Introduction:

The literature supports the notion that no single language intervention or approach is best for all young children. Ongoing research recognises the importance of determining certain characteristics (developmental or language levels and verbal interaction style) when deciding whether to use a clinician directed, hybrid of child centred (more naturalistic) intervention approach (Owens, 1996; Weitzner-Lin, 2004).
Despite mixed and varying degrees of evidence for syntax (including morphology) and semantics treatment (refer to General Evidence Table) there is general consensus that therapy methods progress from more directive towards more naturalistic approaches to enable integration of the child’s acquired language skills into everyday conversation (Hedge & Maul, 2006).
Language techniques found to enhance and facilitate syntax and semantics skills in preschool children include a range of general language therapy approaches ranging from clinician directed to child directed approaches and can be implemented in a variety of settings (individualised therapy or in the classroom or preschool setting) and conducted by speech pathologists in collaboration with parents or carers and early educators (Paul, 2002; Tiegerman-Farber, 1995; Shames & Anderson; 2002).
In 1986 Mark Fey identified 3 basic approaches to intervention: Trainer-Oriented Approaches, Child-Oriented Approaches, and Hybrid Intervention approaches (Fey, 1986). Rhea Paul (2001) slightly adapted these terms to Clinician-Directed approaches, Child-Centred approaches and Hybrid approaches, however each still held the basic premise. It is within these three classifications (Clinician Directed, Hybrid and Child Oriented) that the following specific language enhancing approaches are presented.

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Treatment options:

• Clinician Directed Approaches:
  - Overview
  - Drill
  - Drill Play
  - CD Modelling

• Hybrid approaches:
  - Overview
  - Milieu therapy-Incidental Teaching & Mand Model
  - Vertical Structuring
  - Focused Stimulation
  - Script Therapy

• Child-centred approaches (CC):
  - Overview
  - Indirect Language Stimulation
  - Whole Language
  - Daily activities-Literature-based scripts & Auditory Bombardment

• Hanen Program
  

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Title:

CLINICIAN DIRECTED PROCEDURES

In CD approaches the clinician determines when and where the intervention will occur, decides on the type of stimuli and how often stimuli is presented, and governs the terms in which responses are to be judged correctly. Paul (2001) describes these approaches as attempting ‘to make the relevant stimuli highly salient, to reduce or eliminate irrelevant stimuli, to provide clear reinforcement to increase the frequency of desired language behaviours, and to control the clinical environment so that the intervention is optimally efficient in changing language behaviour’ (p.68).
These approaches are not considered naturalistic because of the degree of control that the clinician has, and their lack of adherence to the conventions of genuine reciprocal communication (Hedge & Maul, 2006; Paul, 2002; Paul 2001).

Population:
Clinician Directed approaches are believed to be most effective during the initial stages of language therapy to establish a new language skill. Once established, commencement of transitional activities provide the client with more naturalistic contexts in which to practice and use the newly acquired communicative behaviour, allowing generalisation of skills to occur (Hedge & Maul, 2006;Paul, 2002). Current literature has also described this approach as appropriate for teaching particular skills that require massed practice. It has also been suggested that Clinician Directed approaches are effective with highly distractible children or children with language impairments who are not seen to benefit from natural language experiences (Haynes, Moran & Pindzola, 2006).
In terms of developing a first lexicon, these techniques have been reported to be more effective with language delayed children with low IQs than children with higher IQs (Freidman and Friedman, 1980, cited in Paul, 2001). Thus these approaches may be beneficial for an older child with the developmental age of 18 – 36 months.
However, when Yoder, Kaiser and Alpert (1991) set out to determine whether the efficacy of two approaches, milieu teaching, and ‘the Communication Training Program’ (a more direct language teaching model typically employed by teachers) related to pre-treatment differences in preschoolers, their findings suggested that the directive approach may be more effective with children who have close to normal cognitive abilities (Fey, Windsor and Warren, 1995; Yoder, Kaiser and Alpert, 1991).

Clinician directed procedures:
In each of the Clinician Directed approaches there are three key elements which are involved during therapy as listed below:
S: Stimulus: The clinician provides a model of the desired behaviour, or a prompt to produce the language target.
B: Behaviour: The client responds by producing a target language structure.
C: Consequence: The clinician provides reinforcement if the client’s communicative response was produced correctly. If not, the clinician provides feedback or correction or may ignore the incorrect behaviour.
Adapted from Paul, R. (2002). Introduction to Clinical Methods in Communication Disorders, Baltimore, Maryland: Paul H. Brook.
Cues, prompts, imitation (direct and delayed), fading, reinforcement and shaping are all common techniques employed during clinician directed approaches (see glossary for definitions).

Resources/Training:

No requirements for specialised training. However there are many useful resources widely published on numerous speech and language websites and commercial educational companies which produce and sell drill orientated play tasks materials/games.

Timeframe:

Not applicable, though as previously mentioned, CD approaches are optimal for language intervention in the initial stages which are later followed up with more naturalistic approaches (Child Directed) to aid generalisation of the language skills. Fey (1986) proposed guidelines to increase the naturalness of clinician directed approaches which include making the client's contribution informative, creating intervention contexts where there is a real motivation to communicate, providing distracter items, and presenting stimuli within cohesive texts (Paul, 2001).

Advantages

•  Allows a child to receive the most opportunities possible to produce a new language form.

•  Focuses on specific linguistic targets.

•  Utilises explicit instructions and requirements for appropriate productions.

•  Provides reinforcement which increases the frequency of accurate and correct responses.

•  Has a high level of efficiency in evoking maximal numbers of responses per unit time.

•  Has proven effectiveness in eliciting new language behaviours (Paul, 2001).

Limitations

•  CD approaches are relatively unnatural in presentation and therefore do not allow for automatic generalisation of language structures and targets used in the clinic to every day environments (Paul, 2001, Weitzner- Lin, 2004, Law, 2004).

•  It has been reported that neither clients nor clinicians (who were enrolled in a particular study) really enjoyed drill therapy. Although efficient and effective, the clients and clinicians found it lacked motivation (Paul, 2001) .

•  This approach appears to promote passive participation from clients rather than spontaneous interaction (Haley, Camarata and Nelson, 1994).

Summary of Level of Evidence:

Fey (1986) completed a thorough systematic review of all available literature at the time regarding language treatment approaches. His conclusion, supported by a plethora of researches, was that operant procedures such as imitation in drill therapy are highly effective in facilitating a child's acquisition of new language forms. However, Fey (1986) reported that several studies failed to obtain the desired generalisation to natural speaking environments. Although performing well in traditional clinic contexts, the children would often fail to use the target forms in realistic communicative situations.

There is evidence to support CD approaches utilised to enhance syntax and morphology in preschoolers. The clinician directed, operant based approaches have been found to be highly successful in improving grammar production (Cleave and Fey, 1997).See Evidence Table 1.-“Semantics and Syntax :Clinician Directed Approaches”.

Evidence Table 1: Semantics and Syntax: Clinician Directed Approaches.

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DRILL:
Drill is considered the most highly structured format. The clinician selects the training language stimuli, explains the specific target response required by the child, presents stimulus items in a predetermined order, and reinforces correct responses tangibly (e.g. with a lolly or token), verbally (e.g. “Good job, I like the way you said…”), or nonverbally (e.g. the child gets a “high five” from the clinician) (Paul, 2001; Paul 2002; Owen, 1996; Hedge & Maul, 2006).

Procedure:

Semantics

A drill activity targeting naming may consist of the following:

• The clinician instructs the child as to the type of response they are required to give, (e.g. “ You need to tell me the name of the objects I show you …”)
• The clinician trains the stimulus by repeating a word or phrase, (e.g. “ This is a ball. Ball”).
• The clinician prompts the child as to how to respond correctly using imitation, (e.g. “ Say it after me. Ball”).
• The clinician reinforces correct responses by providing the child with verbal praise or a tangible reinforcer, (e.g. “ Great talking! Have a stamp”).
• The clinician gradually eliminates prompts.
• If child's responses are not the intended target, the clinician attempts to shape response .

Syntax

An example of a drill activity for syntax is as follows :

• The clinician states the instructions as a request, (e.g. “ Look at the pictures and do what I say” ).
• The clinician presents a stimulus to target a particular grammatical marker, such as an irregular past plural tense, (e.g. Clinician shows a picture of a girl eating cake. “ Say, Ann is eating cake today… She ate cake yesterday also. What did she do yesterday? Say, Ann ate cake yesterday . ”).
• Clinician waits for client to respond, allowing sufficient time for child to formulate response (child responds “Ann ate cake”) .
• Clinician presents consequent event or reinforcement (primary, such as food, or secondary, such as social praise [“Great you said ‘Ann ate cake!' ”], tokens to accumulate for a prize, or feedback regarding the acceptability of the response) .

• Feedback might include biofeedback instrumentation or information on performance “You said four out of the five correctly!” This is only appropriate for older children)

Adapted from Roth and Worthington , (1996) as presented in:

Paul, R. (2001). Language Disorders from Infancy through Adolescence: Assessment and intervention. 2 nd Ed. Missouri : Mosby.

The Environmental Language Strategy, developed by MacDonald and associates in 1974 is an example of a clinician-directed approach to intervention, which has been used extensively in eliciting early language (Paul, 2001). Consisting of 3 phases, the first phase, ‘Imitation' provides an example of drill therapy. This is as follows:

• The Clinician pairs a linguistic stimulus (e.g. verbal output) and a non-linguistic stimulus, (e.g. action- “ Hug the puppy. You say it ‘Hug the puppy' (while hugging a stuffed animal”).
• If the child provides target response, the clinician repeats the response and provides reinforcement, (e.g. “ Hug the puppy. Lovely talking! Have a sticker)
• If the child provides an incorrect response, or no response, the clinician looks aside for a duration of 3 seconds, before repeating the stimuli.

Adapted from MacDonald et al. (1974).

Evidence for Drill Therapy:

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DRILL PLAY
The drill play approach is almost identical to general drill activities. The only difference is that drill play has motivational characteristics (Hedge and Maul, 2006). There are 2 motivational events in a drill play activity, the antecedent motivating event (offered before elicitation) and the subsequent motivating event which follows reinforcement (Weitzner-Lin, 2004) .

Procedure:

Semantic Therapy

An example of Drill Play for naming is as follows:

• The clinician introduces an antecedent event, (e.g. “ You can choose which animal we talk about, point to one of them …”)
• The clinician instructs the child as to the type of response they are required to give, (e.g. “ You need to tell me the name of the animal ...”).
• The clinician provides training of the stimulus which involves a word or phrase to be repeated, (e.g. “ It's a lion”).
• The clinician prompts the child as to how to respond correctly, (using imitation, e.g. “ Say it after me. Lion”.)
• The clinician reinforces the correct responses by providing the child with verbal praise or a tangible reinforcer, (e.g. “ Great talking! Have a stamp”.)
• The clinician subsequently presents a motivating event, (e.g. “ Now you can colour in the lion .”)

Syntax therapy

•  Example activity (morphology target): Playing a game of memory with regular plurals in simple sentences as the language target.

•  The clinician places all regular plural cards face down and provides instructions in declarative form, (e.g. “You need to find pairs. When you turn over a card say the name of the picture. Watch and copy me first ”).

•  Clinician demonstrates and selects two cards to turn over, (e.g. “I have two dogs [card 1] and three bats ”[card 2].

•  The clinician waits for the child to respond, allowing sufficient time for child to formulate response.

•  The clinician presents consequent event or reinforcement (primary, such as food, or secondary, such as social praise, (e.g. “Good talking! ”), tokens to accumulate for a prize, or feedback regarding the acceptability of the response).

•  Feedback might include biofeedback instrumentation or information on performance, (e.g. “Great, you remembered to say ‘s' on the end of your ‘more than one' words ”).

Computer Programs

Computer language intervention may be an option for some children , as there are many children who find using computers enjoyable and motivating. The skills required to use this method may deem it more suitable to older pre-school children, or otherwise a clinician's assistance and mediation may be necessary. There are many CD programs commercially available to target vocabulary development and concepts, and these typically use a drill or drill play format (Paul, 2001). Cochrane and Masterson (1995, cited in Paul, 2001) reported from a number of research studies that the efficacy of clinician-mediated computer language programs was similar to the more traditional approaches.

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CD MODELLING

Fey (1986) presented CD modelling as an alternative to drill and drill play procedures and based this on a m ore socialistic approach whereby a third person-model is used to demonstrate target language structures or responses. It is similar to the other two procedures where the clinician and child work within a highly structured, prescribed, interactive setting and utilise external reinforcers (Paul, 2001). CD modelling differs from Drill and Drill play in that it employs a third-person model, and the child is required to listen rather than imitate. Leonard (1975) presented a modelling procedure that involves a ‘confederate' such as a parent, student clinician or puppet, to provide the models.

Procedure:

Semantic Therapy

An example of how this may be implemented for focussing on building 2 word combinations (talking about semantic relations) is as follows:

• The clinician sits with child and confederate at a table
• The clinician administers a pre-test by presenting a set of pictures to child and requesting the child to provide information (e.g. “ Tell me what's happening here ”).
• The clinician shows the confederate a set of pictures (not used in pre-test) and asks the child a question (e.g. “ What's happening here? ”).
• The confederate provides 2 word combinations relating to a picture (e.g. confederate says “ boy run ”, “ dog eat ”, “ girl drink ”).
• The clinician presents the confederate with a token after each correct model and gives no reinforcement to the confederate as they provide incorrect models on 20% of occasions.
• After training 10 or 20 stimuli, the clinician instructs child to ‘talk like' the confederate.
• The clinician presents the child with a set of similar (but not identical) pictures.
• The clinician directs the confederate and child to take turns in talking about the pictures until the child has 3 consecutive correct responses.
• The clinician continues presenting stimuli to child only until a criterion of 10 consecutive correct responses is reached.
• The clinician administers a post-test (using pre-test stimuli).

Syntax Therapy

• The child, clinician and model are seated at a table.
• A pre trial is administered by showing/exposing the child to the stimuli designed to elicit target language models and responses (e.g. target: possessive morpheme. Clinician shows 5 pictures with different people holding a possession- [object] and describes each one, e.g. “This is Sarah. This is her doll. Whose doll is it? We say, this is Sarah's doll ”).
• The clinician directs the child to listen to the model who will talk in a ‘special way' when a picture is shown and will be rewarded for their good talking e.g. When the model produces a possessive morpheme in a sentence, they receive a stamp and are given a sticker after collecting 5 stamps.).
• The clinician shows 10 pictures to the model and requests a response (e.g. “ This is David. This is his car. Whose car is it? ”) Pre trial stimuli are not included during this training period. The model is reinforced on a continuous schedule, following correct productions of sentences featuring possessive morphemes.
• To highlight the target forms or desired structures used, the model produces several incorrect responses (“That David car”) in which no reinforcement/ praise is provided.
• Following the 10 models the child is requested to talk like the model about the pictures shown. The pictures presented are not the exact one used throughout the training period.
• The child and the model are asked to take turns in responding to presented pictures until the child is able to produce three consecutive correct sentences featuring possessive morphemes. (“This is John 's cup. This is Mary 's brush. This is Peter 's dog). The child continues on until they reach the criterion of 10 correct productions of target sentences.
• The pre trial pictures are then shown a second time round to the child with no models provided to assess the level of acquisition the child has achieved for using the target structure (possessive morphemes).

Adapted from Leonard's modelling procedure as presented in:

Fey, M. (1986). Language intervention with young children. Boston: Allyn & Bacon.

Evidence for CD Modelling:

A review of the literature evaluating language interventions conducted by Law (1997) revealed modelling to be a more successful approach than imitation, which is the basis of drill and drill play approaches. One researcher however found that in some circumstances modelling was the more successful approach, maintaining that “imitation is more effective than modelling because it demands fewer cognitive operations on the part of the child” (Connell, 1986, 1987, cited in Law, 1997, p.3) thus possibly more relevant to a child with a language disorder.

In a recent study by Kouri (2005) the effectiveness of a modelling approach and a mand based intervention ( Mand-Elicitated Imitation: MEI ) to facilitating early lexical learning with late talking pre-schoolers were compared. The results indicated both training approaches yielded success in facilitating lexical production skills. Due to the nature of the MEI approach, children receiving MEI were introduced to more target words during training, however there was no significant difference in terms of the number of total treatment productions, and there were no significant group differences regarding the generalisation of the total target words to spontaneous use. Overall the findings suggest that both interventions were effective training procedures, and that delivering the approaches in a naturalistic setting may further increase their effectiveness. See Evidence Table 1.-“Semantics and Syntax: Clinician Directed Approaches”.

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Title:

HYBRID APPROACHES

Explanation:

Hybrid approaches to therapy are those which draw on qualities from both Clinician –Directed, and Child-Centred approaches. These approaches lie centrally on a continuum from Clinician-Directed approaches to Child-Centred approaches. Fey (1986) referred to Hybrid approaches as those which have a high degree of naturalism, yet also allow the clinician to ‘make use of procedures that will maximise the speed, durability, and generalisability of language learning' (p.205). The 3 major characteristics of hybrid approaches to intervention are as follows as outlined in Paul, (2002): 1. the clinician can select several specific goals on which to focus, 2. the clinician prepares activities and materials that will facilitate the child's spontaneous productions of the targets, 3. the clinician's own language use will model and emphasise the forms being targeted in addition to making general responses to the child's communication.

Population:

It has been reported (Freidman and Friedman, 1980, cited in Paul, 2001) that children with low IQs who are minimally verbal may benefit more from Clinician-Directed approaches for developing a first lexicon, whereas more naturalistic approaches may work better for children with higher IQs. The more naturalistic approaches such as Child-Centred and Hybrid approaches were recommended as being more suitable for children with IQs closer to the normal age and chronological ages closer to 18 – 36 months (Paul, 2001). However, when Yoder, Kaiser and Alpert (1991) set out to determine whether the efficacy of two approaches, milieu teaching, and ‘the Communication Training Program' (a more direct language teaching model typically employed by teachers) related to pre-treatment differences in preschoolers, their findings suggest that the directive approach may be more effective with children who have close to normal cognitive abilities (Fey, Windsor and Warren, 1995; Yoder, Kaiser and Alpert, 1991.)

Based on the findings of a critical examination of literature relating to milieu therapy in particular, Kaiser et al (1992) concluded that this approach may be most suited to children who are learning vocabulary or early semantic relationships.

Time frame:

Not applicable

Resources/Materials required:

Not specified.

Training:

None required.

Evidence Table 2: Semantics and Syntax: Hybrid Approaches.

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Hybrid procedures:

MILIEU THERAPY

At present, there exists more than 25 published studies of milieu teaching, and this approach has been gradually gaining empirical evidence and support over the last 4 decades (Warren, Gazdag, Bambara, and Jones 1994; Kaiser et al. 1992).

There are 2 types of Milieu teaching methods that are commonly employed in semantic and syntax intervention. These are the Incidental Teaching method (Hart and Risley, 1975, 1980) and the Mand-Model approach (Rogers-Warren and Warren, 1980; Warren, McQuarter and Rogers-Warren, 1984). Milieu therapy involves clinician instruction following the child's lead with provision of numerous examples of language forms/meanings in ongoing routines while also integrating behavioural (operant) learning principles including modelling, imitation and reinforcement (Kaiser, Yoder & Keetze, 1992; Law, 1997).

A) INCIDENTAL TEACHING METHOD

Procedure:

Semantics Therapy

An example of how an incidental teaching method may be used to elicit 2 word phrases is as follows:

• The clinician arranges the setting so that the things that the child may want, or need to complete a particular activity (pencil etc) can be seen by the child but are not in reach, (e.g. Place a set of stuffed animals high on a ledge).
• The clinician waits for child to begin conversation by making a request, gesturing, or looking at an object, (e.g. Child points to a toy dog).
• The clinician moves toward the child and makes eye-contact. The clinician appears as if waiting for the child to continue their request (Focussed Attention)
• If child does not offer a request, the clinician asks the child a question which is determined by the goal of the session, e.g. ( “What do you want me to do?” if working on making action-object requests)
• If child produces desired response, the clinician confirms this response by including a model of the target, ( e.g. “Okay, you want me to get the dog ”)
• If the child does not produce the target response, provide a prompt, (e.g. “You need to tell me”, “Do you want me to get the dog? “Say, get the dog”).
• The clinician provides confirmation with a model if the child produces the target response. If not, the clinician attempts another prompt, and then proceeds to present the child with what they wanted.

Syntax Therapy

An example of incidental teaching method for syntax targeting production of simple verb (‘want') is as follows:

• The clinician organises the environment so that desired objects/items are visible to the client but out of reach (e.g. a truck).
• The child begins the communication exchange verbally or non-verbally (e.g. the child squeals and points to a truck on top of a cupboard).
• The clinician prompts the child with a question to extract pre-selected target response, (e.g. “ What do you want ?”).
• The child responds with an approximation of the target phrase, (e.g. “Want that” ).
• The clinician then uses cues to extract a more detailed/elaborate response, (e.g. “ Say, want car”

B) MAND-MODEL

The Mand-Model approach is similar to the incidental teaching method described above, except that the clinician requests, or mands the child to produce an utterance by using stimulus (Paul, 2001). A time delay component may also be included where a delay period is inserted (the adult is in close proximity to the child and looks at the child questioningly for about 15 seconds as noted by Olswang & Bain, 1991) into the interaction sequence to optimise the chances of the child responding correctly and becoming less reliant on the prompt of an adult (Law, 1997).

Procedure:

Semantics Therapy

The following is an example of the Mand-Model approach for eliciting one-word utterances:

• The clinician begins by observing the child.
• The clinician waits for child to appear to be interested in something, (e.g. the child moves towards a book).
• The clinician requests an utterance from the child, (e.g. “What's that?” ).
• If child provides target response, the clinician presents the desired object in addition to verbal reinforcement, (e.g. the book).

Syntax Therapy

An example of a Mand-Model approach targeting adjectives (big/small) in simple sentences

• Clinician begins by observing the child
• Clinician waits for the child to appear to be interested in something, (e.g. the child looks towards a two balls)
• The clinician requests an utterance from the child (e.g. “Do you want the small ball or the big ball?” )
• If the child provides the target response, the clinician presents the desired object in addition to verbal reinforcement, (e.g. one of the balls).

Evidence for the Mand-Model approach :

In a recent study by Kouri (2005) the effectiveness of a modelling approach and a mand based intervention ( Mand-Elicitated Imitation: MEI ) to facilitating early lexical learning with late talking pre-schoolers were compared. The results indicated both training approaches yielded success in facilitating lexical production skills. Due to the nature of the MEI approach, children receiving MEI were introduced to more target words during training, however there was no significant difference in terms of the number of total treatment productions, and there were no significant group differences regarding the generalisation of the total target words to spontaneous use. Overall the findings suggested that both interventions were effective training procedures, and that delivering the approaches in a naturalistic setting may further increase their effectiveness. See Evidence Table 2.-“Semantics and Syntax: Hybrid Approaches”.

Enhanced Milieu Teaching

Kaiser and Hester (1994) examined the effects of a hybrid intervention described as ‘Enhanced Milieu teaching (EMT). This approach combines the following 3 elements:

1. ‘Environmental Arrangement Strategies' which involves the clinician selecting and arranging materials of interest to promote requests, and engaging in activities with the child.
2. ‘Responsive Interaction Strategies' involving the clinician following the child's lead, balancing turns, maintaining the child's topic, modelling appropriate language (linguistically and topically) and matching the level of complexity of the child's language, expanding and repeating the child's utterances and responding communicatively to the child's communication (verbal and non-verbal)
3. ‘Milieu Teaching Techniques' such as Mand-Modelling and Incidental Teaching.

Evidence for Enhanced Milieu Teaching

The results from the study by Kaiser and Hester (1994) suggested that EMT is an effective early intervention strategy. After the intervention was implemented each of the children who participated in the study showed increased use of the target language, as well as displaying increases in frequency, complexity and diversity of language. There was also evidence of generalization of these effects into the children's home and pre-school classroom settings. See Evidence Table 2.-“Semantics and Syntax: Hybrid Approaches”.

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VERTICAL STRUCTURING

This approach involves the clinician taking a child's incomplete utterances and combining and expanding into a complete utterance.

Procedure

Semantics Therapy

The following example is taken from Paul (2001):

• The clinician presents the child with a picture or toy, (e.g. the clinician shows the child a picture of children at a zoo).
• The clinician asks a question relating to the stimulus, (e.g. “ What do you see here?”).
• If the child responds with an incomplete utterance (e.g. “ Lion ”), the clinician asks a contingent question, (e.g. “ Yes, and what is the lion doing?”)
• If child responds with a second incomplete utterance (e.g. “ Roar ”), the clinician expands the two utterances made by the child, (e.g. “Yes, he's roaring. The lion is roaring”).
• If the child spontaneously imitates model, the clinician reinforces with verbal praise.

Syntax Therapy

•  The child is shown a picture designed to evoke production of syntactic structures, (e.g. a picture of a park is shown which includes a boy throwing a ball to a dog standing under a tree) .

•  The clinician guides the child to the stimulus as required, (e.g. “ Look at this picture ”) .

•  The clinician asks the child an open ended question and waits for a response, (e.g. “ What's happening ?”)

•  If the child produces a multiword response (e.g. “ A big dog ”) the clinician provides verbal confirmation, (e.g. “ Yes ” or “ Uh huh ”).

•  If the child does not produce an utterance or produces something irrelevant then another general, open ended question is posed, (e.g. “ What's happening ?”).

•  Following a positive response from the child another stimulus or further questioning may occur with time for the child to respond, (e.g. “ Where is the dog ?”).

•  The clinician then acknowledges the child's response and if correct, (e.g. “ Under the tree ”), the clinician then expands the child's production, modelling a grammatically and semantically intact utterance containing the semantic- syntactic relationship encoded vertically by the child, (e.g. “ Yes, the big dog is under the tree. ”).

(Fey, 1984; Paul, 2001 & Paul 2002).

Evidence for Vertical Structuring

Research findings indicate that Vertical Structuring may have a facilitating effect on a child's ability to produce multiword combinations. Schwartz, Chapman, Terrell, Prelock and Rowan (1985) investigated parents' use of vertical structuring in interactions with their children. The data revealed an increase in the number of word combinations used by most children in the treatment group. Vertical structuring has also been an effective technique as it encourages early developing content-form interactions (Fey, 1986). See Evidence Table 2.-“Semantics and Syntax: Hybrid Approaches”.

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FOCUSED STIMULATION

In a focused stimulation approach to therapy the child is not requested to imitate or produce a target, however the clinician arranges the context of the activity so that there may be many opportunities to model the desired forms, and so the child may be motivated or tempted to produce utterances that use the target forms (Weitzner-Lin, 2004) . Fey (1986) describes focused stimulation as concentrating more on comprehension than on production, however its success is usually measured by whether the child can produce the desired forms post-treatment.

Procedure:

Semantics Therapy

An example of using focused stimulation utilising carrier phrase ‘I can see' to encourage naming of nouns in simple sentences is presented below:

• The clinician prepares the activity, (e.g. the clinician provides a poster of things in the sky)
• The clinician presents many models of target form, (e.g. “ I can see the plane. I can see the tall building. People in the building would see a lot from up there! What can you see?”).
• If the child makes a response that does not use the target form (e.g. “ cloud ”) the clinician responds contingently, (e.g.” Yes, I can see the cloud too.”)
• The clinician continues to provide models, e.g. ( I can see a bird. I wonder what the bird can see up there?).

Syntax Therapy

An example of focused stimulation targeting copula ‘is' and using toy zoo animals, a zoo keeper figurine, and other scenery props is presented below:

•  Clinician: “Let's pretend we're going to the zoo and visiting all the animals. Ooh look, the seal is in the water. The dolphin is in the water. The fish is in the water… ”

•  Child: “fish in water”

•  Clinician: “Yes it is . The fish is in the water. That is good. Is the duck in the water? It is . The duck is in the water. Tell the zoo keeper. Tell him the duck is in the water”

•  Child: “duck is in water”

•  Clinician: “Good. Now we've seen all the animals that live in the water, let's go to the tree area and see who is in the trees.

Evidence for Focused Stimulation

In a study by Girolametto, Pearce and Weitzman (1996), parents of late-talking toddlers were trained to administer focused stimulation intervention in order to teach their children a selection of specific target words. Post-intervention, there were significant differences between the focused stimulation group and the control group (delayed treatment group) in terms of the mothers' language (slower, less complex, more focused) and the children's language (used more target words, higher frequency of output in free-play situations and displayed larger vocabularies). The data indicated success of a focussed stimulation approach administered by parents to toddlers with expressive language delays. See Evidence Table 2.-“Semantics and Syntax: Hybrid Approaches”.

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SCRIPT THERAPY

Script therapy, also known as Joint Action Routines (JAR) was discussed by Olswang and Bain (1991) as a method where a routine or ‘script' is instituted into the context of the intervention. Olswang and Bain (1991) assert that if a child's language learning occurs within a familiar routine, there is likely to be a reduction in the level of cognitive effort required of the child in learning language. There are many possible routines that could be established, such as pinning on the child's name tag as soon as he/she enters the session, learning a song with corresponding actions that the child then knows ‘off by heart', or always giving the child a particular set of materials during activities. Scripts can also be in the form of verbal routines. For example at the beginning of each session the clinician prepares a number of phrases relating to the child's targets which they then use in the initial conversation with the child.

In the script therapy approach, once routines have been established, a disruption is made by ‘violating' the routine, in order to challenge the child to repair this disruption (Paul, 2001). Some examples would be to present the child with the wrong name tag (or none at all), to provide the client with incorrect materials, or sing the wrong words in the learnt song.

Procedure:

Syntax (target: ‘wh' questions )/Semantics Therapy (target: using names)

Paul (2001) describes an activity using the song ‘Where is Thumbkin?' targeting the question marker ‘where':

• The clinician sings ‘Where is Thumbkin?' several times with the child while performing the actions.
• Once the child appears to know the song, the clinician violates it by singing the incorrect words, (e.g. “What is Thumbkin?”)
• The clinician lavishes praise if child corrects appropriately (e.g. “ No! Where is Thumbkin? ”)
• The clinician violates song by delaying production of the next line, ( e.g. While holding up ‘pinky', the clinician refrains from singing ‘Where is Pinky?' for the first few beats).

The clinician provides verbal praise if the child responds with “Where Pinky ?” etc .

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Title:

CHILD CENTRED APPROACHES (CC)

Explanation:

When considering service delivery, a clinician is faced with 2 primary options, direct treatment (where the clinician is the ‘agent for change'), or indirect treatment (where the clinician will instruct others, such a parent care-giver or teacher to be the agent for change) (Olswang and Bain, 1991). These 2 modes of service delivery options are usually more suitable to a particular set of approaches. If implementing indirect treatment with a child, where a parent is trained to facilitate their child's language learning, naturalistic approaches such as Child-Centred (CC) approaches are especially suitable (Olswang and Bain, 1991; Weitzner-Lin, 2004)).

Child centred approaches are based on social interactionist/social modelling perspectives of language development whereby quality and quantity of adult speech input is seen to support and assist children's growth in knowledge and use of language in everyday communication (Owens, 1996; Paul, 2001: Shames and Anderson, 2002). CC approaches emphasise the provision of communication therapy in natural communication environments. The theory underlying these approaches is that individuals will achieve therapy goals more easily and generalise newly learned communication skills more spontaneously when taught in the context of familiar experiences and activities with supportive communication partners (Weitzner-Lin, 2004). Supportive communication partners wait for the child to begin communicating, follow the child's lead and offer consistent and meaningful responses that relate to the child's own utterances or actions as appropriate. The principal of ‘following the child's lead' is a significant aspect of CC approaches. It involves following the child's focus of interest in therapy, and is supported, as a principle, by empirical findings from a variety of sources (Cogher, 1999; Fey, Windsor and Warren, 1995; Yoder, Kaiser and Alpert, 1993). In CC activities, the child negates the therapy and determines the content, timing and sequence the intervention (Gibbard, 1994; Eadie, 2004).

Population:

Naturalistic interventions, such as CC approaches, are the favoured intervention by many clinicians for increasing a child 's early vocabulary , or first lexicon (Lahey, 1988; Owens, 1999).

Naturalistic interventions at the initial stages of therapy may be appropriate for children who are not yet ready to benefit from directive intervention approaches (e.g. the inflexible and unassertive child (Fey 1986; Paul, 2001)). This may include children at earlier levels of language development including children with general developmental delays. Naturalistic interventions are more effective than directive approaches in increasing spontaneous language and in promoting generalisation to non-treatment settings (Law, 1997). Client-Centred approaches are appropriate additions to many programs for a number of children with language disorders to assist in generalisation of acquired skills (Hedge & Maul, 2006).

Advantages

•  Child Centred interventions can be effective for children who are not yet ready to benefit from direct instruction. This may particularly be the case for some children with general developmental delay.

•  Child Centred interventions usually result in greater generalisation to non-treatment situations than do the Clinician Directed interventions.

•  Child Centred interventions can be effective for children who have produced target structures but have not yet generalised these skills to use in communicative situations.

•  Parents and teachers taught to use CC interventions with ongoing monitoring, professional supervision, and support.

•  CC approaches are often enjoyable and naturally motivating for the child.

Limitations

•  Child Centred approaches may not be as effective as more directive approaches in eliciting initial imitative speech and gestures (Nelson et al., 1996; Law, 1997).

•  CC approaches do not allow clinicians to select specific language goals for their clients.

Summary of Level of Evidence.

A literature review conducted by Fey (1986) revealed that there was a paucity of empirical evidence supporting CC approaches. Although these approaches had been becoming increasingly popular and many authors had described and recommended their use, only a small selection of researchers had conducted well-controlled, experimental studies. Since then, a number of studies have developed regarding CC approaches, however it appears that the majority of these are primarily concerned with children's social-communicative behaviour and social valence, and the effects of naturalism in therapy, rather than the efficacy of specific, language directed techniques.

CC approaches do appear to have a number of evidence-based strengths, as there is evidence to support a number of aspects inherent in CC approaches. These are: the aspect of naturalism and following the child's lead (Cogher, 1999; Fey, Windsor and Warren, 1995; Law, 1999; Yoder, Kaiser and Alpert, 1993), the recasting technique (Camarata, S., Nelson & Camarata, M., 1994; Fey, Cleave & Long, 1997; Nelson, Camarata, Welsh, Butkovsky & Camarata,1996, Saxton, 2005), the use of expansions ( Bellon-Harn, Hoffman, and Harn, 2004; Yoder, Spruytenburg, Edwards, and Davies, 1995), book reading (Kirchner, 1991; Bellon-Harn, Hoffman, and Harn, 2004) and auditory bombardment (Cleave & Fey, 1997; Paul, 2001). See General Evidence Table.

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INDIRECT LANGUAGE STIMULATION (ILS)

(also known as facilitative play)

Procedure:

The clinician arranges the physical/clinic environment to encourage a child to produce target responses spontaneously during a natural play setting. The clinician uses several techniques to promote the child's communicative participation during a play based session (Paul, 2002).The key techniques include the following:

Generic procedure in Indirect Language Stimulation:

1. The clinician arranges a play environment which encourages the child to produce/use target responses as they occur in the natural setting.
2. The clinician waits for child to respond (verbally and non- verbally) to play stimuli (e.g. toys) and follows child's lead.
3. The clinician responds to the child's language with one of several techniques (self talk and parallel talk, expansions, extensions, recast sentences, build-ups and breakdowns as described above) .
4. If the child does not initiate verbal output the clinician responds to child's actions and interprets these as intentional communication, responding with an appropriate language model.

(Owens, 1999; Paul, 2001).

Evidence for Indirect Language Stimulation:

Indirect Language Stimulation also known as facilitative play has been widely critiqued in the literature. Regarding syntax therapy, recasting has been viewed as particularly effective in supporting growth of syntax and morphology (receptive and expressive) in preschool children (Camarata, S., Nelson & Camarata, M., 1994; Fey, Cleave & Long, 1997; Nelson, Camarata, Welsh, Butkovsky & Camarata, 1996, Saxton, 2005). Leonard and Fey (1991) provided additional detailed examples of using modified ILS techniques to elicit grammatical forms in the developing language phase. See General Evidence Table.

Particular types of recasts are also thought to be more effective in grammar development for particular language forms such as development of verb structures supported by ‘verbal reflective questioning', (i.e. If the child says “bird tree”, the clinician responds with “The bird is in the tree, isn't he?” as outlined by Paul, 2000). Further research is yet to be conducted to identify other forms of recasts considered to be beneficial for acquisition of grammatical forms in children (Saxton, 2005). See General Evidence Table.

It is believed that using the technique of ‘expansions' in particular is useful in facilitating a child's production of utterances at higher semantic levels ( Bellon-Harn, Hoffman, and Harn, 2004) . The effectiveness of this technique has been revealed within the context of storybook reading sessions, where the level of semantic complexity of children's utterances have been shown to increase from a basic level (naming objects and characters , etc) to a level of providing descriptions of objects' attributes and the actions made by characters (Yoder, Spruytenburg, Edwards, and Davies, 1995). See General Evidence Table.

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WHOLE LANGUAGE

This approach is based on language learning principles, which suggest that children learn language through experiencing a ‘language-rich' environment. This viewpoint envisages the child to be self directed to achieve communication goals with the support of adults/parents who provide appropriate models of communication and respond positively towards the child's communicative attempts (Sawyer, 1991). Whole language has been most widely referred to regarding literacy development.

Procedure : Whole language has been described in the literature as a three step approach. This is as follows:

• Step 1. A story or theme is utilised and developed into diverse activities employing all modalities of reading, writing, speaking and listening.
• Step 2. Opportunities are provided for communicating, which allow the child to solve language based dilemmas.
• Step 3. Naturalistic consequences for the child's communicative attempts are provided.

There are two main types of consequences . These are:

• Positive consequences (5 subtypes)-
• expansion
• extension (as described in ILS)
• reaction
• acknowledgement
• paraphrasing
• Requests for repair-
• repetition
• negation
• revised models
• requests for clarification
• prompts for further info
• reinterpretations.

These may be seen to encourage the development and use of various semantics and syntactic forms though the specifics are not individually targeted (Paul, 2001).

(Hedge & Maul, 2006; Fey, Windsor & Warren, 1995; Paul, 2001)  

Evidence for Whole Language:

 As noted in Paul (2001) research conducted by McFadden and Van Kleeck (1995) found that the whole language technique was effective in improving the language (receptive and expressive) of children's narratives, however CD approaches were considered more effective in facilitating content and form in spoken and written language. It has therefore been suggested that this approach be utilised in collaboration with more directive approaches, for example, CD or hybrid techniques (Paul, 2001). Whole Language has also been found to be beneficial for children with delayed speech and language, or for those children from a language impoverished background (Paul, 2001). The details of whole language intervention for oral language were explained by Norris and Hoffman (1990). See General Evidence Table.

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DAILY ACTIVITIES

Literature-based scripts

Finger Play Routine, Songs, Rhymes

Procedure: The Clinician or significant adult encourages the child to participate in a song, rhyme or finger play routine which contains a target language structure/s. Examples may include singing ‘If Your Happy and You Know it' to target conjunction ‘and' or partaking in finger play routine such as ‘This Little Piggy' to teach past tense as listed in Paul (2001).

Joint Book Reading

Procedure:

1. The selected adult reads a selected book on multiple occasions with the child using salient prosodic cues to break the text into components and emphasise target syntactic patterns.
2. Following substantial exposure to the selected text, the adult provides pauses and utilises cloze prompts during reading to encourage the child to produce and complete the missing word or phrase.
3. The adult continues reading the book to allow the child to memorise the text while carefully segmenting the sentences to allow the child to analyse the language structures.
4. The adult presents pauses in places that require the child to progress from reciting small parts of the text to repeating the entire book off by heart.
5. The adult encourages the child to ‘read' the book to other peers and the adult (who can provide support as required).
6. The adult produces a new book with the child which targets the same language form/s to allow for the child to practice their newly acquired language skills in a different scenario/setting which may also be taken home.

Adapted from Paul, R. (2001). Language Disorders from Infancy through Adolescence: Assessment and intervention. 2 nd Ed. Missouri : Mosby.

Evidence for Joint book reading: Book reading and recitation of passages has been shown to be beneficial in encouraging practice and establishment of new language forms, providing an enjoyable supportive learning environment (Kirchner, 1991). Bellon-Harn, Hoffman, and Harn, (2004) conducted a study where, during story book reading, a number of strategies were employed (cloze procedures, cloze procedures with expansions, and contrast words) as an intervention for children with both language and phonological disorders. The results indicated that the combined use of the 3 procedures during the story book reading has the potential to be effective in increasing the level of semantic complexity of the child's utterances.

Auditory Bombardment

(specifically utilised in targeting receptive language)

Procedure:

•  The clinician uses an assisted listening device and places it on the child while they are engaging in a hand oriented play task (e.g. drawing, play doh)

•  The child listens to examples of the targeted linguistic form, which may assist in comprehension.

Auditory bombardment material may be based on a ‘syntax story' (as developed by Cleave and Fey, 1997) which focuses on a target form/s within a story context.

The following is an example of a mini syntax story targeting ‘are' (an example ‘Lets Go Shopping' modelled on an excerpt from “Dad's Bad Joke”, Cleave & Fey, 1997):

“Let's go shopping” said Mum. “Where are the shops?” asked Tam. “They are near your school, remember!” “ Are there lots of people at the shops?” asked Tam. “I know there are today because there are lots of sales on.” “Oh. What are we going to buy?” “mmm we need some groceries, I think. Are you going to come? asked Mum. “Ok, but only if I can sit in the front passenger seat of the car” “Sure, no problems” sighed Mum. “When are we going?” asked Tam. “Right now. Why are you asking so many questions today? Come on lets go” chuckled Mum.

Evidence for Auditory Bombardment : There is some evidence that auditory training devices might be useful in auditory bombardment activities for children with language needs (Paul, 2001). Cleave & Fey (1997) report increased levels of success with auditory bombardment facilitating grammar development in young children when using syntax stories, presenting the story a number of times with rereading incorporating cloze prompts (Cleave & Fey, 1997; Paul, 2001).

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Title :

HANEN PROGRAMS

Explanation:

The first Hanen Program was developed over 2 decades ago in Canada . The ‘Hanen Centre' is now the base of internationally accessed treatment programs for the management of children with language-delay. Hanen is an indirect, child to caregiver, naturalistic intervention. The Hanen program is based on the premise that children best learn language with their caregivers in naturally occurring interactions, and in communicating in these natural situations, they are more likely to be successful in generalising newly acquired language skills to other contexts (The Hanen Centre, 2002; Rossetti, 1996). Hanen is based on a holistic model that provides family-centred intervention . Efficacy research demonstrates that Hanen Programs may positively affect a child's developmental outcomes in numerous ways, not only impacting on parents' interactive behaviour and their child's language and communication skills (The Hanen Centre, 2002).

Population:

Hanen Programs are said to serve a range of target populations, such as children diagnosed with specific language impairment, cognitive delay and autism spectrum disorders. Different programs are more suitable to particular children. The programs are applicable for preschool children.

Procedure:

There are a number of Hanen Programs offered.

The original, "regular" Hanen Program is titled ‘It Takes Two to Talk – the Hanen Program for Parents' . This program is suitable for parents of children who are not yet communicating, communicating non-verbally, or are beginning to use single words and/or two and three word combinations. A Hanen Certified Speech Pathologist leads group sessions involving experiential learning through participative lectures, small group discussions and activities, and analysis of videotaped interactions (The Hanen Centre, 2002). In addition are individual consultation sessions with each parent, where parents are provided with video feedback.

The following are strategies that parents are taught during the program (cited from The Hanen Centre website):

• How to become more sensitive to their child's communication by observing, waiting and listening
• How to follow their child's lead and respond to their child in ways that promote interaction and communication and establish a foundation for early conversations
• How to create and take advantage of everyday opportunities to help their child communicate and use language
• How to use language with their child in ways that improve the child's ability to understand and express him or herself
• How to play with their child and use toys, books, music, and creative activities as opportunities to enhance communication.”

Target Word - The Hanen Program for Parents of Children Who Are Late Talkers

This Hanen Program has been developed for parents with children who have been formally identified as late talkers (adequate comprehension with minimal verbal expression).

Again, a Hanen Certified Speech Pathologist leads the program, facilitating parents' awareness of how to create language learning opportunities with their child during interactions and conversations. The most significant difference in this program is that parents are trained to use focused stimulation including following the child's lead, imitating, expanding, interpreting the child's communication, and making comments with their child (Weitzner- Lin, 2004). Parents are also taught to manipulate their own output so to facilitate their child's vocabulary growth (The Hanen Centre, 2002).

The program developed for children with Autism Spectrum Disorder is called More Than Words – The Hanen Program for Parents of Children with Autism Spectrum Disorder. The Learning Language and Loving It program is designed for preschool-educators, teachers and day care providers.

Time frame:

3 days of training are typically involved in order to lead a Hanen program.

The It Takes Two to Talk Program typically runs one evening per week over 11 weeks, and the Target Word Program runs over a 10 - to 12-week period where there are two weeks between sessions.  

Resources/Materials required:

A number of resources have been developed for Hanen Certified Speech Pathologists to administer Hanen programs. These include:

• Step-by-step, illustrated guidebooks
• Teaching tapes
• Additional optional resources

Training:

Speech Pathologists are required to undergo training to lead each of the Hanen Programs. Speech Pathologists are taught to lead Hanen Programs for groups of parents or childhood-educators in training workshops, which are held internationally. A schedule of workshops available in Australia can be found on the main website of the Hanen Centre.

Workshops offered by Hanen are as follows:

• Level One - Hanen Certification Workshop for Speech-Language Pathologists
• Level Two – Advanced Hanen Workshops for Hanen Certified Speech-Language Pathologists
• More Than Words Workshop
• Target Word Workshop
• Learning Language and Loving It Workshop

Summary of Level of Evidence:

A number of intervention studies have been conducted on children and their mothers who attended It Takes Two to Talk – The Hanen Program for Parents (Girolametto, 1988.; Tannock, Girolametto & Siegel, 1992.; Girolametto, Pearce and Weitzman, 1996). Evidence yielded from these studies support It Takes Two to Talk – The Hanen Program for Parents , as accelerating a child's level of language learning to a higher extent than what is expected from normal development. There were a number of children in the experimental group who finished the program with age-appropriate language skills. There was also significant evidence that the program was effective in comparison to no-treatment studies.

A study conducted by Baxendale and Hesketh (2002) aimed to compare the effectiveness of the Hanen Parent programme within a clinic-based, direct intervention. Two experimental groups were compared, one receiving intervention through the Hanen program, and one direct intervention within in the clinic. The study took other factors into account, such as parent outcomes and cost implications. Child outcome results appeared to indicate that children with low receptive scores improved more with Hanen therapy, whereas children with expressive language difficulties appeared to improve more quickly with direct intervention. Overall, children in both groups made progress, with the majority of child participants (71%) improving in language skills over 12 months, however there were no major group differences apparent (Baxendale and Hesketh, 2002).

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General Evidence Table:

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