International Journal of Language & Communication

Disorders

ISSN: 1368-2822 (Print) 1460-6984 (Online) Journal homepage: https://www.tandfonline.com/loi/ilcd20

Building vocabulary knowledge and phonological

awareness skills in children with specific language
impairment through hybrid language intervention:
a feasibility study

Natalie Munro, Kerrie Lee & Elise Baker

To cite this article: Natalie Munro, Kerrie Lee & Elise Baker (2008) Building vocabulary knowledge
and phonological awareness skills in children with specific language impairment through hybrid
language intervention: a feasibility study, International Journal of Language & Communication
Disorders, 43:6, 662-682, DOI: 10.1080/13682820701806308

To link to this article: https://doi.org/10.1080/13682820701806308

Published online: 03 Jul 2009.

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INT. J. LANG. COMM. DIS., NOVEMBER–DECEMBER 2008,
VOL. 43, NO. 6, 662–682

Building vocabulary knowledge and

phonological awareness skills in children with
specific language impairment through hybrid
language intervention: a feasibility study

Natalie Munro, Kerrie Lee and Elise Baker

Discipline of Speech Pathology, Faculty of Health Sciences, The University of
Sydney, Sydney, Australia

(Received 10 April 2007; accepted 9 November 2007)

Abstract
Background & Aims: Preschool and early school-aged children with specific
language impairment not only have spoken language difficulties, but also are at
risk of future literacy problems. Effective interventions targeting both spoken
language and emergent literacy skills for this population are limited. This paper
reports a feasibility study of a hybrid language intervention approach that targets
vocabulary knowledge and phonological awareness skills within the context of
oral narrative, storybook reading, and drill-based games. This study also reports
on two novel, experimental assessments that were developed to expand options
for measuring changes in lexical skills in children.
Methods & Procedures: Seventeen children with specific language impairment
participated in a pilot within-group evaluation of a hybrid intervention
programme. The children’s performance at pre- and post-intervention was
compared on a range of clinical and experimental assessment measures targeting
both spoken language and phonological awareness skills. Each child received
intervention for six one-hour sessions scheduled on a weekly basis. Intervention
sessions focused on training phonological awareness skills as well as lexical–
semantic features of words within the context of oral and storybook narrative
and drill-based games.
Outcomes & Results: The children significantly improved on clinical measures of
phonological awareness, spoken vocabulary and oral narrative. Lexical–semantic
and sublexical vocabulary knowledge also significantly improved on the
experimental measures used in the study.
Conclusions: The results of this feasibility study suggest that a larger scale
experimental trial of an integrated spoken language and emergent literacy

Address correspondence to: Natalie Munro, Discipline of Speech Pathology, Faculty of Health
Sciences, Cumberland Campus C42, The University of Sydney, PO Box 170, Lidcombe, NSW 1825,
Australia; e-mail: n.munro@usyd.edu.au

International Journal of Language & Communication Disorders

ISSN 1368-2822 print/ISSN 1460-6984 online # 2008 Royal College of Speech & Language Therapists
http://www.informaworld.com
DOI: 10.1080/13682820701806308
Hybrid language intervention 663

intervention approach for preschool and early school-aged children with

specific language impairment is warranted.

Keywords: specific language impairment, hybrid language intervention, emergent

literacy.

What this paper adds

Research indicates that children with specific language impairment are at
significant risk for literacy difficulties. There is, however, limited evidence for
interventions that simultaneously target both spoken language and emergent
literacy ability in children with specific language impairment. This paper
reports on a feasibility study of a hybrid language intervention that presents
phonological awareness and vocabulary knowledge within the context of oral
narrative, storybook reading, and drill play. This study suggests that hybrid
spoken language and emergent literacy interventions might improve the
targeted component skills of phonological awareness and vocabulary
knowledge as well as discourse related oral narrative outcomes. The
preliminary nature of the findings suggests that an experimental
investigation including a control group would be a worthwhile endeavour.
This paper also adds to the research examining methods of assessing
vocabulary knowledge in children with specific language impairment beyond
single-word expressive and receptive vocabulary tests.

Introduction
Children with specific language impairment (SLI) have impaired spoken language in
the absence of other developmental, sensory or behavioural disabilities (Leonard
1998). Their spoken language profile is varied and can include problems with some
or all of the components of language including phonology, semantics, syntax,
morphology and pragmatics. Children with SLI are four times more likely to have
reading difficulties compared with their typically developing peers (Catts et al. 1999).
Their spoken and written language difficulties are likely to persist, particularly for
those with semantic and syntactic deficits in spoken language (Stothard et al. 1998).
Intervention approaches for spoken language problems in preschool children
with SLI fall into two broad categories: those that focus on either individual
components of language, or those that adopt a whole-language approach.
Component-based interventions target a single component (e.g. syntax, Fey et al.
1993) or two different components of spoken language (e.g., phonology and
morphosyntax; Fey et al. 1994). Whole-language interventions emphasize con-
textualized meaning rather than the specific components of spoken language (e.g.,
Norris and Hoffman 1993). Whilst researchers have advocated for and against both
component and whole-language approaches (Paul 2001), there is no agreement
about which approach is the most effective for spoken language intervention.
This dichotomy of approach to spoken language intervention is also evident in the
emergent literacy intervention literature. Emergent literacy refers to the period where
precursory sets of skills, knowledge, and attitudes form and contribute to the
development of subsequent conventional forms of literacy (Whitehurst and Lonigan
664 Natalie Munro et al.

1998). Intervention approaches for emergent literacy target either specific skills, such as
phonological awareness (PA), print awareness and alphabetic knowledge (Bus and Van
IJzendoorn 1999), or take on a whole-language approach using tasks such as joint book
reading and immersion in literacy-related artefacts (Justice and Pullen 2003).
There is good evidence to support the relationship between literacy achievement
and PA instruction (Gillon 2004). However, other spoken language skills have also
been identified as important for developing literacy (e.g., Greenfield Spira et al.
2005). Fey et al. (1995) have argued that preschool language intervention should not
only address children’s immediate spoken language problems, but also prepare them
for the literacy challenges ahead. This would mean that intervention targets for
children with SLI should cover both spoken language and emergent literacy skills.
Despite this logical recommendation, there is still limited evidence to guide speech
language therapists (SLT) about the most efficacious intervention approach for
spoken language and emergent literacy in children with SLI.
The present paper reports a feasibility study of an intervention for young children
with SLI that targets two components of spoken language: vocabulary knowledge and
PA. These are embedded within a whole-language approach, using oral narrative and
storybook reading as well as using clinician-directed, drill-based games. This hybrid
intervention approach is adapted from Justice and Kaderavek (2004). The investigation
is preliminary by design. As Fey and Finestack (in press) note, feasibilities studies (e.g.,
Justice et al. 2005, Girolametto et al. 2007), do not establish efficacy. Rather, they are a
necessary first step in determining whether an approach is clinically viable, and as such
whether a more labour-intensive and costly efficacy trial would be worthwhile. What
follows is a review of the literature supporting the development of the hybrid
intervention under preliminary investigation.

Phonological awareness and vocabulary knowledge: components of emergent literacy

hybrid language intervention
Phonological awareness (PA) is the ability to use and reflect upon the sound
structure of spoken language at the sublexical level (Lonigan et al. 1998). PA skills
underlie the ability to decode a written word phonologically, which in turn improves
word-recognition ability, thus contributing to reading accuracy and reading
comprehension (Gillon 2004). PA has been identified as a critical skill for reading
and spelling acquisition (e.g., Stackhouse 1997). In addition to PA, other spoken
language skills such as vocabulary knowledge also contribute towards word
recognition and reading comprehension ability (e.g., Catts and Kamhi 2005). Gillon
(2004) provides the following example to illustrate the working relationship between
non-phonological components of spoken language and PA in word recognition.
Here, a child is asked to read the last word in a sentence: ‘The horse likes to eat …
grass’ (Gillon 2004: 32). In this task the child needs simultaneously to integrate
phonological and orthographic information (e.g., /gr/, ‘gr’) as well as infer and
access semantic information and likely word associations such as ‘hay, corn, grass,
straw, and oats’. Each of these abilities contributes to the success of decoding and
recognizing the written word ‘grass’.
The relationship between spoken vocabulary, word recognition, and reading
comprehension ability is a complex and interdependent one (for a review, see
McGregor 2004). Vocabulary abilities have been strongly correlated to PA skills in
Hybrid language intervention 665

both preschool and early school-aged children (Bowey 1994, Lonigan et al. 1998).
Spoken vocabulary growth has also been posited as the impetus for the
development of PA and word recognition (Walley et al. 2003). Expressive and
receptive vocabulary measures have also shared significant variance for regular
and irregular word recognition (Ouellette 2006). With regard to reading
comprehension skills, an array of lexical/semantic skills (such as receptive and
expressive vocabulary, word association, and synonym judgement) have all been
identified as skills which are important and predictive of later reading
comprehension (e.g., Roth et al. 2002). Other research suggests that the
contribution of spoken language components to the development of word
decoding and reading comprehension changes over time. Studies have shown that
while PA is an important skill for early word-recognition ability, semantics and
syntax become more influential over time, particularly for reading comprehension
(e.g., Muter et al. 2004). These findings have also been reported in children with
SLI (Catts et al. 2002).

Component-based intervention approaches for children with specific language

impairment
Children with SLI exhibit an array of difficulties related to vocabulary knowledge,
narrative discourse, and PA ability (e.g., Boudreau and Hedberg 1999, Kaderavek
and Sulzby 2000, Brackenbury and Pye 2005), yet despite our growing under-
standing of the nature of language impairment, it is difficult to determine the best
course of intervention that facilitates both spoken and written language
development. A number of studies have demonstrated the effectiveness of single-
component intervention programmes using PA or semantic instructional
approaches. The efficacy of PA intervention has been shown in children with
spoken language impairment (Gillon 2002); developmental language delays
(O’Connor et al. 1998); and speech and/or language disorders (Van Kleeck et al.
1998). Other studies have demonstrated the effectiveness of improving vocabulary
knowledge at the level of the lexicon via elaboration and retrieval techniques in
children with language impairment (McGregor and Leonard 1989, McGregor 1994),
whilst Hayward and Schneider (2000) have demonstrated improved story
information and macrostructure abilities in preschool children with language
impairment. However, given that PA and other spoken language components
contribute to the development of word recognition and reading comprehension,
single-component intervention programmes might be less able to address both the
present and future needs of children with SLI.
In this paper it is argued that interventions for preschool and early school-
aged children with SLI should target both PA and vocabulary knowledge
embedded within the context of narrative discourse as well as explicitly presented
through component-based instruction. The term ‘vocabulary knowledge’
encompasses both word-level and text-level, meaning-based language abilities.
This methodology allows the SLT to work on lexical–semantic (i.e., word label/
meanings) and sublexical processes (i.e., awareness of the phonological form) at
word level as well as other discourse-level semantic processes involved in spoken
and written language development. Narrative discourse is a critical element as it
encourages children to develop more literate forms of language (Westby 1991).
666 Natalie Munro et al.

Narrative discourse is also a significant predictor of reading ability and academic

success (e.g., Speece et al. 1999). Syntactic structure is embedded within narrative
discourse and is not identified as a separate intervention target. This approach is
consistent with emergent literacy instructional principles and recommendations
identified by Roth and Troia (2006).

Existing evidence for hybrid language interventions for children with specific language
impairment
Justice and Kaderavek (2004) used an embedded-explicit emergent literacy
intervention approach. Their hybrid intervention offers an opportunity to embed
components of emergent literacy including PA, vocabulary knowledge, and other
linguistic factors within literacy related activities such as adult mediated play or
adult–child scaffolded storybook reading. Evidence for such an approach largely
comes from studies using children from low-income families (e.g., Whitehurst et al.
1999). In these studies, PA is explicitly taught via component-based instruction in
addition to dialogic reading at home and in preschool. Dialogic reading utilizes
adult–child storybook interaction and conversation in order to develop spoken
language ability (for a review of this approach, see Cole et al. 2006). The combination
of component-based PA instruction and dialogic reading resulted in improvements
in PA, print concepts, writing skills and expressive vocabulary. Justice et al. (2003)
compared an emergent literacy component intervention to an embedded whole-
language, adult–child storybook reading intervention. The emergent literacy
component intervention focused on written language awareness and PA skills
whilst the adult–child storybook intervention programme used several dialogic
reading strategies, prediction, and discussion strategies as well as scaffolded
storybook retelling strategies. The component intervention resulted in gains on the
targeted written language and PA measures while the whole-language storybook
reading approach did not. Spoken language skills were not evaluated as part of the
outcomes used in this study, therefore the relative merits of either approach on
spoken language skills is not known.
Other hybrid interventions have included meaningful and contextualized PA talk
within the context of adult–child shared storybook tasks. In a study by Ukrainetz
et al. (2000), a group of typically developing kindergarten children with mixed
emergent literacy abilities received a 7-week intervention programme that focused
on PA conversational exchanges within the context of print and literature. The
intervention group showed greater PA gains than an age-matched control group that
received no intervention. The intervention used both storybook and writing-related
activities, so the relative contribution of each activity is not known.
Finally, a search of the literature revealed only one hybrid language intervention
feasibility study involving preschool children with SLI. Justice et al. (2005) studied
changes in PA using a parent-led intervention. They used parent–child storybook
reading in conjunction with either PA drill-based games or vocabulary drill-based
games. The children who received the parent–child storybook reading in
conjunction with the PA drill-based games performed better on measures of rhyme
but not alliteration compared with the comparison SLI group. The study did not
include measures of spoken language so the relative effects of this intervention on
the children’s spoken language abilities are not known.
Hybrid language intervention 667

In summary, the available evidence for hybrid language emergent literacy

intervention approaches for children with SLI is limited. It is also clear that in the
extant literature, there is a focus on PA measurement rather than an examination of
both PA and spoken language growth despite the growing body of research
identifying the importance of PA and spoken language ability to later reading success
(National Reading Panel 2000).

The present study

The nature of SLI is characterized by complexity and heterogeneity. The present
hybrid language intervention study extends previous research by the following:
N Focusing on spoken language component targets, specifically vocabulary
knowledge and PA.
N Embedding these component targets within whole-language tasks including
oral narrative discourse and storybook reading
N Facilitating the children’s awareness of phonological and semantic properties
of words by embedding these properties within oral narrative and storybook
reading as well as drawing attention to these properties during dialogic adult–
child storybook interactions
N The use of drill in game-based activities to supplement oral narrative and
storybook reading.
The study used clinical as well as new experimental assessments to measure lexical–
semantic and sublexical (phonological) storage and access. Brackenbury and Pye
(2005) comment that the assessment of semantics has largely focused on receptive
and expressive vocabulary size and not on other areas of semantic deficit evident in
children with SLI such as word-learning abilities and lexical storage and access. As
part of the present intervention study, the present paper reports on the development
and outcome of two assessment measures of lexical–semantic and sublexical storage
and access that will be further described in the Methods section of this paper.
The research questions included the following:
N What are the treatment effects of a hybrid language intervention targeting
vocabulary knowledge and PA for children with SLI who are functioning
within the emergent literacy period?
N Within a hybrid language intervention, are there generalized treatment effects
for oral narrative production and listening comprehension (skills not
explicitly targeted but embedded by virtue of the intervention context)?
N What changes can be measured in lexical–semantic and sublexical storage and
access pre- post-hybrid language intervention?

Methods
Participants
Preschool and early school-aged children were recruited from waiting lists for
community-based speech pathology services located in the greater region of Sydney,
Australia. Parents were contacted about participation in the study if the referral
668 Natalie Munro et al.

questionnaire indicated a suspected language impairment and the parent(s) primary

concern(s) were based on their child’s oral language difficulties. Twenty-eight
families were identified and 20 agreed to participate in the study.
Two experienced SLTs carried out a standardized speech and language assessment
battery on each child individually. These assessments were typically done in two sessions
of one hour each. The children were required to meet the following inclusionary criteria:
N A language impairment characterized by:
N expressive language impairment: performance at least 1 standard
deviation (SD) below the mean on the Information and Grammar
scores of the Action Picture Test (APT: Renfrew 1997) and/or;
N receptive language impairment: performance at least 1 SD below the
mean on the Test of Auditory Comprehension of Language — Revised (TACL-R;
Carrow-Woolfolk 1985); and
N hearing for both ears each within normal limits defined by Type A
tympanograms and pure-tone hearing screening (20 dB HL at 1000,
2000, and 4000 Hz; American National Standards Institute (ANSI)
1989).
N Cognitive abilities within normal limits as assessed by the Test of Nonverbal
Intelligence — 3rd Edition (TONI-3: Brown et al. 1997).
N Australian English as their only language.
N No reported behavioural, neurological or motor skill impairments.
N No previous intervention targeting spoken language or emergent literacy
abilities including intervention explicitly targeting PA.
Of the 20 potential participants, 17 children met the above inclusionary criteria. Three
children were excluded; this included two who failed the hearing screen and one whose
parents requested intervention targeting mild speech production difficulties only.
Table 1 summarizes the group results on the tests used for inclusion in the study.

Participant profiles
The participants included 17 children (four girls, 13 boys) with ages between 4 years 8
months and 6 years 5 months. The high proportion of boys in the study reflects the

Table 1. Participant characteristics, including the mean, standard deviation (SD) and range
for chronological age, non-verbal cognitive ability, and results for receptive and expressive
language and speech production

Variable Mean SD Range

Chronological age (months) 67 8.4 56–77
Non-verbal intelligence (standard score) (TONI-3) 98 7.9 87–109
Receptive language (percentile), total TACL-R 10 8.5 2–29
Expressive language (raw score):
Grammar score APT 14 5 6–23
Information (vocabulary) score APT 27 5.6 21–35
Speech production (percentile), GFTA-2 41 16 7–66

TONI-3, Test of Nonverbal Intelligence — 3rd Edition (Brown et al. 1997); TACL-R, Test of Auditory
Comprehension of Language — Revised (Carrow-Woolfolk 1985); APT, Action Picture Test (Renfrew 1997);
GFTA-2, Goldman–Fristoe Test of Articulation — 2nd Edition (Goldman and Fristoe 2000).
Hybrid language intervention 669

higher prevalence of SLI in males (Flax et al. 2003). The participant’s speech production
skills were assessed using the Goldman–Fristoe Test of Articulation — 2nd Edition (GFTA-2;
Goldman and Fristoe 2000). Based on the results of the speech and language
assessments, twelve children had both receptive and expressive language impairments
without speech production difficulty; one child had receptive and expressive language
impairments with concomitant speech delay; three children had expressive language
impairment only; and one child had receptive language impairment only. The inclusion
of the children with speech production impairments reflects the heterogeneous nature
of SLI within preschool and early school-age development. Fourteen of the children
had a positive familial history of speech–language impairment based on a parent/
caregiver interview (Lewis and Freebairn 1993). Seven children were attending a
preschool, seven children were enrolled in their first year of school (kindergarten), and
three were enrolled in their second year of schooling (first grade). The study was
conducted in the second term of the school year.

General procedures and research design

Standard clinical assessments as well as experimental tasks were used to measure
spoken language and emergent literacy skills at pre- and post-intervention. Assessment
tasks were conducted by two experienced SLTs who were not involved in the
intervention. The study used an applied pre– post–within subjects design. The decision
to use this design, as opposed to a quasi or experimental design, was driven by both the
context and preliminary nature of the study. This was a clinical study of feasibility
conducted in a setting where the children and their families had been waiting over a
year for speech–language pathology services. It was deemed difficult, both ethically and
practically, to recruit a control group of adequate size for statistical analyses to be
conducted with sufficient power. This meant that while the design served to generate
hypotheses, causal statements could not be made about the results.

Clinical assessment tasks

Each participant was assessed at pre- and post-intervention using seven clinical
assessment tasks which targeted both components of spoken language as well as
whole-language aspects of the intervention. The specific components included PA
and expressive vocabulary assessments. Measures of listening comprehension and
oral narrative production were included to reflect whole-language listening and
speaking approaches. In addition, a drawing skills task was included as a control task.
Drawing is a developmental motor skill which is unrelated to the skills targeted in
the intervention. Changes in performance on the motor task should, therefore,
reflect developmental changes over the 8–10 weeks of the study, rather than any
intervention related changes.

Experimental assessment tasks

The study included two experimental tasks to measure changes in the children’s
developing lexicon. Both these experimental tasks aim to examine the depth of
vocabulary knowledge (how well a word is known) in terms of associated
670 Natalie Munro et al.

Table 2. Clinical assessment tasks used to assess participants at pre- and post-intervention

Measure
1. Listening comprehension
2. Expressive vocabulary
3. Oral narrative production
4. Phonological awareness
5. Drawing skills
Test
The Token Test for Children (TTC; Di Simoni 1978)
Total correct expressed as standard score
Hundred Picture Naming Test (HPNT; Fisher and Glenister 1992)
Accuracy score converted to percentile rank
Total response time in seconds
The Bus Story (Renfrew 1995)
Information raw score
Sentence length raw score
The Preschool and Primary Inventory of Phonological Awareness
(PIPA; Dodd et al. 2000)
Rhyme awareness; total correct expressed as standard score
Alliteration awareness; total correct expressed as standard score
The Developmental Test of Visual-Motor Integration (VMI; Beery and
Buktenica 1989)
Total correct expressed as standard score

lexical–semantic and sublexical (phonological) properties rather than the breadth of

vocabulary knowledge (how many words are known) (Ouellette 2006).

Experimental task 1: Word attribute identification task

This was a closed set, receptive task to examine the retrieval of lexical items and
their associated semantic and phonologic properties. The stimuli were 36 concrete,
high-frequency nouns; 18 of these words were explicitly trained within the
intervention programme and the remaining 18 were untrained words. The trained
words are a direct measure of the training while the untrained words tested for
generalization of training to untrained items. Before testing, the child was asked to
label a picture of each stimulus to ensure that the items were within their receptive
vocabulary. The pictures were displayed in sets of six. The tester then asked the child
a series of questions designed to assess the child’s knowledge of lexical–semantic
and sublexical (phonological) features of each stimulus word. The questions focused
at the lexical–semantic level, tested knowledge of semantic function (e.g., ‘Which
one do you wear?), attribute (e.g., ‘Which one has handles?) or associative feature
(e.g., ‘Which one goes with windy?’). The questions about sublexical (phonological)
features of the stimulus words tested rhyme or alliterative knowledge (e.g., ‘Which
one starts with the sound /k/?’). The child received a score for trained and
untrained lexical–semantic items and sublexical (phonological) items as well as a
combined total score for lexical–semantic and sublexical (phonological) stimuli. The
data were further analysed to examine the three areas of lexical–semantic knowledge
(semantic function, attribute and association) and the two skill sets of sublexical
(phonological) knowledge (rhyme and alliteration). Although rhyme and alliterative
knowledge reflects sublexical (phonological) knowledge, these two skills are labelled
more often as a PA skill. Analysis of this experimental task will therefore simply
label sublexical (phonological) knowledge as PA. Similarly, lexical–semantic
knowledge as assessed via semantic function, attribute and association will simply
be referred to as semantic knowledge.
Hybrid language intervention 671

Experimental task 2: Word-association task

In this task the tester said a stimulus word and the child was asked to say any words
they thought of when they heard the word. The stimulus set was made up of twelve
high frequency words (ten nouns and two adjectives). The child was given 20 seconds
to respond with as many words as he/she could associate to the stimulus. The
responses were coded using a system adapted from Cronin (2002) and Sheng et al.
(2006). Each response was classified as one of six possible categories: Syntagmatic,
Paradigmatic, Clang, Multiword, Repeat, or Not Related. In a continuous word-
association task in which the child is asked to give multiple responses, it is possible for
the child to give a word association to a response word and not the stimulus. These
secondary chaining responses constituted less than 3.0% of the total responses at pre-
test and 3.7% of responses at post-test, and were not included in the analysis.
Responses coded as syntagmatic included those words that related to the
stimulus item according to a thematic relationship, that is, words that are typically
found within a sentence/discourse (e.g., toast-burn, horse-ride). Paradigmatic
included words that shared a taxonomic relationship to the stimulus such as words
that are synonyms/antonyms, subordinates/superordinates and coordinates (e.g.,
bike-car, hot-cold). Clang responses included words that shared either a rhyming or
alliterative feature related to the stimulus item (e.g., plate-date, sun-sandwich).
Multiword responses are typical in young children and may reflect difficulties
understanding the meta-linguistic aspects of the task. Previous researchers have
excluded these from analysis (e.g., Entwisle 1966) however in this study multiword
responses were coded and contained in the data set to determine the proportion of
multiword responses versus other single word responses pre- post-intervention and
whether these multiword responses were predominantly paradigmatic or syntagma-
tically related (e.g., the response; ‘red-is a different colour’ is predominantly a
paradigmatic multiword response whilst the response ‘bike-ride a bike’ is
predominantly a syntagmatic multiword response). The final two categories
(Repeat and Not Related) included repeated stimulus items or superfluous or
irrelevant responses, respectively. Two coders conducted item-by-item reliability
analysis of the response classification for all responses. The coders agreed on
classification for 93.8% of the responses and consensus agreement was obtained for
the remaining 6.2% of the data.

Intervention procedure and materials

After completing the pre-intervention assessments, each child attended individual
intervention sessions once a week for 6 weeks. All sessions were conducted by the
same SLT and each session lasted 60 minutes with 10 minutes allocated to discuss
home follow-up activities with the parent. Each session began with a scripted oral
narrative contextualized within a picture-based story, followed by a card or board
game. The scripted oral narratives were adapted from a series of published story
books (Sound Starters, Sound Stories and Sound Rhymes; Love and Reilly 1999).
These stories are predominantly picture-based with very limited written text. They
offer multiple discussion points for PA features, in particular rhyme and alliteration,
as well as semantic features from within the pictures and the stories that can be
generated from these as well as from the limited text (e.g., ‘Teddy brushed his teeth
with a toothbrush and turned off the tap’). Rhyme or alliteration features were
672 Natalie Munro et al.

embedded in the script as extra-textual comments or questions (e.g., ‘Tap, teddy and
tiger all start with the sound /t/’). Semantic elaborations (e.g., ‘A forest is a place
with lots of trees’) and semantic networks (e.g., lexical items such as ‘dog’, ‘paws’ and
‘dig’ being located within the same utterance) were also highlighted. The scripted
narratives were characterized by a majority of embedded PA and semantic
statements rather than direct PA and semantic questioning as well as more story
content-related utterances than extra-textual PA and vocabulary-related utterances.
Children’s own conversational initiations reflecting semantic, PA or narrative-related
utterances were also reinforced by the SLT by positive and contingent semantic or
PA-related responses. These strategies and scripted narratives therefore incorporated
both dialogic reading strategies and structured, component intervention features.
The scripted oral narratives and supporting storybooks also allowed for both
lexical–semantic and sublexical (phonological) storage elaboration techniques (i.e.,
learning new information about words) via narrative discourse. The card or board
games that followed the storybook within the session featured some of the lexical
items from within the scripted oral narrative. This was to reinforce and retrieve the
PA and semantic features that were originally presented via storage elaboration
techniques at discourse level. Games included snap and odd one out formats,
external reinforcement board games as well as auditory closure semantic and PA
exercises. The combination of scripted storybooks and games therefore offered
storage and elaboration intervention techniques for both phonological and semantic
information at word and discourse level. This approach follows intervention
principles highlighted by McGregor and Leonard (1995). The use of the card and
board games also increased treatment intensity which is consistent with the notion
that children with language impairment need frequent or intense exposure formats
(Ukrainetz 2006). Modest vocabulary outcomes have also been reported from
shared storybook intervention approaches that have not featured an intensive
format instruction (Dale et al. 1996). Other research also suggests that children with
language impairments are more engaged in child-directed games than in interactive
book reading (Kaderavek and Sulzby 1998) so a combination of short storybooks
and games was therefore chosen.
At the end of each session the child and their parents were given a ‘story pack’
which contained the therapy materials, a similar story book that featured the same
PA target and related card/board games for follow-up home activities. Written
instructions were provided as well as an oral narrative/story template that parents
could base their own stories on. Parents were encouraged to describe and
comment about the pictures in order to generate an oral story (as per
Hockenberger et al. 1999) rather than use direct questioning techniques. They
were asked to include either a rhyme or alliterative feature comment on each page
during the storybook interaction with their child. These techniques were modelled
by the SLT during the intervention. Parents were asked to spend 10–15 minutes
each day with their child focusing on one of the books and an associated game.
Parents verbally reported compliance with home follow-up activities. At the
following clinic session, children would retell one of the stories from the story
pack to the SLT who then probed for identification of PA or semantic features
relevant to the text.
After all six treatment sessions, the children were again tested using the same
clinical and experimental assessments used in the pre-intervention period.
Hybrid language intervention 673

Treatment fidelity
Treatment fidelity was evaluated by an independent SLT to determine the
consistency of the delivery of the oral narratives and extra-textual talk that occurred
within each storybook used during the intervention. For each storybook, written
templates were developed and consisted of the oral narrative which included the
limited written text in the storybooks (e.g., the character’s name) as well as the extra-
textual PA and vocabulary talk surrounding those narratives. Six randomly selected
video-recorded therapy sessions (one session for each treatment week) was observed
by the independent SLT and coded in terms of the following characteristics: (1) the
percentage of SLT utterances that reflected the written narrative template, (2) the
percentage of SLT utterances that contingently responded to child initiated
comments or questions relevant to the narrative template, (3) the percentage of SLT
utterances that did not reflect (1) or (2) where these utterances typically reflected on-
task behavioural support.
A fidelity score (percentage observed) was determined for each of the six video-
recorded sessions. The average percentage observed for SLT utterances that
reflected the written narrative templates was 52% with scores ranging from 36% to
68%. The average percentage observed for SLT utterances that contingently
responded to child-initiated, narrative-related comments and/or questions was 39%,
with a range of from 24% to 61% whilst an average of 9% of the SLT utterances
reflected on-task behavioural support (range 2–16%). These results show that the
narrative template and child-initiated, narrative-based utterances accounted for a
mean of 91% of utterances during the intervention. This confirms the integration of
child-initiated comments/questions and appropriate adult levels of responsiveness
occurred. The lower number of behaviour support comments suggests that the
children were engaged and responsive to this type of intervention.

Data analysis
Clinical pre- post-dependant variables were analysed using multiple, paired t-tests.
To reduce Type I error, a Bonferroni adjustment was introduced to give an overall
significance level of 0.05. For the clinical assessments eight comparisons were
carried out so the level used for significance was 0.006. Effect sizes were calculated
via eta squared (e2) (Cohen 1988) using recommended cut-off values for small
(0.01), moderate (0.06) and large effect size (0.14).

Results
Spoken language component and embedded clinical outcomes
The results on the clinical assessments tasks at pre- and post-intervention were
compared. Measures included the areas of PA and vocabulary knowledge (directly
trained in the intervention) as well as the areas of listening comprehension and oral
narrative production (not directly trained in the intervention.) Table 3 presents the
results of paired t-tests and e2 on each clinical assessment task comparing
performance at pre- and post-intervention.
The results of the paired t-tests show that the children’s performance significantly
improved on each clinical language and PA measure at post-intervention and the
674 Natalie Munro et al.

Table 3. Results for clinical assessment tests of language and phonological awareness at pre-
and post-intervention (n517) and results for paired t-tests comparing performance on each
task at pre- and post-intervention

Difference
Measure Pre-mean Pre-SD Post-mean Post-SD post- pre t e2
Expressive vocabulary 36.2 24.4 49.4 28.3 13.2 22.456* 0.27
accuracy
Expressive vocabulary 341.9 99.9 276.2 81.6 65.7 3.686* 0.46
response rate
Rhyme awareness 5.0 2.0 7.8 2.8 2.8 23.786* 0.47
Alliteration awareness 5.8 2.0 8.1 1.3 2.8 24.604* 0.57
Listening comprehension 491.9 5.0 494.7 5.8 2.8 22.866* 0.34
Oral narrative — 16.7 7.4 21.0 8.8 4.3 23.297* 0.40
(information)
Oral narrative — 7.3 2.0 8.2 1.7 0.9 24.103* 0.51
sentence length
Control drawing task 82.0 7.9 78.9 7.3 23.1 1.839 NS

*Statistical significance at p50.05 with Bonferroni correction.

NS, not significant; SD, standard deviation.

e2 statistic indicates that there is a large effect size for changes in performance pre-
versus post-intervention on all of the language and PA measures. Performance on
the control drawing task showed no change in performance between pre- and
post-intervention.

Outcomes on experimental assessment tasks

Word attribute identification task
Table 4 presents the mean correct score at pre- and post-intervention for semantic
and PA items for trained and untrained stimuli and all stimuli combined on the word
attribute identification task. The mean performance improved post-intervention for
both semantic and PA items. The results of the word attribute identification task
were analysed using a repeated measures analysis of variance with within subject
factors of time (pre- and post-), component language area (semantics, PA) and type
of lexical target (trained, untrained). Using a significance level of 0.05 the results
show a significant main effect for time (pre- and post-intervention) [F(1, 16)587.65,
partial e250.846] indicating that performance at post-intervention was significantly
better than at pre-intervention; there was also a significant main effect for

Table 4. Mean correct performance on semantic and phonological awareness questions for
trained and untrained items on the word attribute task at pre- and post-intervention

Word attribute identification task Pre-mean (SD) Post-mean (SD)

Semantic attributes trained 74 (18.0) 89 (11.7)
Semantic attributes untrained 72 (16.0) 83 (10.3)
PA attributes trained 40 (24.7) 73 (33.1)
PA attributes untrained 51 (32.0) 78 (25.5)

Standard deviations (SDs) are in parentheses.

PA, phonological awareness.
Hybrid language intervention 675

component language area, [F(1, 16)517.65, partial e250.525]. This result reflects
differences in the task difficulty for semantics and PA items. Performance at pre-
intervention on semantic items was 73% while performance on PA was at 45%.
Semantic items were therefore limited by test score ceiling in demonstrating
improvement. There was no main effect for lexical target indicating that
performance on trained and untrained items was similar, [F(1, 16)51.05]. There
is a significant interaction between time (pre- post-intervention) and component
language area, [F(1, 16)58.49, partial e250.347] and a significant interaction for
component language area 6 lexical target, F(1, 16)57.61, partial e250.322. These
interactions reflect the ceiling effect found for the semantic items.
These findings indicate that, the children made significant overall lexical–
semantic and sublexical (PA) gains post-intervention. These changes were further
analysed using separate paired t-tests on the total semantic and PA scores which
showed that performance significantly improved at post-intervention on both the
semantic [t(16)525.35] and PA scores [t(16)526.67] compared with performance
at pre-intervention. e2 values revealed large effect sizes for both semantics (0.64) and
PA (0.74).
The semantic items in the word attribute task were made up of three component
skills, including semantic function, semantic attribute and semantic association.
The PA items were comprised of two component skills, rhyme and alliteration.
Table 5 presents mean per cent scores for each component skill at pre- and
post-intervention.
The performance on these specific components skills for semantics and PA were
compared at pre- and post-intervention with a series of paired t-tests with a
Bonferroni adjustment for multiple comparisons. Results showed that the children’s
scores significantly improved at post-intervention on semantic function,
t(16)524.12, semantic attributes, t(16)523.40, rhyme recognition, t(16)525.60,
and alliteration recognition, t(16)525.25. The exception to this was semantic
association which showed no significant change between pre- and post-intervention
t(16)521.95. Large effect sizes using e2 are reported for semantic function50.52,
semantic association50.19, semantic attributes50.42, rhyme recognition50.66, and
alliteration recognition50.63.
These results indicate that post-intervention, the children made substantial gains
in both the recognition of lexical–semantic and sublexical (PA) features of words
and that these gains were evident in all but one of the individual subcomponents as
well as composite semantic and PA scores.

Table 5. Results showing the mean per cent correct performance on each component skill in
the word attribute task at pre- and post-intervention

Subcomponents of the word attribute

identification task Pre-mean (SD) Post-mean (SD)
Semantic function 81.5 (16.6) 95.8 (6.7)
Semantic association 75.5 (22.9) 86.3 (15.9)
Semantic attributes 64.7 (23.0) 79.1 (12.3)
Rhyme recognition 33.1 (25.7) 71.3 (29.9)
Alliteration recognition 59.8 (33.4) 80.4 (26.5)

Standard deviations (SDs) are in parentheses.

676 Natalie Munro et al.

Word-association task
Each response on the word-association task was coded into one of six possible
categories. The number of times each category was used as a proportion of the total
number of responses related to the stimulus for all twelve stimuli was calculated to
determine relative scores for each category. Figure 1 depicts the mean proportion of
responses in each code category at pre- and post-intervention. As illustrated, the
majority of the children’s associations were single word responses in both pre- and
post-intervention conditions. Of those multiword responses, multiword syntagmatic
responses were more common than multiword paradigmatic responses, constituting
92% of all multiword responses.
A Wilcoxon signed-rank test compared the use of different response categories
at pre- versus post-intervention. The results show that the children changed their
type of responses after intervention. At post-intervention the children significantly
increased their use of paradigmatic (Z522.91, asymptomatic significant (two-
tailed)50.004); syntagmatic (Z523.51, asymptomatic significant (two-
tailed)50.000); and clang-related responses (Z522.50, asymptomatic significant
(two-tailed)50.012), while there was no change on the other categories (multiword-
syntagmatic, Z520.18, asymptomatic significant (two-tailed)50.86; multiword-
paradigmatic, Z520.96, asymptomatic significant (two-tailed)50.33; repeated
stimuli, Z521.40, asymptomatic significant (two-tailed)50.161 and not related,
Z520.49, asymptomatic significant (two-tailed)50.62).
In the word-association task the children varied in the number of responses they
gave to each stimulus. At pre-test the mean number of responses per stimulus was
2.1. At post-intervention the mean number of responses per stimulus was 4.1. A
statistical analysis was carried out using only the children’s first response to each
stimulus item. This equated the response frequency for the test at pre-intervention
to post-intervention. That is, the children had an equal number of responses in pre-
and post-intervention. Whereas the previous analysis had looked at the relative
proportion of each category response (when the actual number of responses more
than doubled for the post-intervention), this analysis compares their category usage

Figure 1. Results for the word-association task showing the proportion of responses in each category
for all responses related to the stimulus.
Hybrid language intervention 677

when the rate of giving a response was equal at pre- and post-intervention. The
response category usage, at pre- and post-intervention for the first response only,
was compared using a Wilcoxon signed-rank test. The results show that the children
significantly increased in their use of the paradigmatic, syntagmatic, and clang, while
they significantly decreased their usage of repeat-stimulus, unrelated and multiword
responses. These results indicate that the increase in responses between pre- and
post-intervention is a result of increased use of the syntagmatic, paradigmatic and
clang categories.
This may reflect shifts in understanding the meta-linguistic nature of the task,
that is, the requirement for single word and novel word responses to stimulus items.

Discusssion and conclusions

This paper reports the first study into the language and emergent literacy outcomes
for a hybrid intervention programme on young children diagnosed with SLI.
Significant improvements in spoken language and emergent literacy skills were
evident after a 6-week intervention programme. The use of the pre– post–within
subject design meant that the intervention alone may not have caused these results.
It is possible that the improvements in clinical and experimental measures were a
result of maturation or Hawthorn effects. This point aside, as a feasibility study, the
content and delivery of the intervention programme represents a promising
approach to intervention for SLI. Firstly, in terms of content, the hybrid nature of
the intervention programme targeted both specific components of vocabulary
knowledge and PA skills which were embedded within a whole-language context of
oral narrative and storybook reading. PA and vocabulary knowledge was also
targeted via clinician-led drill based games. As a group, the children made significant
improvements in the rate and accuracy of their expressive vocabulary labelling as
well as improvements in rhyme and alliteration awareness. The PA and vocabulary
results of this study are consistent with previous intervention research in children
with SLI (e.g., McGregor and Leonard 1989, Van Kleeck et al. 1998). However, the
lack of orthographic expectancies (sound–letter correspondences) within the
present PA treatment or measurement outcomes needs to be addressed in future
studies. As a group the children with SLI also made significant improvements on
measures of listening comprehension and oral narration which were skills that were
embedded and not explicitly targeted during the intervention. These outcomes using
standard clinical measures provide initial support for the intervention approach
however an alternative oral narrative measure that addressed both comprehension
and other aspects of narrative such as narrative macrostructure and overall narrative
quality (e.g., Fey et al. 2004) might better reflect discourse level outcomes. These
issues aside, the current clinical outcomes of this feasibility study suggest that
dichotomous approaches to spoken language and emergent literacy interventions
can be reconciled through the use of hybrid language interventions. Hybrid language
interventions that target components of vocabulary knowledge and PA within the
context of oral narrative, storybook reading, and drill-based games may be an
efficient and more holistic way of targeting both current spoken and future written
language skills in children with SLI rather than single component approaches to
intervention. It is in keeping with Ukrainetz’s (2006) notion that children need
‘Repeated opportunities, Intensity, Systematic support and Explicit skill focus’
678 Natalie Munro et al.

(RISE). Ouellette’s (2006: 564) recommendation, that an emphasis on ‘phoneme

awareness and phonics should not be at the expense of vocabulary enrichment’, can
also be reconciled through the use of hybrid language interventions. Finally, the
heterogeneous nature of SLI warrants further investigations into hybrid language
interventions so that SLTs can better prepare both spoken and written language
needs but also improve on the efficiency of intervention by avoiding sequential
component based approaches to language intervention. It would be important that
future research examine individual children’s responses across the multiple skills that
are targeted. In the present investigation, although all the children showed
improvements, the improvements were not commensurate across each skill, for each
child. Some children showed considerable improvement on one skill but relatively
little on another. Such research would have important clinical implications for
understanding how hybrid interventions might be tailored to meet the needs of
individual children.
The method for delivery of this pilot intervention programme also warrants
discussion. A combination of weekly clinical sessions and parent delivered home-
based activities were used in this study. The home-based activities were structured to
complement, practice and extend the skills targeted each week in clinic as well as
being interesting and entertaining for the parent and child to promote compliance
with the homework schedule. The present study encompassed both preschool and
early school-aged children. There was a 100% attendance rate with parents reporting
that the combination of short storybooks, an emphasis on conversation and board
games promoted compliance. The use of a parent diary or the collection of audio/
video home tapes may add value to issues of treatment fidelity and our
understanding of clinical plus home-based intervention practices. The fact that
the parents of the children involved in the study had been waiting to receive speech
pathology services for 12 and in some cases up to 18 months may have influenced
the parents’ commitment to follow-up at home. Future research, on a larger scale
with parents from varying socio-economic and cultural backgrounds would be
needed to determine the broader clinical viability of the home-based component of
the intervention.
This study also trialled two experimental measures which targeted the children’s
identification of lexical–semantic and sublexical (phonological) features of words.
The word attribute identification task focuses on receptive skills and the results
demonstrated significant improvements in correct identification of semantic and PA
features of words post-intervention. These changes in performance were found not
only for items that were trained within the intervention but also on untrained items.
This suggests the children were able to generalize skills targeted in the intervention
to novel stimuli. Generalization effects from trained to untrained items have been
reported in other PA and vocabulary intervention studies (e.g., Wright 1993,
Moriarty and Gillon 2006). As noted above, the stimulus words were already
established within the children’s receptive lexicon thus allowing other semantic or
PA features of the words to be focused upon rather than on word-learning per se.
The second experimental measure trialled in this study was the word-association
task, which is an expressive test, in which the child must generate novel responses.
The results showed significant changes in both the lexical–semantic and sublexical
(phonological) associations of words at post-intervention. The children with SLI not
only gave significantly more word associations following intervention, but the type
of response they used changed at post-intervention for the semantic categories
Hybrid language intervention 679

(syntagmatic, paradigmatic) and the PA category (clang). The increase in the number
of novel word association responses post-intervention may also reflect improve-
ments in the children’s overall meta-linguistic knowledge. Increased meta-linguistic
demands have been reported on other types of semantic assessments (e.g., word
definitions; Benelli et al. 2006). The data offer support for further investigation of
word-association tasks as a developmentally appropriate measure of lexical–semantic
and sublexical change for children with SLI. The data also suggest that word-
association tasks may be an effective way of examining growth and lexical
organization in children particularly in terms of their depth of vocabulary
knowledge.
The two experimental tasks used in this study collectively reflect positive change
in the children’s lexicon both in terms of lexical–semantic and sublexical storage and
access measured using both expressive and receptive formats. They contribute to an
understanding of children’s semantic skills following intervention where we observe
shifts in vocabulary knowledge rather than just vocabulary size. They also further
validate the results of the clinical measures used in this study where significant
improvement in the rate and accuracy of single word expressive labelling skills was
also observed.
In summary, this feasibility study provides initial support for a hybrid-language
intervention approach that focuses on component skills of vocabulary knowledge
and PA within the context of oral narrative, storybook reading and drill-based
games. The efficacy of this intervention approach warrants experimental
investigation utilizing a randomized control or comparison group. Future studies
could address the specific interactional and cognitive processes that underlie spoken
language and PA learning during hybrid language intervention approaches for
children with SLI. Clinically, it would also be important to explore the efficiency and
long term effectiveness of the approach on spoken and written language
development.

Acknowledgements
This research was supported by a Central Coast Health Research Grant awarded to
the first author. The authors thank the parents and children who participated in the
study, and are grateful for helpful comments from two anonymous reviewers.

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