Clinical Focus
Two Approaches to the Facilitation of
Grammar in Children With Language
Impairments: Rationale and Description
Patricia L. Cleave
Dalhousie University, Halifax, Nova Scotia
Marc E. Fey
University of Kansas Medical Center, Kansas City
This article describes in detail the design
and rationale of two effective approaches for
the facilitation of grammar in children with
language impairments. One program was
clinician directed and the other was adminis-
tered by parents. The focused stimulation
techniques, cyclical goal attack strategy, and
F
ey and his colleagues (Fey, Cleave, Long, &
Hughes, 1993; Fey et al., 1994; Fey, Cleave, &
Long, 1997) have reported on the effects of two
intervention packages designed to foster grammatical
development in preschoolers with impaired language.
One program was administered by a speech-language
pathologist and the other by parents. In previous reports of
this intervention project, the approaches were outlined
briefly, as is typical in research papers. This paper
describes in detail the two approaches and their rationales.
Each component of these comprehensive grammar
facilitation approaches is described and exemplified. This
level of detail is necessary for clinicians interested in
replicating our approaches and in performing clinical
manipulations designed to match and improve the pro-
grams’ effectiveness.
Thirty-one children between the ages of 3;8 and 5;10 at
the outset of the investigation were involved in the
treatment efficacy study. Although they varied somewhat
in terms of their receptive language and phonological
skills, the primary area of difficulty for all the children was
expressive language, particularly morphosyntactic devel-
opment (see Fey et al., 1993, for a complete subject
description). Participation in either program for 4-1/2
months resulted in clinically significant effects on the
children’s grammatical development as measured by
Developmental Sentence Scoring (DSS; Lee, 1974) (Fey et
Ruth Watkins served as guest editor for this article.
22 American Journal
American of Speech-Language
Journal of Speech-Language Pathology •• Vol.
Pathology
specially designed stories employed in both
programs are outlined, as are the unique
features of each program. In addition, we
provide our clinical impressions and sugges-
tions for modifying the programs to increase
their effectiveness and efficiency.
al., 1993). An additional 4-1/2 months of treatment led to
additional gains, although, in general, improvements were
not as great in this second phase as they were in the first
(Fey et al., 1997). Gains in each phase were most consis-
tent for those children who received the clinician-directed
intervention. This consistency did not come without cost,
however. Over two intervention phases (a total treatment
plus evaluation time of approximately 10 months), the
clinician program required approximately 3.5 times more
clinician time than did the parent program.
Phonological development, which was not directly
targeted, was not affected by either intervention approach.
Small improvements noted in the speech of children who
received immediate treatment were no greater than the
gains made by children who got intervention only after a
4-1/2 month waiting period (Fey et al., 1994).
The two language intervention programs were based on
identical principles, but because they involved different
intervention agents, they also differed in many important
respects. The common features of the two programs are
discussed first, and then the unique aspects of the clinician-
directed and parent-directed programs are described. Finally,
we include some of our clinical impressions and sugges-
tions for modifications and extensions of the programs.
Common Features of the Two Programs
The clinician-directed and parent-directed programs
shared many features. These included the method for
Vol. 66 •• 1058-0360/97/0601-0022
No. 1 February 1997
© American Speech-Language-Hearing Association
setting goals, the goal attack strategy adopted, and the use
of focused stimulation procedures.
Goal Setting Method
When developing a language intervention plan, it is
possible to set a number of goals representing various
levels of specificity (Fey, 1986; Fey & Cleave, 1990).
Basic goals, which are the most general goal statements of
an intervention plan, are based on a child’s social-
interactional skills. They identify those areas of weakness
that present the greatest obstacles to the child’s social-
communicative success and focus the intervention
program on those areas. Based on interactions with adults,
all the children in our programs were judged to be
normally responsive and able to play an assertive role in
conversation. Thus, they were judged to be active conver-
sationalists (Fey, 1986). Because all of the children had
impairments in expressive grammar as their main diffi-
culty, one set of basic goals was selected. The basic
intervention goals were:
1. to increase the frequency and consistency of the child’s
use of grammatical forms and operations that typically
are used infrequently and inconsistently;
2. to foster the child’s acquisition of new content-form
interactions to perform available conversational acts; and
3. to set the child’s existing language-learning mecha-
nisms in motion to promote the acquisition of general
linguistic principles, and to foster broad, systemic
changes in the child’s grammar.
The first goal stemmed from the fact that all the
children had as part of their language system some
grammatical structures that were used inconsistently or in a
limited number of contexts. For example, the copula (e.g.,
John is sad; the girls are angry) may have been present in
some statements and omitted altogether in questions. For
these structures, treatment focused on encouraging the
child to use the language forms consistently in all obliga-
tory contexts.
The second basic goal focused on the acquisition of
language structures that the child never used even though
their use was required to correctly convey meanings the
child was expressing. For example, the child may have
talked about past events and occasionally used irregular
past tense forms but never used the regular past tense
marker.
The third goal was somewhat different from the other
two in that it did not focus on the development of specific
language structures. Rather, it represented a more general
goal of intervention to have broad, system-wide effects on
the children’s language. Both intervention programs sought
to encourage the children to observe grammatical forms
and operations, seek the boundaries for their use, and
recognize that their use under certain conditions is obliga-
tory. Stated differently, this basic goal reflects our interest
in stimulating children’s existing language-learning
processes so that the children can learn language outside of
the clinical setting more efficiently.
To attempt to achieve these basic intervention goals,
individualized intermediate and specific goals were chosen
for each child. Goals were selected based on a language
sample collected while the child was interacting with a
parent or other primary caregiver. For an existing structure
to be considered as a direct target for treatment (i.e., a
specific goal), it had to have been omitted in more than
half of the contexts in which it was judged to be obligatory
or rarely or never used in contexts in which it could have
been used to positive effect. For a new structure to be
considered, the child minimally had to provide evidence of
a cognitive/semantic readiness and a communicative need
for the structure. This typically came in the form of
sentences in which a required form was consistently
omitted or in failure to use developmentally appropriate
forms judged to be important for communicative success,
such as phrasal and clausal postmodifiers (e.g., the dog in
the window; the dog that barks).
The list of potential specific goals generated in this
manner was always much too large to allow for direct
focus on each. Therefore, the list had to be trimmed in
some meaningful way. One way in which the list of
potential targets was shortened was by selecting intermedi-
ate goals. Intermediate goals reflected general areas of
weakness in which several potential specific goals played a
subordinate role. For example, common intermediate
objectives included auxiliary verbs, nominative case
pronouns (e.g., he, she) and sentence coordination (e.g.,
and, but, or) and/or subordination (e.g., John hit the ball
before he ran). Each of these categories or operations
involves numerous specific forms. For example, auxiliaries
included modals (e.g., can, should), forms of do and have
(e.g., Did you eat? Have you finished?), and all of the
manifestations of be (e.g., is, are). The identification of
intermediate goals reflects the fact that language is a
system that comprises related structures. It was our
intention to devise intervention plans that would lead the
children to an awareness of broad linguistic categories and
principles.
Our approach to goal selection was based on the
assumption that by presenting related specific goals in
ways that demonstrate their similar grammatical properties
as well as their different meanings, the child might
recognize the broader category. If such insights can be
triggered through intervention, the child may be in a better
position to attend to and learn the other members of the
category. Therefore, by working on a few targets, it may be
possible to facilitate the acquisition of related forms with
little or no further treatment. Although this rationale is not
common in language intervention, it has a well-known
parallel in phonological intervention. There, the intermedi-
ate goals are phonological processes or rules (e.g., stopping
or final consonant deletion) and the specific goals are the
specific speech sounds targeted, which are selected from
the larger set of sounds affected by the target process or
rule (Hodson & Paden, 1991; Tyler & Sandoval, 1994;
Tyler & Watterson, 1991).
Following the identification of the intermediate goals,
the target set of specific goals was chosen. Because of our
clinical hypotheses cited above and our need to standardize
Cleave • Fey 23
our procedures across children, four specific goals were
targeted for each child. In all of our cases, two or more of
the specific goals exemplified the more general grammati-
cal principle, category, or operation designated by the
intermediate goal. For example, when auxiliary usage was
an intermediate goal, at least two auxiliary forms (e.g., is
and will or is and are) were chosen as specific goals. If
phrasal postmodification was targeted, prepositional
phrases headed by in and under might have been selected
(e.g., the juice in the pitcher, the doll under the bed).
To summarize the goal selection procedure for our
programs, the basic goals were the same for all the
children, because they all demonstrated primary difficulty
with expressive grammatical skills. For each child,
individualized intermediate goals were selected to target
areas of general weakness. Finally, four specific grammati-
cal structures that exemplified the broader intermediate
level categories and principles were identified as interven-
tion goals.
Cyclical Goal Attack Strategy
To deal with the four specific intervention goals
concurrently, we used a cyclical goal attack strategy in
both programs. To our knowledge, reports of this goal
attack strategy have involved phonological intervention
exclusively (Hodson & Paden, 1991; Tyler, Edwards, &
Saxman, 1987; Tyler & Sandoval, 1994), although the
potential for this strategy in other forms of intervention has
been noted by Fey (1986, 1988). Under this approach, one
goal is worked on for a specified period of time, for
example, 1 or 2 weeks. Then, regardless of whether any
progress is demonstrated, the second goal is targeted in the
second period. Goal 3 is the focus of the third period, goal
4 the fourth, and so on, until all goals have been targeted.
After completion of the first cycle, a second cycle is begun
with goal 1. When a goal is attained, it is dropped or
combined with an existing target and a new goal may be
added to the cycle.
There were three rationales for the choice of a cyclical
goal attack strategy. First, this strategy is based on the
assumption that progress on any language goal will be
gradual (Hodson & Paden, 1991). Children can be taught
to produce a new form in a relatively short period of time.
However, the net result of such teaching frequently is not
the language rule the clinician intended to teach (Connell,
1987; Fey, 1988; Johnston, 1988; Leonard, 1981). Second,
the cyclical goal attack strategy allows the child to be
actively engaged in learning more than one target at a time.
Not only is this how normal language acquisition occurs, it
is also critical for the assumptions underlying the choice of
intermediate goals. It seems more likely that a child will
note the grammatical similarities and the semantic differ-
ences between two related specific goals if they are
targeted together or in close temporal proximity rather than
working on one goal to mastery before focusing on the
related goal. The third rationale is that the cyclical goal
attack strategy allows the clinician to present fairly
concentrated “doses” of the target during the period when
it is the focus. The fact that only one goal is focused on at a
24 American Journal of Speech-Language Pathology • Vol. 6 • No. 1
time also has some practical advantages. During group
sessions, the clinician never has to target more than one
goal per child in any one session. It also may be easier for
parents learning new techniques to focus on one goal at a
time rather than learning to employ the appropriate
procedures for several different goals.
In our programs, the cycles were 4 weeks long with
each goal being targeted for one week. Again, the 4-week
cycle was selected to standardize the procedures across
subjects rather than from any belief on our part that it was
ideal. In some cases, more or less time on each specific
goal may be optimal. During week 1 of a cycle, goal 1 was
targeted and then, regardless of whether any progress was
demonstrated, the second goal was focused on during
week 2. Goals 3 and 4 followed in weeks 3 and 4, respec-
tively. During week 5, a new cycle was begun with goal 1
as the target. After a cycle, related goals were sometimes
combined. For example, if a child had the auxiliaries is
and will as two separate goals, after one or two cycles, we
combined the two auxiliaries into one goal and targeted
them together during the same week. When there was
evidence of productive spontaneous use of a target by the
child, it was dropped as a goal or combined with other
specific targets directed at the same intermediate goal. In
order to maintain four active specific goals, we added a
new goal whenever a space was left open.
Focused Stimulation Procedures
Focused stimulation, as described by Fey (1986), was
the basic approach used in both the clinician-directed and
parent-directed treatment programs. With focused stimula-
tion, the interventionist provides a high density of a target
language form or operation in a variety of semantically and
pragmatically appropriate contexts (Fey, 1986; Johnston,
1985). The child is not required to respond at any point in
time. However, efforts are made to arrange the linguistic
and nonlinguistic contexts to encourage the child to
attempt the target form.
A number of procedures can be used in a focused
stimulation approach. The parents in the parent treatment
program were trained to apply the same procedures that were
employed by the clinician in the clinician treatment program.
In both programs, natural conversation between the child and
the intervention agent was the context for intervention. Care
was taken to ensure that the various procedures were used in
pragmatically appropriate contexts. In addition, target
structures were contrasted with related structures to highlight
the semantic and syntactic features of the target. For ex-
ample, when targeting nominative case pronouns, accusative
case forms would be modeled in close proximity (e.g., Give it
to him. He needs it). The goal of intervention was for the
children to learn the underlying language rule(s) that govern
the use of their target structures, rather than isolated language
behaviors. To achieve this, it was necessary to demonstrate
the critical circumstances under which a target form is and is
not used (Connell, 1982; 1987). By presenting both target
and contrasting forms together, these circumstances were
highlighted, thus (potentially) simplifying the rule induction
for the child.
February 1997
 Modeling the Targets. There were many ways in which
the correct use of a target was demonstrated to the child.
Simple modeling involved the use of a target by the adult
that was not contingent on a child’s attempt at the target. It
was used to demonstrate the range of appropriate uses of
target structures. The linguistic context was manipulated so
that the target was modeled in contexts in which it might
be most readily perceived and analyzed, for example,
sentence initial position or elliptical contexts. The follow-
ing exchange demonstrates modeling of the target will
while mixing up some juice.
Child: We need water.
Adult: Will you get some?
Child: Yeah.
Adult: You will?
Good. Then I will get the glasses.
When the child attempted the target, there were three
different types of sentence recasts (Nelson, 1989) used by
the clinician and parents to respond. The simplest recasts
were simple expansions in which errors in the child’s
utterance were corrected. The following is an example.
Child: Him too big.
Adult: Yeah, he is too big.
A second type of recast kept the child’s utterance
largely intact but changed the basic modality of the
utterance. For example, the child’s use of a declarative
sentence could be changed into a yes/no question. This
resulted in the auxiliary form being placed in the sentence
initial position, which may be more salient than a sentence
internal position. Also, an affirmative statement could be
recast as a negative. For example, the child’s utterance
“This too hard” could be recast as a question (e.g., Is it too
hard?) or as a negative (e.g., It isn’t too hard) while adding
missing grammatical markers, if needed. Recasts of this
type can be very informative because they demonstrate the
variety of ways in which a structure, such as the copula or
auxiliary, can be used (e.g., to affirm, request, correct)
(Nelson, 1989; Watkins & Pemberton, 1987).
Buildups and breakdowns were the third type of recast.
A buildup involves taking one or more child utterances or
phrases and building it up to a single, complete sentence.
Buildups demonstrate a way of using a given structure in a
more complex utterance. The following exchanges
demonstrate buildups.
Child: I drawed a picture. It pretty.
Adult: Yeah, you drew a pretty picture.
Child: me get another cookie. me hungry.
Adult: Oh, you’re gonna get another cookie because
you’re hungry.
These exchanges often result in sentences that differ
from the child’s utterance in more than one structure.
When more than a single element in the child’s sentence
undergoes change, the recast is viewed as complex as
compared to a simple recast when only a single aspect of
the child’s sentence is modified (Nelson, 1989; Nelson,
Welsh, Camarata, Butkovsky, & Camarata, 1995).
A breakdown involves breaking the child’s utterance
into its individual constituents. In the following inter-
change, the adult produces breakdowns of the child’s
utterance and then builds up her own elliptical utterances.
Note that the adult is also expanding the child’s utterances
by adding missing grammatical markers. By breaking the
child’s utterance into its constituent phrases, the grammati-
cal markers within the phrases can be placed into contexts
that are potentially more salient and informative, thus
increasing the chance that the child will incorporate them
into the language system.
Child: I need book, not boot.
Adult: Oh, the book.
Not the boot.
OK, I’ll get the book.
Child: No, I get it.
Adult: No, I will.
I will get it.
Eliciting Attempts at the Targets. The linguistic and
nonlinguistic environments were manipulated in ways that
increased the likelihood that the child would attempt the
target form. This gave the clinician opportunities to operate
on the child’s own sentences even when the child’s
productions contained errors in the use of target forms.
False assertions were used to encourage the child to
produce sentences that required use of the target. These
were carefully planned so that the child’s correction of the
adult obligated the use of the target structure. In the
example below, the child’s language goal is the use of
can’t and the child and adult are putting a puzzle together.
Adult: That can go there (knowing that the piece does
not fit).
Child: No it not.
Adult: Yes, it can.
Child: No.
Adult: Yeah, you’re right. That piece can’t go there.
Feigned misunderstandings in which the adult intention-
ally misinterprets an utterance by the child also were used.
As with false assertions, care was taken so that the child’s
correction of the adult would require the target form. In the
following example, the target is I.
Child: Me want it.
Adult: (pointing to another boy in the group) He wants
it?
Child: No, me want it.
Adult: No, I do (pointing to herself).
Thus, even when the child failed to use the target form,
the adult recast the child’s sentence to provide a salient
model of the structure in context.
Forced-choice questions (Crystal, Fletcher, & Garman,
1976) that provided a model of the correct use of the target
were also employed. Again, these prompts were designed
so that the child’s response required the targeted structure.
For example, if the use of articles was the goal, an appro-
priate forced-choice question would be, “Do you want an
apple or an orange?” These may be especially effective
when they are responses to child utterances in which the
clinician feigns confusion, as in the following example.
Cleave • Fey 25
 Child: I get it.
Adult: You already got it or you will get it now?
Other contingent queries, especially requests for
elaboration, were used to encourage the child to code
linguistically omitted semantic information. This technique
is particularly useful for language goals that involve
sentence coordination or subordination. By carefully
employing this technique, the clinician often can get the
child to create a compound or complex sentence using a
vertical structure (Fey, 1986; Schwartz, Chapman, Terrell,
Prelock, & Rowan, 1985). This is demonstrated in the next
example in which a child is showing the clinician a favorite
book.
Child: I like that.
Adult: Why do you like swimming?
Child: Cool me off.
Adult: Oh, you like swimming because the water cools
you off.
An important part of this procedure is the building up of
the child’s original utterance by the adult using the
additional information supplied by the child in response to
the adult’s query. So, this technique is like a buildup in
which the adult first queries to get the child to produce
additional material, then recasts both child utterances into a
single, more complex form.
The nonlinguistic environment also was manipulated to
increase the likelihood that the child would attempt the
target form or structure (Constable, 1983; Fey, 1986;
Lucas, 1980). Routine events were violated by omitting a
step or performing it incorrectly. For example, when
mixing up juice, the water would be forgotten, prompting
the child to ask for it. This might set up an exchange like
the following:
Child: Us need water.
Adult: We do.
We do need some water.
Withholding objects and turns also served to encourage
the child to make a statement or request. For example,
skipping a child’s turn may elicit the response It my turn.
Then, the clinician could respond Oh, it is your turn or Is it
your turn? Similarly, by “forgetting” the glue during an art
activity, the children were encouraged to ask for it. Hiding
objects was another technique used to elicit and provide
models for questions by setting up a guessing game (e.g.,
Where are the cups? Are they in the drawer?).
Finally, violation of object function was used. An
example of this strategy is for the adult to try to stir the
juice with a spoon that is obviously too small. This
procedure often results in sentences that require a negative
form (e.g., That won’t work. Don’t use that spoon.)
Both the linguistic and nonlinguistic manipulations
were designed to encourage the children to use sentences
that required the target structure. Obviously, the children
frequently made errors in their attempts. This then set the
stage for the adult to respond using one of the types of
recasts. Because the various procedures were useful for
different things and because the overuse of some of these
26 American Journal of Speech-Language Pathology • Vol. 6 • No. 1
procedures can stop conversation rather than facilitate it,
all the procedures were used in a coordinated fashion rather
than relying on one or two.
Use of “Syntax Stories.” The focused stimulation
techniques outlined above also were used to create stories
that were used in both programs. These stories were
written with a focus on a particular grammatical goal, and
they were designed to make liberal use of the same focused
stimulation procedures described earlier in the narrative
context. The stories were developed and stored using a
word processor so that the same stories could be used with
different children. The search and replace function of the
computer software made it simple to customize the same
story for several children by substituting the names of the
new child and that child’s friends and family for the names
already existing in the story. Each week, the parents were
given a story that highlighted their child’s goal. Although
these stories might have been used in many different ways,
the parents were asked only to read their story to their child
once a day.
An example of a story is contained in the Appendix.
Examples of the focused stimulation procedures are
labelled in the Appendix, although these labels were not
present on samples given to the children and their parents.
The Clinician Program
Although the two intervention programs shared many
features, there were some significant differences between
the two approaches. In this section, the unique aspects of
the clinician program are described. The children involved
in the clinician program were seen three times a week,
once in an individual session and twice in a small group
involving four to six children. All sessions lasted for one
hour. In the individual session, the child’s goal for the
week was introduced. This goal then served as the focus
for the child during the two group sessions of the same
week.
Individual Sessions
In the individual session, focused stimulation was the
main treatment approach, but a structured, imitation
protocol was used at the beginning of each session. A brief
story was acted out with the child imitating the clinician’s
sentences. These stories were neither as carefully planned
nor as creative as the stories described in the last section
and exemplified in the Appendix. They were created by the
clinician using props that had been selected for their ability
to stimulate many sentences containing target forms and
operations. They differed from traditional imitation stimuli,
such as sets of unrelated pictures, however, in that the
same characters were involved in related events throughout
the imitation exercise. In this way, even though they lacked
many properties of good children’s stories, the imitation
stories exemplified and required imitation of the targets in
a bona fide text (e.g., going shopping, preparing for a
party).
Each imitation story involved imitation of the target
form and a contrast form. The contrast target was chosen
February 1997
such that it highlighted the structural and semantic proper-
ties of the target. For instance, if the target was the
auxiliary will, possible contrast targets were the auxiliary
can or is or the regular past tense marker -ed.
The protocol began with 10 rote imitations of the target
form (e.g., the nominative case pronouns he and she) using
no props. Then the clinician began to act out the story’s
events using the props, requiring the child to imitate 10
productions of the contrast target (e.g., accusative case
pronouns him and her) and then 10 imitations of the target.
Finally, there were 10 imitations of the target alternated
with 10 imitations of the contrast target (e.g., Now, he
needs the sponge. Give it to him).
The imitation protocol took approximately 10 minutes
at the beginning of the individual session. We did not
assume that the imitative procedures would teach the child
a new form. Rather, this exercise was included as a way to
focus the child’s attention on the week’s target and how its
use differed from a related form. We hypothesized that
contrasting the target with another form would stimulate
and focus the child’s hypothesis-testing mechanism so that
greater benefit could be derived from the more naturalistic
models of the target presented in the rest of the treatment
sessions and from exposure to the target outside the clinic
(Connell, 1982, 1986, 1987).
Following the imitation protocol, the child and clinician
played briefly with the story props if the child had shown
an interest in them. Then the clinician read the child’s new
story for the week. This story was sent home for the
parents to read daily for that week. The remainder of the
session was spent in play using whatever materials were
required for the activity and employing focused stimulation
procedures. Play with Play-Doh, a doctor kit, and an
airport are examples of the type of activity that took place
in treatment. The individual session ended with 10 imita-
tions of sentences containing the target using no props.
Group Sessions
The group sessions were structured into three sections.
For 20 to 40 minutes, the children participated coopera-
tively in a group activity such as baking muffins, popping
popcorn, carving a pumpkin, making Play-Doh, and
making crafts such as masks. A snack time lasted for 15 to
20 minutes. The children learned roles of passing out
napkins, juice, and snacks and talked as they ate their
snack. Finally, if time permitted, a free play period took
place. The children played with their choice of toys such
as blocks, dress-up clothes, houses, and cars. During this
time, the clinician spent a few minutes with each child or
each naturally formed small group of children. Through-
out the session, the clinician used focused stimulation
procedures to highlight the particular week’s goal for each
child.
The number of models of each target provided in the
individual and group sessions varied greatly, depending
primarily on the target form itself. For example, opportuni-
ties for presenting relative clauses were considerably more
difficult to generate than were opportunities for the past
tense -ed or the copula is. The number of models directed
towards a particular child ranged from 25 to 100 in the
group sessions.
By having both individual and group sessions, the
clinician program had the advantages of each. During the
individual sessions, the clinician could focus specifically
on the child’s target and, therefore, provide a higher
density of the target structure than in the group sessions. In
the group sessions, the children were exposed to the goals
of the other children. The children also served as models
for each other. The children did not have difficulties with
exactly the same language structures, although consider-
able overlap was common. Therefore, within the group,
there was often a child who had mastered a particular
structure. By setting up the situation, the clinician could
encourage that child to use another child’s target appropri-
ately as a model for the second child. The group also
provided an opportunity to encourage peer interaction.
The Parent Program
The parent program included both group sessions,
which involved five or six sets of the parents, and indi-
vidual sessions, which involved the parents and their child.
For the children who lived with both parents, both parents
were encouraged to be involved whenever possible. In our
program, both parents participated in approximately one-
third of the cases.
Group Sessions
The parents were taught to use the same focused
stimulation procedures that the clinician employed in the
clinic-based program. For the first 12 weeks of the pro-
gram, the parents met as a group with the clinician weekly
for 2 hours without their children. It was during these
sessions that the focused stimulation techniques were
taught. Handouts that defined the techniques and contained
examples of each were given to the parents. The group
reviewed videotapes of the procedures being applied. For
the first few weeks, these were tapes of the clinician using
the techniques, but in later weeks, videotapes of the parents
themselves were used. Role plays were used to allow the
parents to practice and receive corrective feedback. In
addition, written transcripts emphasizing the new tech-
niques were studied, analyzed, and discussed.
Because the parents were only gradually adding
procedures to their repertoire, goals were not cycled during
the first 4 weeks. Goal 1 remained the target so that the
parents did not have to adjust to a new goal each week.
Weekly cycling of goals began in week 5. See Table 1 for
the topics and goal schedule for each week.
As noted earlier, we asked the parents in both programs
to read specially constructed stories to their children. In the
parent program, stories were also used in teaching the
parents the focused stimulation techniques. At the first
session, the parents were given three stories and asked to
study the characteristics of each for a discussion at the next
meeting. One of the stories was written along the guide-
lines of the stories used in the intervention program (see
Appendix). This meant that it told an interesting story and
Cleave • Fey 27
TABLE 1. Weekly parent group sessions.
Specific
Week Topic
1 Introduction to parent programming and
focused stimulation—principles and rationale.
2 Demonstrating use of the target using
focused modeling and contrast forms
Story for goal 1 is provided
3 Responding using recasts
Story for goal 1 is provided
4 Responding using recasts
Story for goal 1 is provided
5 Constructing a story using focused stimulation
techniques
Story for goal 2 is provided
6 Eliciting the target using questions—closed-
ended versus open-ended
Parents bring a story they wrote focusing on
goal 4. Story for goal 3 is provided
7 Eliciting the target using forced choice and
contingent questions
Parents bring a story they wrote focusing on
goal 1. An edited version of their goal 4 story
is returned to be used as the week’s story
8 Eliciting the target using false assertions and
feigned misunderstandings and by manipulating
nonverbal environment
Parents bring a story they wrote focusing on
goal 2. An edited version of their goal 1 story
is returned to be used as the week’s story
9 Integrating techniques and incorporating them
into daily activities
Parents bring a story they wrote focusing on
goal 3. An edited version of their goal 2 story
is returned to be used as the week’s story
10 Integrating techniques and incorporating them
into daily activities
An edited version of the parent’s goal 3 story
is returned to be used as the week’s story
11 Integrating techniques and incorporating them
into daily activities
Weekly story is provided by the clinician for the
rest of the program
12 Integrating techniques and incorporating them
into daily activities
was written so that a particular language structure was
frequently modeled and contrasted with other language
forms (i.e., it was constructed using focused stimulation
procedures). A second story also had an interesting story
line but did not contain a language focus. The third story
had an obvious language focus, but there was really no
coherent story involved. The parents’ impressions of the
stories were used in the second session to begin a discus-
sion of focused stimulation. In the fifth session, after
modeling and various forms of recasts had been covered,
28 American Journal of Speech-Language Pathology • Vol. 6 • No. 1
the parents constructed a story similar to those they had
been reading to their children. The use of the procedures to
highlight the target was stressed. For the next 4 weeks, the
Goal parents constructed the stories that they read to their
children. To ensure that the parents’ stories provided
sufficient models, they were edited by the clinician before
being used as the child’s weekly story. Writing these
1 stories for 4 weeks gave the parents practice in using the
techniques with their child’s particular goals under
conditions that did not require split-second decisions about
1 how to respond. It also required the parents to identify
situations in which the language target could be used
frequently. After the parents had been writing stories for 4
1
weeks, we provided stories from our own collection for the
rest of the program.
2 After the completion of the 12 weekly sessions, the
parents continued to meet on a monthly basis. During these
sessions, the procedures were reviewed to increase the
3 probability that the parents would continue to use all the
procedures. Weekly stories for the next month were
provided. These meetings were also important for the
support they provided to the parents, both from the
4
clinician and the other parents. In these monthly meetings
where there was less of a focus on learning procedures,
other issues, such as difficulties at school, discipline, and
concerns about the future, were frequently brought up by
the parents and discussed by the group.
1 Throughout the program, the parents were seen indi-
vidually with their child on a monthly basis. For the first 3
months, these visits took place in the children’s homes. For
the remainder of the program, the visits were held in the
clinic. These appointments had many purposes. The
parents were videotaped using the focused stimulation
2 procedures while interacting with their child. The tapes
were then reviewed so that the parents were able to
evaluate their own performance. This also gave the
clinician an opportunity to provide feedback in a situation
that was less threatening than the group meetings. These
3 videotapes were used in the group meetings. By thoroughly
reviewing the tape with the parents before showing it to the
group, any anxiety that the parents may have felt appeared
to be lessened. In addition to videotaping the parent and
4 child, the clinician demonstrated the techniques for the
parents when necessary and dealt with any problems or
concerns that arose. The individual appointments also
provided an opportunity to monitor the children’s progress
1 so that goals could be modified when appropriate.
Clinical Impressions and Suggestions for
Modifications
The intervention programs were conducted as part of a
research project involving group comparisons. As such, we
made a number of decisions to meet research requirements
and to standardize procedures across children. In clinical
application of the programs, some modifications should be
made to meet individual children’s needs. In addition,
although objective data were not always collected, we can
make a number of observations and suggestions for
modification or extension of the programs.
February 1997
 One such modification would be to combine the treatment
packages and thus involve the parents in a parent program
while simultaneously providing clinic-based services (see
Fey et al., 1997). In order to examine the effects of each of
the programs individually, the parents in the clinician-
directed program were not taught the focused stimulation
techniques. However, they were aware of their children’s
specific goals and most observed both the individual and
group treatment sessions. For a few parents, these unguided
observations were enough for them to learn the techniques
and apply them, at least in the parent-child tapings done
during the assessment periods. In general, however, it ap-
peared that learning to use focused stimulation techniques,
such as sentence recasts, required formal instruction as was
offered in the parent program (Fey et al., 1997).
As part of the experimental control, the children were
randomly assigned to the clinician-directed or parent-
directed programs. In a clinical situation, how services are
delivered should be determined based on an individual
family’s needs, with the parents as active participants in
the decision-making. Both child and parent factors should
be considered in making the decision. Furthermore, in
cases where a formal parent program is not appropriate, it
would be possible to teach parents the focused stimulation
techniques individually, ideally in conjunction with their
child’s intervention sessions. In this situation, the parents
would not benefit from the support offered by a parent
group, but the children would have the benefit of more
frequent models of their targets in non-intervention
contexts, provided by individuals to whom they were
highly emotionally attached.
Another decision we made for experimental reasons was
to continue the programs unmodified for a second 5-month
phase of treatment following the first 5-month period.
Based on what we know now, some modifications would
have been appropriate and desirable for a number of the
children. For example, for children with significant
phonological problems, improved intelligibility should
have been adopted as a basic goal and appropriate interme-
diate and specific goals should have been selected to
facilitate greater intelligibility (Fey et al., 1994). Our
experimental regimen also required us to maintain four
specific goals throughout the study. Clearly, some children
(and parents) would have functioned better with more
goals and others would have benefitted from having fewer
than four specific goals at a time.
A final example of modifications that could and probably
should be made in clinical implementations involves the
syntax stories created for our studies. These stories were used
without pictures or other props to model intervention targets
in a narrative context. In addition, parents were required
merely to read the stories to their children. The same stories
could be used in many other ways to provide greater focus on
preliteracy skills as well as grammatical targets. For example,
after reading the stories, parents could have the children
illustrate the stories, using their own drawings. With greater
familiarity of the story’s content, a child could tell the story
in a picture-by-picture fashion or even retell the stories,
giving the parents more opportunities to use focused stimula-
tion procedures.
In conducting the programs, we made a number of
clinical observations that may be important in planning
similar programs in the future. Goals that targeted later
developing, less frequent forms, such as relative clauses or
embedded clauses headed by that, were more difficult,
particularly for the parents in the parent-directed program.
This difficulty was due, in part, to the relative infrequency
of such forms, especially in conversations. In addition,
appropriate contexts for later-developing structures often
were difficult for the parents to identify because the forms
used serve multiple functions. For example, that can be
used as a relative pronoun (e.g., I want the dog that
barked) or as a much more common demonstrative
pronoun (e.g., I want that) or determiner (e.g., I want that
dog). If such targets are addressed in parent programs such
as ours, additional parent training or alternative interven-
tion contexts, such as a greater reliance on stories and other
non-narrative textual forms, seems necessary.
The developing complexity of the children’s sentences
had another negative impact on parental performance. In our
study, only parents in the parent program used sentence
recasts frequently in their final spontaneous language sample
with their child (i.e., greater than 38 recasts in a 30-minute
sample) (Fey et al., 1997). All of the parents in the parent
program whose children had DSSs of 5.0 or below (i.e.,
characteristic of many children 2-1/2 to 3-1/2 years old) were
in the group of frequent recasters. In contrast, some parents in
the parent program whose children had higher DSSs used no
more recasts than the parents of children who received no
parent training (i.e., less than 20 recasts in a 30-minute
sample). Clearly, additional instruction and practice is
necessary to keep parents focused on using their facilitative
techniques even when their children are producing lengthy
and simple, but well-formed, sentences.
For all goals, the parents found it easier to model and
recast target forms than to elicit them. Based on their
reports and our observations, arranging verbal and nonver-
bal contexts in ways that made target forms necessary was
particularly difficult for many parents. One way to improve
this situation would be to rely more on commercially
available children’s literature. Parents could be instructed
in the use of focused stimulation techniques as they shared
storybooks with their children. This type of activity would
ensure opportunities for the use of intervention procedures,
especially for forms that are infrequent in conversation
(Whitehurst et al., 1988; Scott, 1995). As noted above, this
also might have a positive impact on children’s early
literacy development (Fey, Catts, & Larrivee, 1995).
In both programs, we used the syntax stories to highlight a
child’s specific target forms. One of the activities we used to
teach the parents the intervention techniques was to have
them write stories for their children for 4 weeks. A number of
parents reported that writing the stories for the first 4 weeks
was difficult but valuable in helping them learn to apply
focused stimulation techniques. Obviously, this activity
would not be appropriate for some parents. Still, this
procedure might assist parents in better understanding their
children’s intervention programs and might also help them to
learn and apply the intervention procedures more reliably in
both conversational and narrative contexts.
Cleave • Fey 29
 The focus of the research project and the prime diffi-
culty of all the children was the development of grammati-
cal skills. Thus, less attention was given to other language
areas, although they were not ignored entirely. For ex-
ample, as already discussed, the stories exposed the
children to narrative structure and required the parents to
read to their children. In addition, the group sessions in the
clinician-directed program provided occasions for peer
interaction, which the clinician facilitated as necessary.
Thus, there were many opportunities to focus on social
interactive skills. Still, numerous possibilities exist for
making the programs more comprehensive and more
appropriate for more children.
Finally, for any intervention program, the cultural
background of the family must be considered and appropri-
ate techniques developed. This is true for clinician- and
parent-directed programming (see van Kleek, 1994, for a
discussion dealing with cultural bias and parent programs).
The discourse and story styles we used would not be
appropriate for children from all cultures and thus other,
culturally sensitive forms of discourse should be developed
when necessary.
Conclusions
If we are to improve the services provided to individuals
with language impairments, it is important that investiga-
tions of intervention effectiveness be performed. Once
such studies have been completed, clinicians have a vested
interest not only in the results but also in the details of the
intervention programs evaluated. In this article, the two
intervention programs, whose effectiveness was docu-
mented by Fey and his colleagues, and the rationale behind
them were described.
It is important to remember that the intervention
programs described here have been evaluated as total
packages. Both programs involved a number of compo-
nents. There is a growing literature supporting the impor-
tance of sentence recasts that maintain the essential
meaning of a child’s utterance but correct or modify its
form in one or more ways (e.g., Fey et al., 1997; Nelson,
1989; Nelson et al., 1995; Watkins & Pemberton, 1987).
Similarly, the contrastive imitation used in the clinician-
based approach has been successful in earlier applications
(Connell, 1986, 1987). The importance of any other
components and the effects of interactions among compo-
nents on the success of intervention are less clear. The
contribution of these components (e.g., the imitation
protocol, the number or breadth of goals, the cyclical goal
attack strategy) should be the focus of future research. It is
important that speech-language pathologists continue to
develop more effective ways of working with children
with language impairments. To do this, well designed and
carefully implemented treatment efficacy research is
needed. It is hoped that this report helps in that endeavor.
Author Notes
This research was conducted in London, Ontario, Canada,
while the authors were at the University of Western Ontario. It
was sponsored by the Ministry of Community and Social
30 American Journal of Speech-Language Pathology • Vol. 6 • No. 1
Services, Ontario. This funding was administered by the Research
and Program Evaluation Unit in cooperation with the Ontario
Mental Health Foundation and was funded from the MCSS
Research Grants Program. We also gratefully acknowledge
equipment contributions from the Ontario District Association of
the Society for the Preservation of Barbershop Quartet Singing in
America (the Barbershoppers).
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Received April 11, 1996
Accepted September 25, 1996
Contact author: Patricia L. Cleave, PhD, School of Human
Communication Disorders, Dalhousie University, 5599
Fenwick Street, Halifax, NS, Canada, B3H 1R2
Email: pcleave@is.dal.ca
Key words: intervention, grammar, preschool, language
impairment

Appendix
Dad’s Bad Joke

Target: are Well, just a little, said Warren.

We are very brave. model
Neil and Warren liked to play in the attic. We really are. breakdown
It was fun up there but it was a little scary too.
They always turned on the light so they Well, what are we going to do? asked
could see. Neil. model

One day Neil and Warren started to go I am going downstairs, said Warren. contrast auxiliary
upstairs. Are you coming with me? model/recast
Are you? breakdown
Where are you going? asked Dad. model
Are you going to the attic? model Why are you going downstairs?
asked Neil. model
Yes, we are, shouted Warren. recast/breakdown Are you going to hide? model
Neil and I are going up now. buildup Are you going for help? model
We are going to play up there. model
I am going to look for a flashlight,
Oh you are, are you, thought Dad. breakdown/recast said Warren. contrast auxiliary

Dad had a big grin on his face. Are you really? Neil asked. model
Warren and Neil started to play.
They were having lots of fun. Yes I am, answered Warren. contrast auxiliary
Then, something happened. Are you coming with me? model
The light went out. Or are you going to wait here. model

Oh no, said Neil. Oh no! said Neil.

We’re in the dark. model We are going together. model
You are going downstairs. model
We sure are, said Warren. breakdown So I am going downstairs. contrast auxiliary
Are you afraid? recast
Are you afraid of the dark? model So Neil and Warren started to go downstairs.
It was very dark.
No I’m not, Neil answered. contrast auxiliary At the bottom of the stairs, Warren bumped
I am not afraid. contrast auxiliary into someone.
Are you? model/recast (continued)

Cleave • Fey 31
 Ouch! yelled a voice. I am going to turn on a light, answered
the voice. contrast auxiliary
Are you all right, Warren asked. model
Are you okay? model You are? asked both Neil and Warren. model

Watch where you’re going, said the Yes, I am, said the voice. contrast auxiliary
voice angrily. model
What are you doing? model And suddenly, the lights were on.

We are looking for a flashlight, Neil Dad!! shouted Neil and Warren.
responded. model What are you doing? model

You are looking for a flashlight?! said Well, said Dad, I thought I would play
the voice. model a trick on you.
Are you both looking for a flashlight? recast When you weren’t looking, I turned off
the light in the attic.
Yes we are, said Neil. breakdown It was just a joke.
We are in the dark so we’re staying
together. buildup Warren and Neil were really mad.

But who are you? asked Warren. model We are very angry Dad, said Warren. model
And what are you doing here. model Yes, we are, agreed Neil. breakdown
Don’t you ever play such a dirty trick
The voice walked away. again.

Where are you going? Neil screamed. model And you know what?
He never did.

32 American Journal of Speech-Language Pathology • Vol. 6 • No. 1 February 1997