dackVerb (kick)

Noun (ball)

Adjective (brown)

tooz the dack

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tooz the dackVerb(kick)

Noun (ball)

*Adjective (*brown)

a tooz dack

A tooz dack*Verb(*kick)

Noun (ball)

Adjective (brown)


Across languages, children have the most difficulty learning verb forms that are optional or irregularly represented in the input (e.g., verb aspect in Cantonese, Fletcher et al., 2005 or 3rd person singular in English).

• Telegraphic models and requests for imitation create artificial optionalities in the child’s input and may serve to confirm the child’s immature grammar.

– Adult: The baby is crying. Say, “baby cry”.

– Child: baby cry.

– Adult: The baby is crying.



• Removing grammatical functors may disturb the prosody of the utterance, ridding the stimulus of important cues to word, phrase, and clause boundaries and making it more, not less, difficult to process (cf. Bedore & Leonard, 1995).

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• Many children can comprehend grammatical constructions before they produce them.

• Telegraphic input designed from the child’s productions may significantly limit the child’s comprehension development.

Do Children Make Use of Cues Provided by Grammatical Functors?

• Fernald and Hurtado (2006) used a preferential looking paradigm to test even younger children

• Compared 18 month olds’ recognition of words in contexts with grammatical detail to contexts with no grammatical detail

Look at the baby baby

Fernald and Hurtado (2006)

• Also compared sentences with a word that served as a prompt for the upcoming noun to elicit attention to the target word

Look. Baby! Look at the baby!


• The target word presented in the full grammatical sentence resulted in faster and more accurate responses.

• Complete sentences, with the familiar prosodic contours and predictability of the co-occurrence of determiners with nouns preserved, offer an advantage to young children learning language.


• Van Kleeck et al., 2010

– Do children in the early stage of intentional communication and word production (P) learn target words and semantic relations (O) more reliably when presented with models of their targets that are telegraphic (I) than with models that are grammatically complete (C)?

Do telegraphic utterances help with comprehension or production?

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• Van Kleeck et al., 2010

– Results of 10 studies, most with weak designs, were equivocal, but tended to favor non-use in comprehension tasks

– Willer (1974), with 10 subjects in an early efficacy trial that received a validity score of “D”, is the strongest evidence in support of use of telegraphic input for facilitation of production.

Do telegraphic utterances help with comprehension or production?

• Do children in the early stage of combining words (P) imitate target semantic relations (O) more reliably when presented with elicited imitation prompts that are telegraphic (I) than with elicited imitation prompts that are grammatically complete (C)?

– Directly addresses Kaiser’s assumptions

Grammatical versus Telegraphic Prompts to Imitate (Bredin-Oja & Fey, 2014)

• Alternating treatment design

– Sessions alternate between elicitivemodels that are grammatical (e.g., Say, “the frog is jumping”) and elicitive models that are telegraphic (e.g., Say, “frog jumping”)

• Each 30 minute session included 15 elicitivemodels

Grammatical versus Telegraphic Prompts to Imitate (Bredin-Oja & Fey, 2014)

• Five children with expressive language disorder

• Aged 30 – 51 months

• Early stage of word combinations

• MLU between 1.2 and 2.1

• Leiter Brief IQ - above 97

Participant Characteristics

Results Results

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Bredin-Oja & Fey (2014) is only one Early Efficacy experiment.

Nevertheless, given importance of recognizing the potential hazards of telegraphic input and Bredin-Oja’s clear pattern of results, I regard the evidence as compelling in support of the claim the telegraphic input does not facilitate early language learning and may substantially slow down development, especially in comprehension.

Telegraphic vs. Grammatical Input: Conclusion

• Recasting is repeating the child’s utterance into a more complete phonologically, grammatically and semantically appropriate word, phrase, or sentence.

• A recast expands the child’s utterance by repeating but also adding to or correcting the child’s immature grammar, and/or speech production error.

What are Recasts?

• They immediately follow the child’s utterance

• They must maintain the essential meaning of the child’s utterance.

• They must reproduce at least one content word found in the child’s utterance.

Key Characteristics of Recasts

• Recasts can be found in the most child-oriented approaches as well as the most clinician-oriented approaches.

• They are intervention “kernals” that find themselves in comprehensive intervention approaches.

• Are recasts efficacious, or “active” ingredients?

Omnipresence of Recasts in Early Language Intervention Packages

• Do 18-mo to 10-year-old children with grammatical deficits (P) learn morphosyntactic forms (O) more quickly when high rates of recasts (C) are included in adult responses to child communications compared to high rates of non-contingent models or requests to imitate without recasts (I)?

Recasts versus non-recasts to Facilitate Grammatical Development (Cleave,

Becker, Curran, van Horne, & Fey, 2014)

• Included both a systematic review and meta-analyses.

– SR included children with SLI and NSLI (borderline intellectual disability).

– SR included studies of tx containing only recasts (+ possibly models).

(Cleave, Becker, Curran, van Horne, & Fey, 2014)

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– MA included only studies with children with SLI.

– MA compared recast packages (e.g., recasts + imitation prompts) with alternatives that did not contain recasts.



– One MA combined Early Efficacy Studies• There were seven such studies in the MA.

– One MA combined Later Efficacy/Effectiveness Studies

• There were eight such studies in the MA.


– One MA combined Early Efficacy Studies• These eight studies had an averaged and

weighted d of .96 (CI = .76 – 1.17) such studies in the MA.

– One MA combined Later Efficacy/Effectiveness Studies

• These seven studies had an averaged and weighted d of .76 (CI = .46 – 1.06).


Both the systematic review and meta-analysis provide compelling evidence in support of the claim that recasts facilitate grammatical development in children with language impairments.

The evidence is compelling.

Only studies of focused use of recasting found clear, positive results.

Recasts vs. Other Interventions

Afternoon Presentation

Evidence Based Management of Early Communication and Language Using

Responsivity Education/Milieu Communication Teaching

The Central Role of Dosage in InterventionBasic Goals

Intentional Communication

Spoken/Signed Words

Dosage

Procedures

Imitation - Modeling – Recasts

Stimulus Selection

Goal Attack Strategies

Vertical – Horizontal - Cyclical

Activities

Drill – Play

Book Reading – Story Telling

Reassessment & Program Modification

Probes - Language Samples -Parent Report

Specific Goals

Distal Point- Specific WordsIntervention Context

Clinic - Home - ClassroomIntervention Agent

Clinician - Parent - Teacher

Intermediate Goals

Gestures- Canonical Vocalization

Spoken/Signed Words

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A Model of Intervention Intensity/Dosage:

Some Critical Concepts

1. Dose

2. Teaching Episode

3. Active Ingredient

4. Dose Form

5. Dose Frequency

6. Intervention Duration

7. Cumulative Intervention Intensity

A Definition of Dose in Speech/Language Intervention

• Dose is:

the number of properly administered teaching episodes during a single intervention session.

A Definition of Teaching Episodes in Speech/Language Intervention

• A teaching episode is:

the intervention agent’s administration of one or a sequence of behaviors that contain or represent the active ingredients of therapy.

A Definition of Active Ingredients in Speech/Language Intervention

• Active Ingredients are:

the essential intervention procedures assumed to result directly in the child’s learning of specific goals.

A Definition of Dose Form in Speech/Language Intervention

• Dose form represents:

a) the activities within which teaching episodes are delivered;

b) the pattern of delivery, or density, of the teaching episodes, e.g., one episode per minute at regular intervals for 20 min. vs. two episodes per minute for 10 min. followed by 10 min. with no teaching episodes

A Definition of Dose Frequency in Speech/Language Intervention

• Dose frequency is:

the number of doses per unit of time, e.g., day, week, or month.

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A Definition of Intervention Duration in Speech/Language Intervention

• Intervention Duration is:

the length of time over which intervention is carried out.

A Definition of Cumulative Intervention Intensity in

Speech/Language Intervention

• Cumulative intervention intensity is:

the product of dose x dose frequency x total intervention duration.

The Basic Goal of Milieu Communication Teaching

• The basic goal of Milieu Communication Teaching is to help the child to establish and/or increase the frequency, clarity, and complexity of nonverbal (e.g., nonverbal requests and comments) and verbal communication acts.

• Ensure high rates of maternal responsivity using a responsive interaction approach.– Enhance parents’ responsiveness to their children’s

nonverbal communicative attempts, using a parent responsivity education program.

• Ensure that children have a broadly based prelinguistic system for communicating beforetargeting language.– Increase the frequency and complexity of nonverbal

requests and comments, using Prelinguistic Milieu Teaching (PMT).

– Increase use of words and word combinations, using MT.

RE/MCT: A Two-Pronged Solution to Early Communication Intervention

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1. Establish routines to serve as the context for communicative acts

2. Increase the frequency of nonverbal vocalizations

3. Increase the frequency and spontaneity of coordinated eye gaze

4. Increase the frequency, spontaneity, and range of conventional and non-conventional gestures

5. Combine components of intentional communication acts

6. Use words and word combinations to produce behavior regulation and joint attention acts.

RE/MCT Intermediate Goals

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PMT and MT Teaching Episodes

Preparatory Ingredients:1. Follow the child’s lead

2. Engage in play and social routines

3. Interrupt or change the routines

Potential Active Ingredients:1. Wait for a response (i.e., time delay)

2. Prompt the child to communicate more clearly

3. Provide natural consequences, i.e., complete the routine as is typical.

4. Use words to recast the child’s communication act.

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Responsivity Education: Parent Goals

1. Increase awareness of their child’s developing non-intentional and intentional communication behaviors;

2. Wait for their child to produce interpretable behaviors;

3. Attend to their child’s focus of attention by following their child’s lead;

4. Provide appropriate verbal and nonverbal consequences to their child’s acts.

5. Parents are not trained to do PMT.

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PMT Intermediate Goal 1

• Establish routines to serve as the context for communicative acts.– Imitate the child’s motor acts.

– Imitate the child’s vocal acts.

– Interrupt the child’s established pattern of actions with an adult turn, and then wait for the child to take a turn.

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• Increase the child’s vocalizations– Imitate the child’s spontaneous vocalizations as

precisely as possible to encourage vocal turn-taking.

– Imitate the child’s spontaneous vocalizations with sounds and syllable shapes known to be within the child’s repertoire but different from the child’s original vocalization.

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• Increase the child’s vocalizations– Use words when the child clearly marks referents

as part of the communicative act.

– Model a sound within the child’s sound and word shape repertoire when the child is clearly not communicating.

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• Increase the frequency and spontaneity of coordinated eye gaze– Intersect the child’s gaze by moving the adult’s

face into the child’s line of regard.

– Move the desired object to the adult’s face to encourage a more explicit look.

– Verbally prompt for eye gaze (e.g., say Look at me or call the child’s name).

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• Increase the frequency, spontaneity, and range of gestures

– Create a need for communication within a routine (e.g., by placing a desired object out of reach); then, if the child does not produce a gesture:

• help the child to form an appropriate gesture,

• model an appropriate gesture, or

• pretend not to understand by looking and gesturing quizzically and saying What? or What do you want?

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• Combine components of intentional communicative acts. The three components are vocalizations, gestures, and eye gaze.

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MT Intermediate Goal 6

• Use words and word combinations to clarify requests and comments.

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Evidence Regarding the Use of RE/PMT

• Under what conditions does the external evidence indicate that RE/PMT is likely to be of greatest benefit?

• Under what conditions is RE/PMT contraindicated?

• What recommendations for the selection of RE/PMT may be considered “evidence-based.”

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Empirical Evaluations of RE/PMTYoder & Warren (1998)

• 58 children between the ages of 17-32 mos. participated (mean = 23, sd = 4) .

• All children fit the Tennessee definition for having developmental delay.

• All children had less than 10 words based on parent report and observation in 3 language samples.

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• Children were randomly assigned to either a RE/PMT group or a Responsive Small Group (RSG).– In RSG, adults played with the child and

commented on what they were doing but did not require the child to produce any communicative acts.

• RE was not a part of this study.

Yoder & Warren (1998)

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• PMT dose = 20 minutes a day, ~ 1 teaching episode per minute

• PMT dose frequency = 3-4 times per week

• PMT intervention duration = 6 months


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• What type of study is this, based strictly on its DESIGN?

• What phase of study is this, based on the design, the interventionist and intervention context, and the outcome variables?

• What level of evidence for efficacy does this study represent?


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• Children who received PMT increased their production of intentional communication acts but only if their mothers were highly responsive and/or highly educated.

• For those children with unresponsive mothers or more poorly educated mothers, the RSG therapy was more effective in increasing their production of intentional communication.


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• Twelve months after completing the intervention, children who had received RE/PMT (and had responsive mothers) did significantly better on linguistic measures .– The size of observed effects grew over time.


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• What is the quality of the study?

• How compelling is the study with respect to a claim of efficacy for PMT?


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• Yoder & Warren (2002) conducted the first longitudinal experimental study that combined PMT with MT and Responsivity Education for parents (RE/MCT).– The study was designed to ensure that parents

would be highly responsive to their child’s prelinguistic communication bids.

Empirical Evaluations of RE/PMT(Yoder & Warren, 2002)

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• 39 children with developmental delays and their primary caregiver participated (median age = 22 mos, sd = 4; mental age = 14 mos, sd = 4)

• Child-parent dyads were randomly assigned to RE/PMT group or a no-treatment control group

• RE/PMT dose = 20 minutes a day, ~ 1 teaching episode per minute

• RE/PMT dose frequency = 3-4 times per week

• RE/PMT intervention duration = 6 months


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• Parents in the RE/PMT group were offered up to 12 sessions of responsivity education (3 group; 9 individual sessions)


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• As a total group, the children with RE/PMT did not benefit from RE/PMT.

• Children who began the study low in use of comments (< ~ 2 per 15 min play sample) increased their use of comments at a faster rate if they had RE/MCT than if they did not.

• Those who were high in commenting (> 25 per 15 min sample) showed slower growth with RE/MCT than without it.

Yoder & Warren (2002) Results

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• Children who started with very few communicative acts that were accompanied by canonical vocalizations (~ 1 per 20 min session) grew at a significantly greater rate in vocabulary if they had RE/PMT than if they did not have it.

• Children with frequent use of canonical vocalization (~ 20 per 20 min session) made slower progress with RE/PMT than without it.


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• Children without DS made more rapid growth in requesting if they had RE/PMT than if they did not.

• Children with DS made greater gains if they did not receive RE/PMT.

• Targeting pre-verbal communication does not appear to be adaptive for children who produce a lot of speech-like vocalizations in their communication. A language intervention should benefit these kids more.


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• 51 children with developmental delays between the ages of 24-33 months (mean = 25, sd = 2.7)

• All children had mild to moderate cognitive disability, less than 10 words, and a rate of intentional communication that was less than 2 acts per minute (none were too high in comments).

Empirical Evaluations of RE/PMTFey et al. (2006)

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• Parents of children in the RE/PMT group received eight 1-hour individual sessions of responsivity education.

• PMT/MT dose = 20 minutes a day

• PMT/MT dose frequency = 3-4 times per week

• PMT/MT intervention duration = 6 months.

RE/PMT Dosage for Fey et al. (2006)(and for most RE/PMT studies)

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Fey et al. (2006)

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• Children who received RE/PMT increased their rates of intentional communication acts in one of two contexts (CSBS: d = .68).

– Gains by children with Down syndrome were no different from those for children without Down syndrome (d = .65).

Fey et al. (2006) Results

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• 36 preverbal preschoolers with autism had long-term responses to treatment that depended on their early patterns of object play.– Children with more frequent and more diverse

object play used more different words if they received PECS than if they received RE/PMT.

– Children with lower play learned more words if they got RE/PMT than if they got PECS.

Evaluation of RE/PMT for Children with Autism

Yoder & Stone (2006a, b)

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• a follow-up to Fey et al. (2006) on the long-term effects of RE/PMT on children’s word learning (Fey et al., 2006).– 6 months after discontinuing RE/PMT and again

at 12 months, there were no advantages of the treatment group over the controls on either of two measures of vocabulary learning.

More Evidence on RE/PMTWarren, Fey, Finestack et al. (2008)

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• This is the only experimental test, to date, of a comprehensive early communication intervention study in which the intensity of intervention served as the independent variable.

• Thus, this study addresses the question the question, Is More Better?

Empirical Evaluations of RE/MCT(Fey et al., 2013)

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• 64 children with ID, mean age = 23 mos., divided into two groups.

• High Intensity– dose = 1 teaching episode per minute; 60 minutes a

session

– dose frequency = 5 times per week (actual = 4.19 more)

– intervention duration = 9 mos. + 6 mos.

• Low Intensity– dose = 60 minutes a session

– dose frequency = 1 time per week

– intervention duration = 9 mos. + 6 mos

Empirical Evaluations of RE/MCT(Fey et al., 2013; Yoder et al., 2014)

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• Taking each intensity group as a total, there were no significant differences between groups in verbal or non-verbal communication measures.

• There were consistent conditional effects involving verbal measures (e.g., CDI), however.

– Regardless of DS status, children who engaged in frequent purposeful object play at the start of the study made significantly greater gains in vocabulary if they had the high intensity treatment.

– Children with DS made smaller gains than did the children without DS, regardless of group.

– Children with DS learned more words over the 9-month treatment period if they got the high intensity treatment.

Empirical Evaluations of RE/MCT(Fey et al., 2013; Yoder et al., 2014)

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Growth curves for number of words spoken for four prototypical children.

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Growth curves for number of words spoken for prototypical children with DS.

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A Summary ofRE/MCT Studies

• 244 children from five different samples have participated.

• Children have ranged from 17 – 54 months of age.

• Children have had ID; one study included children with autism.

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A Summary ofRE/MCT Studies

• All studies have involved P. Yoder and most have included S. Warren.

• All studies are later efficacy trials.

• Most studies have included 3 to 4 20-min sessions for 6 months.

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A Summary of Results of RE/MCT Studies

• Most observed effects have involved subgroups of children who have a common characteristic, or moderator.

• Several main effects (i.e., those that involve the whole, unmoderated group) have been short-lived (see Fey et al., 2006 & Warren et al., 2008).

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A Summary of Results of RE/MCT Studies

• Most observed effects have been medium in size, with ds from ~.5 to .7.

• Most studies that have included RE have shown significantly greater parental use of responsive behaviors (especially recasts) following tx.

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• RE/PMT has positive short-term effects (e.g., 6 months) on the communication performance of toddlers and is appropriate for pre-/early verbal children with developmental delay (Fey et al., 2006; Yoder & Warren, 1998; 2001).– Parents should be aware that the intervention

may provide no long term benefits on their children’s language use (Warren et al., 2008) and that different and/or more intensive intervention may be needed.

A Clinical Conclusion from RE/MCT Research

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• Children who do not respond quickly to efforts to improve the frequency and complexity of vocalizations should be considered as candidates for an alternative or augmentative communication system.– This intervention could be provided within an

RE/MCT context (Romski et al., 2010).

A Clinical Conclusion Based on RE/MCT Research

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• Children who do not respond quickly to efforts to improve the frequency and complexity of vocalizations could also be considered as candidates for a more intensive version of RE/MCT.– One or more components of intensity could be

increased.

– What do we know about effects of intensity increases?

Evidence-Based Recommendationsfor Use of RE/MCT

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• RE/PMT should be reserved for children judged to have intellectual disability and language disorder who display spontaneous, meaningful use of fewer than five words and who also meet one of more of the following “evidence-based” criteria.

A Clinical Conclusion from RE/MCT Research

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• The child demonstrates a pre-intervention need for comments as determined by a rate of spontaneous production of no more than 15 comments per 20 min play sample with a parent (i.e., < ~.75 per min).

– A child with autism must produce at least 2 comments per play sample. Otherwise, a discrete trial method may be more appropriate (e.g., PECS).

An Evidence-Based Recommendationfor Use of RE/PMT

127

• The child has ID but not Down syndrome and exhibits a need for requests, as determined by a rate of request productions that is less than 15 per 20 min play sample with a parent (< ~ .75 per min).

An Evidence-Based Recommendationfor Use of RE/MCT

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• The child demonstrates a need for more speech-like vocalizations, as determined by inclusion of canonical syllables in 15 or fewer canonical syllable acts per 20 min CSBS-type sample (i.e.,< ~ .75 per min).

– Such a child is likely to show significantly greater growth in vocalizations and words if he receives 5 hours RE/PMT per week compared to 1 hour (Woynaroski et al., 2014).


129

• The child has Down syndrome and/or the child exhibits different schemes for playing with 10 or more toys in a 20 min play session (> ~ .50 min).


130

• Children with Down syndrome can respond favorably to RE/PMT over the short term (Fey et al., 2006).– Clinicians should not persist if these children

react negatively to clinician prompts for communication, especially for requests.

– Communication and language development of these children is likely to be very slow, with or without RE/PMT.

Evidence-Based Recommendationsfor Use of RE/MCT

131

More RE/MCTIS Better, but Only for Certain

Children Under Certain Conditions!

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• The effects of decisions to increase intensity should be questioned and evaluated, like all other intervention decisions.

evidence-based practice: children’s language disorders...

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