LSHSS
Prologue
Forum on Morphosyntax Assessment
and Intervention for Children
Amanda J. Owen Van Hornea
Purpose: This forum consists of articles that address the
need for and approaches to assessment and treatment of
morphology and syntax in children. Drawing on papers
submitted by diverse laboratories working with multiple
populations, this forum includes several articles describing
different approaches to treatment, guidelines for goal
setting, and assessment methods. Populations described
include monolingual and bilingual children who speak
English, Dutch, and Spanish, who use oral language
G
rammatical difficulties impair the communication
abilities of individuals with language disorders,
influencing their ability to communicate clearly,
to participate fully in academic settings, and to engage in
civic discourse. Although grammatical difficulties are classi-
cally associated with developmental language disorder (DLD;
Bishop et al., 2016, 2017; Moyle et al., 2011; Rice et al.,
1998), grammatical deficits also affect the language of indi-
viduals with autism (Durrleman & Delage, 2016), hearing
impairment (Koehlinge et al., 2013), intellectual disability
(e.g., Finestack, 2018), and complex communication needs
that require augmentative and alternative communication
(AAC) methods (Binger & Light, 2008). Thus, this forum
covers topics that are of interest to nearly every speech-
language pathologist (SLP) working with individuals with
developmental disorders, regardless of the diagnostic cate-
gory of the children being served.
Why Target Grammatical Skills
Binger, Kent-Walsh, Harrington, and Hollerbach (2020)
motivate the need to assess and treat grammar at very early
stages. Typically developing children are credited with
a
University of Delaware, Newark
Correspondence to Amanda J. Owen Van Horne: ajovh@udel.edu
Editor-in-Chief: Holly L. Storkel
Received February 6, 2020
Revision received February 17, 2020
Accepted February 25, 2020
https://doi.org/10.1044/2020_LSHSS-20-00018
Publisher Note: This article is part of the Forum: Morphosyntax
Assessment and Intervention for Children.
Language, Speech, and Hearing Services in Schools • Vol. 51 • 179–183 • April 2020 • Copyright © 2020 American Speech-Language-Hearing Association
and/or augmentative and alternative communication to
communicate.
Conclusion: The current tools available to support
traditional grammar therapy are changing and increasing. An
emphasis on manualized treatments, treatments that include
drill and explicit instruction, and assessment and treatment
tools for a variety of populations across a wide age span are
included here. Further work is needed to fully develop these
promising tools and approaches for the most effective use.
access to grammar as soon as word combinations begin
(Braine & Bowerman, 1976), and young children are sen-
sitive to the language-specific properties that inform con-
cepts such as transitivity and agreement (Slobin & Bever,
1982). Delaying access to grammar can hinder overall lan-
guage development (Naigles, 1990). Grammatical concepts
do not just include verb markers and use of articles, but
also incorporate questions of word order, argument struc-
ture, and embedding (Barako Arndt & Schuele, 2013).
Binger et al. argue that even for very young children, chil-
dren with limited intelligibility, or children with small vo-
cabularies, the focus should be not just on semantics and
pragmatics, but rather on all areas of language. Use of
grammar “is not a lofty goal; rather, grammaticality is
essential for clear communication and is foundational to
attaining basic educational—and eventually employment—
skills and success” (p. 318). Supporting the transition from the
classically ambiguous phrase “Mommy sock” (Bowerman,
1973) to one of many more specific meanings—“Mommy
put on my sock,” “that’s Mommy’s sock,” or “Mommy,
where’s my sock?”—is a worthy clinical goal.
Curran (2020) further motivates the need to work on
grammar by making the academic language demands of
elementary school science concrete. The Next Generation
Science Standards Lead States (2013) emphasize things
like the ability to make claims, construct arguments, explain
findings, and generate evidence, which alters the way science
is taught. Curran coded language in a commonly used sci-
ence curriculum and found that that complex syntactic
frames comprised 17% to 29% of the sentences in student
Disclosure: The author has declared that no competing interests existed at the time
of publication.
179
print material and 31% to 37% of teacher statements in the
instructional scripts. In order to succeed in science learning,
children as young as first grade need to be able to compre-
hend a variety of complex syntax types presented both
orally and in writing.
Approaches to Grammar Treatment
Challenges in Treating Grammar
Using Traditional Approaches
Most of the published evidence for treatments for
grammar supports the use of implicit strategies, or strate-
gies that do not require the child to have awareness of the
treatment targets being taught. Recast therapy, in which
the adult restates the child utterances with a correction or
to highlight the target grammatical form (e.g., child: “Him
jumping”; adult: “He is jumping”), is child-centered and
embedded in naturalistic conversational discourse—two key
aspects of implicit approaches. Focused stimulation is a
slightly more clinician-directed approach in which the clini-
cian arranges the environment to deliberately elicit particu-
lar targets for recasting. A recent meta-analysis reviewed
key active ingredients and delivery contexts and found that
recasting, particularly when embedded in focused stimula-
tion type settings, is highly effective (Cleave et al., 2015).
Since this meta-analysis was published, variations have in-
cluded studying the identity of the provider (Fey et al., 1993),
dose rate (Plante et al., 2019), massed versus distributed
administration (Meyers-Denman & Plante, 2016), use of
auditory bombardment (Plante et al., 2018), stability and
variability of the recasts (Plante et al., 2014), likelihood
of generalization from targets (Leonard et al., 2004, 2006,
2008; Owen Van Horne et al., 2018), and evidence as to which
children are most likely to benefit (Hassink & Leonard, 2010;
Pawłowska et al., 2008), all studied in laboratory settings.
Thus, it seems that recast therapy has good evidence for ef-
ficacy but its effectiveness in natural settings is less clear.
Manualized Approaches
Bruinsma, Wijnen, and Gerrits (2020) provide a pre-
liminary evaluation of the effectiveness of Language in
Interaction Therapy (LIT), a manualized version of fo-
cused stimulation designed for Dutch-speaking SLPs in
the Netherlands as a means of supporting the transition
from lab to natural settings. This manualized program
provides guidance for selecting morphemes to target in
sequence and scripted interactions to support elicitation
of platform utterances and creation of felicitous, or ideal,
situations for recasting. Bruinsma et al. collected data from
five children before, during, and after the introduction of
LIT. The SLPs targeted grammar approximately 10 min
per week during business as usual, using primarily drill-based
activities. When LIT was introduced, the time spent on gram-
mar doubled to one 20-min session per week. The individual
participant graphs suggest that manualization and training did
improve the quality and intensity of grammatical intervention
180 Language, Speech, and Hearing Services in Schools • Vol. 51 • 179–183 • April 2020
to some extent but that the dose may have been too low for
meaningful change in most children. Further understanding
of the minimum dose for improvement is warranted.
Bedore, Peña, Fiestas, and Lugo-Neris (2020) demon-
strate early efficacy for a packaged curriculum, “Language
and Literacy Together,” a curricular supplement designed
to support children who speak both Spanish and English.
In contrast to LIT, Language and Literacy Together in-
corporates goals beyond grammar. The study used lab-based
interventionists and provided treatment at a very high dose
to children with DLD and with low-average language skills
and generally observed improvement in both groups of chil-
dren, though no true control group was included. Given the
extremely limited tools available for treating the oral lan-
guage skills of children who are dual language leaners, this
is promising preliminary evidence.
Explicit Instruction and
Clinician-Directed Approaches
Explicit approaches to grammar treatment are those
that communicate the grammatical target to the child and
may draw on teaching rules directly, incorporate visual
cues, or draw on metalinguistic knowledge. These explicit
approaches are being developed to improve effectiveness
and are often thought to align better with typical practice
than the more implicit approaches referenced previously.
Balthazar, Ebbels, and Zwitserlood (2020) join forces to
review and contrast three different techniques for making
language therapy more explicit and for focusing on complex
syntax. Complex Sentence Intervention, SHAPE CODING,
and MetaTaal all draw on metalinguistic skills and visual
supports to strengthen grammatical interventions, albeit
in somewhat different ways. The first third of the article
highlights the commonalities in principle and practice. Then,
each approach is reviewed to illustrate areas of contrast. This
focus on contrasts supports principled selection among
these related approaches to improving syntactic outcomes.
The tables that summarize the evidence for each approach
and samples of the intervention in practice are valuable
resources.
There has been a common misapprehension that meta-
linguistic approaches are only appropriate for older chil-
dren. Calder, Claessen, Ebbels, and Leitão (2020) use a
high-quality single case experimental design to extend work
focused on SHAPE CODING and cueing hierarchies to
young (5–6-year-old) children (Calder et al., 2018; Kulkarni
et al., 2014). Their findings were particularly interesting in
two respects: First, the treatment was highly effective for
expressive grammatical targets. That is, overwhelmingly,
children’s production improved for both trained and un-
trained verbs, suggesting good generalization, with strong
maintenance over time. Second, results for receptive gram-
mar were substantially more modest than those for expres-
sive grammar. This is interesting since one might generally
assume that improvements on expressive grammar would
be highly aligned with improvements receptively. Taken to-
gether with the evidence reviewed in Balthazar et al. (2020)
and other recent studies (Finestack, 2018; Finestack & Fey,
2009; Smith-Lock et al., 2015), the results suggest that a
variety of explicit methods are worthwhile from early ele-
mentary years onward.
The need for research to isolate the active ingredients
is well illustrated in the article by Eisenberg, Bredin-Oja,
and Crumrine (2020). The authors provide a detailed tuto-
rial that covers all aspects of the use of imitation during
treatment and call our attention to the many unstudied and
understudied aspects of therapy that exists. They highlight
questions like, “How is imitation different than modeling,
recasting, and elicited production?” “Is imitation most valu-
able when it includes only models before the attempt or also
feedback after the attempt?” “Is the timing of the prompt
relative to the child’s imitation attempt critical?” The article
concludes that imitation is generally an evidence-based
treatment approach; however, the nuances of how to maxi-
mize imitation as a treatment technique are not well stud-
ied. All attempts to provide treatment would be improved
by careful attention to how the critical elements are orga-
nized, as illustrated by this article.
Grammar Assessment for Goal Setting
and Progress Monitoring
Assessment of grammar is another area where fur-
ther work is required to make the practices that are most
useful widely accessible. Language samples, theoretically,
provide an ideal opportunity to assess a child: The context
is functional and authentic, they are repeatable, and multi-
ple pieces of information can be derived from the same as-
sessment. Nonetheless, language samples are not regularly
incorporated into either diagnostic clinical decision making
(Fulcher-Rood et al., 2018) or progress monitoring, with
time being the main reason given for disuse (Pavelko et al.,
2016). Pezold et al. (2020) provide a recent overview of
available computer tools, language sample contexts, and
the normative data available for a variety of age groups,
with the focus on the use of language samples for diagnos-
tic purposes. Finestack, Rohwer, Hilliard, and Abbeduto
(2020) add to this rich literature with a tutorial that sup-
ports the use of Computerized Language Analysis (CLAN)
for developing goals and engaging in progress monitoring.
CLAN is freely available and can automatically code lan-
guage samples for parts of speech. Nonetheless, the learning
curve for use is steep, and this tutorial provides precise
codes and clear guidelines for use. Furthermore, they draw
our attention to the assessment of grammar for children
who are older than the normative samples generally avail-
able and with diagnoses other than DLD, including useful
examples of how to set goals and monitor progress in youn-
ger and older children.
Binger et al. (2020) also highlight the role of language
samples in progress monitoring and goal setting, albeit
for individuals who primarily communicate via AAC.
They identify challenges to applying standard grammatical
analyses, such as how does one count words when some
Owen Van Horne: Prologue: Morphosyntax Assessment and Intervention
symbols intentionally serve as phrases, and propose crea-
tive solutions, such as a tiered set of analyses that first
account for number and variety of lexical items used.
This work provides a template for more work to be done
applying these methods, documenting that they effec-
tively capture change following intervention and develop
clear guidelines for when to move from one phase to the
next.
Castilla Earls, Auza, Pérez-Leroux, Fulcher-Rood,
and Barr (2020) highlight two additional areas that are
worthy of deeper attention in the area of grammar assess-
ment: the use of elicited production to assess children’s
language and the role that language profiles—not just the
language being assessed—play in the expected accuracy
levels. Their article reports on elicited production of gram-
matical forms from monolingual Spanish-speaking children
with and without DLD. The first table in Castilla Earls et al.
provides a comprehensive overview of the existing literature
as to how accuracy levels and the detection of group differ-
ences vary across spontaneous and elicited production con-
texts for monolingual and bilingual children. The study then
augments this rich literature review by reporting data from
elicited production results for six different classes of gram-
matical markers (verb morphology, articles, clinics, subjunc-
tive, adjectives, and plurals) from monolingual Spanish-
speaking children with and without DLD. The results of
this article suggest that we must cautiously approach the
generalization of data collected in bilingual contexts to
those collected in monolingual contexts.
Conclusion
This forum provides an illustration of why treatment
of grammar is important for basic communication (Binger
et al., 2020) and academic success (Curran, 2020) and yet
can also be challenging to implement given systemic con-
straints (Bruinsma et al., 2020). The bulk of the articles ad-
vance the evidence base with regard to the development and
adoption of manualized treatment approaches (Bedore et al.,
2020; Bruinsma et al., 2020) and the need to re-examine
assumptions in light of emerging evidence about the use
of explicit treatments that draw on visual supports or are
grounded in building metalinguistic awareness across a va-
riety of ages and populations (Balthazar et al., 2020; Calder
et al., 2020; Eisenberg et al., 2020). We are well served to
look to the literature developing out of the Netherlands for
ideas and inspiration for how to serve the U.S. population.
The extension of the work on assessment and treatment to
populations that are frequently overlooked is also clear.
Grammar therapy is important not only for monolingual
English-speaking children with DLD, but also for children
who use AAC (Binger et al., 2020), have a diagnosis of
fragile X or Down syndrome (Finestack et al., 2020), or
are Spanish speaking, whether bilingual (Bedore et al., 2020)
or monolingual (Castilla Earls et al., 2020). The need for
tools to support goal setting and progress monitoring in
grammar within multiple populations is clear. Similarly,
the need to develop and test effective interventions that
181
work within the constraints of our existing systems is also
highlighted. This is an important area in which much inno-
vation is currently being undertaken and is worthy of the
attention of both researchers and clinicians.
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