UNIT: 5

a) Critical review of developmental scales and norm-referenced tools for language

development for Indian languages
b) Differential diagnosis of child language disorders
c) General principles and approaches to management in child language disorders

Presenter: Ms Rachel Elizabeth Johnson

Guide: Dr Ramandeep

a) Critical review of developmental scales and norm-referenced tools for language

development for Indian languages

Developmental scales:

A developmental scale consists of an inventory of abilities and milestones. It can be regarded as

a simple form of psychometric test whose method of administration is not rigorously
standardised and whose normative data consist only of approximate mean ages at which the
various milestones are reached. A scale should be used primarily as a guide to normal
development. Although a below average performance can be described in terms of age
equivalence-that is, how many months behind the significance of this result is difficult to
evaluate because the psychometric data mentioned previously are not available (Hall, D. M., &
Baird, G. 1986).

Norm-referenced tools:

Norm-referenced tests are language testing approaches that provide information about the
knowledge and skills of the students tested. Norm-referenced test is the process of evaluating
(and grading) the learning of students by judging (and ranking) them against the performance of
their peers. The scores or a performance of a particular group (the ―normal group) as measured
in some way is known as ‘norm’. Norms may be used to compare the performance of an
individual or group with the norm group. Norms may be expressed by reference to such factors
as age, grade, region and special need group on a test (Brown 1976; Noll, Scannell & Craig,
1979). NRT is a test that measures how the performance of a particular test taker or group of test
takers compares with the performance of another test taker or group of test takers whose scores
are given as the norm. Norm-referenced standardized tests can use local, state, or national norms
as a base (Hussain, S., Tadesse, S., & Sajid, S. 2015).

Indian Test Materials:

1. 3D Language Acquisition Test:

Author: GeethaHerlekar (1986)

Age range: 9 to 36 months

Domains: Reception, Expression, Cognition

Total items: 27 (3 items in each group)

• Norm referenced tool

• The test items should be administered till 2 consecutive failures are obtained

• Child’s language age is determined by obtaining a 90% score at the highest level passed

• Norms obtained are based on a relatively small sample (90 no.)

• The reliability of the test could not be established

• Both due to time constraints

2. 3D LAT for Hard of Hearing:

Author: Usha K. R (1986)

Groups: 9

Age range: 9 to 36 months

Testing time: 10 to 20 minutes

Domains: Reception, Expression, Cognition

• Testing using Informant Interview Approach

• Useful in evaluating language and cognition in Hearing impaired

Limitations:

• Norms obtained are based on a relatively small sample (90 no.)

• The reliability of the test could not be established

• Both due to time constraints

• Not standardized

• Certain questions in the cognition domain needs modification (item 11, 13, 22, 23, 24, 26,
& 27) because verbal language is required

Article:
A study by Kamalini Pillai (1986) administered 3D LAT on 2 groups of children (group 1:
normal children 9months to 37 months, group 2: children with intellectual disability matching
the mental age to chronological age of group 1) and their performance on the test (3D LAT).
Results revealed that cognitive and receptive scores were higher than the expressive scores in the
mentally retarded children when compared to chronologically age matched normal.

3. Test of Psycholinguistic Abilities in Kannada:

Author: Karanth P (1980)

Domains: Phonology, syntax, semantics, discourse

Modalities: Receptive and expressive

Age range: children of elder age group

Critical appraisal:

 The test provides both qualitative and quantitative assessments at various linguistic levels
 A pattern of acquisition within the linguistic framework can be formulated
 A hierarchy in terms of achievement and be established and intervention planned
accordingly

Limitation:

 The test has limited applicability for assessing language in young children

4. Linguistic Profile Test – Kannada:

Development of LPT based on Test of Psycholinguistic Abilities in Kannada.

 Author: PrathibhaKaranth
 Domains: Phonology, syntax, semantics, Discourse
 Age range: 6 to 15+ years
 Language: Kannada
 Testing kit: a kit that contains picture cards & few real objects
 5. Syntax Screening Test in Tamil:

Author: Sudha, K.M. (1981)

Domain of language: Syntactic development

Sub tests: 10 (use of negation, determiners, WH questions, Yes/No questions, person, adjectives,
tenses, post position, comparatives superlatives, pronounal terminations)

Age range: 2 to 5 years

6. Test for Acquisition of Syntax in Kannada:

Author:Vijayalakshmi, A. R. (1981)

Age range: 1 to 5 years

Domain of language: Syntactic development

Sub tests: 19 (323 items)

Critical appraisal:

 It is a power test (no time limit imposed for completion)

 Toys and pictures are used as complimentary material to test sentence

7. Screening Test for Acquisition of Syntax in Kannada:short form of TASK

Author:Vijayalakshmi, A. R. (1981; modified in 1986))

STASK assesses the level of syntax acquisition in Kannada speaking children in the age range of
1 to 5 years. STASK has 50 items testing verbal comprehension and expression of 7 grammatical
categories and several sentence types; Simple sentences, person, case markers, adjectives, post-
position, defenite determiner, tense markers, WH questions, Yes/No questions, negations,
embedded sentences, co-ordinated sentences, narration. The test makes use of toys and materials
familiar to Indian society children and some pictures for testing.
STASK yields separate scores for comprehension and expression of different aspects of syntax
of the child’s verbal language. It also yields a language age.

The administration of the test is simple,and scoring is done instantly.

8. Language Test in Kannada for Expression in Children:

Author: Kathyayani H N (1984)

Age range: 5 to 8 years

Domains: nouns, verbs, numbers, gender, tenses, place markers, persons

Testing material: picture stimuli depicting daily activities (30 picture cards)

9. Comprehensive Language Assessment Tool for Children:

Authors: Navitha U. & K. C. Shyamala (2012)

Age range: 3 to 6 years

Domains: reception, expression and cognition

Child’s score is compared with the normative

10. Assessment of language development (ALD):

Authors:Jayashree. S Bhat, SudhaLakkanna, KathyayaniVenkatesh (2007)

Age range: 0 to 7 years

Domains: Receptive and expressive language skills

Has a picture manual

11. Comm DEALL Checklists (CDDC):

CDDC manual consists of checklists covering developmental domains for children, with norms
based on an Indian population.

Author: PrathibhaKaranth
Domains: 8 (Gross motor skills, Fine motor skills, Receptive language skills, Activities of daily
living, Expressive language skills, Cognitive skills, Social skills, Emotional skills)

Age range: 0 to 6 years

• Can be used as a screening measure for identification of developmental delays in specific

areas

• Used to profile children prior to intervention

• Criterion referenced test

Article:

Karanth et. al (2011), evaluated the degree of agreement among raters (inter-rater reliability)
while using a checklist like the CDDC. Results:The correlation between CR1 and CR2, between
PR1 and PR2 and between the average of CR (1 and 2) and the average of PR (1 and 2) over all
the domains, is greater than 0.89. This suggests high reliability.

12. Indian Scale for Assessment of Autism (ISAA):

First tool developed in India by National Institute for Mentally Handicapped for the National
Trust (2009).

• An objective assessment tool for persons with Autism

• Consists of 40 items rated on a ranging from (1-never, 5-always) 5-point scale

• Language: English, hindi

• 6 domains –

i. Social relationship and reciprocity

ii. Emotional responsiveness

iii. Speech - Language and communication

iv. Behaviour patterns

v. Sensory aspects
 vi. Cognitive component

Article:

A study by Sharmila Banerjee Mukherjee et al. (2015)determined the diagnostic accuracy of

Indian Scale for Assessment of Autism (ISAA) in children aged 2-9 year at high risk of autism,
and ascertained the level of agreement with Childhood Autism Rating Scale (CARS). ISAA had
aSensitivity 93.3, Specificity of 97.4, Positive and negative likelihood ratios 85.7 and
98.7Positive and negative predictive values of 35.5 and 0.08, respectively. Reliability was good
and validity sub-optimal (r low, in 4/6 domains).The role of ISAA in 3-9-year-old children at
high risk for Autism is limited to identifying and certifying Autism at ISAA score of 70. It
requires re-examination in 2-3-year olds.

13. Chandigarh Autism Screening Instrument (CASI):

There has not been any instrument developed in India for the purpose of community survey for
ASD, thus the need to develop a screening instrument led to the development of CASI.

• Dichotomous response format of ‘Yes’ and ‘No’

• Age range of 1½-10 year

• 37 items

Examples were added to the items such as ‘does your child look at what you are pointing at, e.g.
moon, bird, flower’ (Item no. 1) and ‘does your child play imaginary games like talking on
phone, playing with dolls or setting up a toy shop’ (Item no. 12)

Critical appraisal:

• CASI instrument developed in the present study was found to have a sensitivity of
89.16% and specificity of 89.13% at a cut-off score of 10.

• The screening instrument had questions that needed to be read out and not explained;
hence, training was not required

• Development of scale was done using recognized procedure

• Easy to administer and takes about 15 -20 min for administration

 14. CASI Bref:

Is a brief screening instrument.

• Four core items pertaining to the essential features of ASD

• Response format of ‘Yes’ and ‘No’

• These items were pertaining to eye contact, ability to communicate needs through verbal
or non-verbal means, peer interaction and odd, repetitive behavior.

Critical appraisal:

• Adequate psychometric properties

• Sensitivity of four-item screening instrument was 73.49 per cent. It was lesser than 37-
item screening instrument (sensitivity 89.16%)

• When time is a limitation, CASI Bref (4-item version) can be used (e.g. in camp setting)

15. Children’s acquired aphasia screening test in Kannada (CAAST-K):

Originally in English CAAST (Whurr& Evans, 1986)

• CAAST was designed to identify the presence of acquired language disturbances in

brain-damaged children

• Authors: Maria Grace Treasa & Shyamala K C (2007)

• Age range: 3 and 7 years

• Test battery comprises of 25 subtests

• Domains: 6 (Visual, Auditory, Pre-speech and speech, Expressive language, Drawing,

Gesture subtests)

Critical appraisal:

• CAAST-K has yielded normative data pertaining to language processes in Kannada

speaking children belonging to South Indian city of Mysore and lower socio-economic
status
 • Is a valuable screening tool

• It is more likely that ACA may go unnoticed or misdiagnosed (as developmental

language disorder) than adulthood aphasia

16. INCELN (INDT-ASD):

INCLEN Diagnostic Tool for Autism Spectrum Disorder (INDT-ASD), has been developed in
India. It takes into account various ethnic and religious variables present in this culturally vibrant
country, especially in respect to peer interaction and play skills.It is also available in various
Indian languages, including Hindi, Malayalam, Odia, Konkani, Urdu, Khasi, Gujarati and
Telugu. It facilitates interviewing of caregivers as well as interaction with the child. Test can be
completed in a short time. performance of the INDT-ASD was stated to be ‘equally good among
pre-school (< 6 years) and primary school (≥ 6 years) children’. INDT-ASD is currently mapped
closely to the DSM-IV TR.

Article:

A study by ShamiliAsokan et al in (2016) demonstrated INDT-ASD’s clinical utility for speech-

language pathologists (SLPs). Children between the age range of 2–10 years with a referral
diagnosis of either ASD or social communication disorder (SCD) were evaluated using CARS-2
and categorized as ASD group and SCD group. INDT-ASD was then administered. When all
children were involved in a play session, observations made were then compared to the
responses obtained through parental interview. All forty children were assessed on the
INDT-ASD, and the scores on this tool showed that, only 34 children qualified to get a diagnosis
of ASD, and 6 children as “no ASD”. The five children who were diagnosed as SCD/no ASD by
CARS were correctly identified as “no ASD” by INDT-ASD. Further, of the 35 children
diagnosed as ASD based on DSM-V guidelines and CARS-2, 34 children were correctly
identified as “ASD present” by INDT-ASD and one child was diagnosed as no ASD.
Thiseffectively put the diagnostic accuracy of INDT-ASD at 97.22%.

17. Manipal Manual of Adolescent Language Assessment

 Authors: Karuppali, Sudhin& Bhat, Jayashree S (2015)
 Age range: 10 – 16 years (includes elder children)
  Language: English
 Modality: auditory and visual
 Domains: semantics and morphology
 Test time: 1.5 hours
 Scoring: based on task specific cut-offs

Limitation:

• This material can be used only on literates and English-speaking population

Other Indian tests:

1. Development of Test for Syntax in Malayalam. In Santhi, S.N. (2008). Unpublished

master’s dissertation. University of Mysore, Mysore, India.
2. Sentence Imitation Test in Malayalam (SIT-M). Treasa, M. G., &Shyamala, K. C. (2013).
Unpublished part of the ongoing Doctoral thesis titled “Emergence of expressive
grammatical morphology in Malayalam-speaking children with and without language
impairment,” AIISH, University of Mysore, Mysore.

b) Differential diagnosis of child language disorders

DIAGNOSIS

Narrowly defined, a clinical activity designed to name a disease or disorder through investigative
methods and finds its causes, diagnosis often is aimed at determining whether a disorder exists,
and if it does, its nature and degree of severity; an element of assessment, which is a more
comprehensive set of activities.

(M. N. Hegde; Hegde’s pocket guide to Assessment in Speech language pathology)

DIFFERENTIAL DIAGNOSIS

Distinguishing disorders that present some common or similar symptoms and sometimes similar
etiologic factors with subtle variations; usually done with the help of symptom complex, and
whenever possible, by identifying different underlying factors or causes; an important task of
assessment needed to make effective and specific treatment recommendations.

(M. N. Hegde; Hegde’s pocketguide to Assessment in Speech language pathology)

The purpose of differential diagnosis is:

● To establish a baseline for the individual child’s language disorder

● To assess reasonable progress

● To help in setting up an appropriate treatment/ management plan

1. INTELLECTUAL DISABILITY (acc to DSM V)

INTELLECTUAL SPECIFIC COMMUNICA ASD MAJOR NEURO

DISABILITY LEARNING TION COGNITIVE
DISORDER DISORDERS DISORDER
Characterized by Impairment Impairments Presence of Significant
global deficits in confined to a that are confined persistent deficits cognitive decline
intellectual specific area of to speech and in social from a previous
functioning and academic language communication level of
deficits in adaptive achievement. problems. There and social performance in one
functioning that There are no are no deficits in interaction, along or more cognitive
result in failure to deficits in intellectual with restricted domains such as
meet developmental intellectual and functioning. repetitive patterns executive function,
and socio cultural adaptive of behaviours, learning, memory
standards for behaviour. interests or and language.
personal activities along
independence and with some IDs. If
social responsibility both the criteria
are met then both
diagnosis should
be given.

Autism vs. ID

The unique characteristics of autism that distinguish it from intellectual disabilities include

 Lack of interest in people, feelings, affection, and communication;

 Preoccupation with routines;
 Interest in objects versus people;
 Unusual language including pronoun reversal, wrong word order, and echolalia
 Child with autism have fascinated with spinning objects, not responding with name
call even though both of them have same type of expressive language delay
 ID children cognitive delay becomes more apparent when they enter preschool or
kindergarten, but some of social skills of autism may present before only

Feature ASD ID

Stereotyped present Present( severe cases)

behaviors

Impairment Specific impairment in social Global impairment

communication and behaviors

2. HEARING IMPAIRMENT

Hearing Impairment Vs Autism

If it’s hearing loss that is NOT related to If there’s hearing loss that can be related
autism to autism

● The child loves to be touched,

● The child does not like to be
enjoys giving hugs
touched or hugged
● The child makes eye contact
● The child often seems “aloof” and
● The child can take another person’s
prefers to be alone
point of view. However, this
● The child may not sustain or make
development may be slow to
eye contact
develop
● The child may have a problem with
● The child can feel socially isolated
taking another’s person’s point of
due to the lack of communication.
view
● The child often communicates with
● The child may not communicate
 pointing or with hand gestures
● The child often asks questions and
is relatively comfortable
language
● The child can often accept change
● The child can often accept multi-
sensory inputs at once
through devices, signs or facial
expressions
with ● The child may “echo” a person
● The child may not understand or
process language
● The child may engage in repetitive
hand gestures and odd postures.
● The child has problems with multi-
sensory input and may prefer to
avoid certain tastes, textures, sights,
sounds, and lights

Hearing impairment Vs Intellectual disabilities

● Characteristic speech, voice and resonance problems associated with hearing impairment
are less marked in individuals with intellectual disability, although omission of
grammatical morphemes and limited syntactic structures will be common features.
● An independent diagnosis of HI and ID will support the distinction between the
communication disorders in two groups (M N Hegde)

HI Vs SLI

● Note that SLI is limited to an obvious and dominant language disability without serious
intellectual or sensory problems (M N Hegde)

3. AUTISM SPECTRUM DISORDERS

Autism vs. Asperger

 When your patient was a child, did they have a “clinically significant” general delay
in language (using single words by the age of 2 years, using communicative phrases by
the age of three years)?”
 If the answer is “yes”, regardless of any other information that is obtained, person does
not have Asperger Disorder
  But Vice versa is not true, where when a child with no language delay comes, we cannot
rule out autism.
 Children with Asperger’s syndrome have better language skills & normal or even
superior intellectual levels compared to those with autism
 children with Asperger’s syndrome are eager to talk, talk on a topic of their interest, &
are unaware of listener’s indifference or lack of interest in what they say

Autism vs. Hearing Impairment

 Children with HI do not exhibit unusual and stereotypic verbal or nonverbal behaviours;
 Children with HI have an independent audiological diagnosis;
 Speech and voice characteristics associated with HI also help distinguish the 2 types of
disorders

Autism vs. Brain Injury

 Children with brain injury may occasionally make inappropriate statements; may have
difficulty concentrating on the task at hand, may be mute or severely impaired in their
expressive speech;
 A clear history and medical evidence or recent brain injury, other physical evidence of
paralysis or paresis, altered states of consciousness, and neurological signs of brain injury
will be absent in children with autism

Autism vs. Childhood schizophrenia

Autism Childhood schizophrenia

“Autism is defined by a triad of deficits in Characterized by hallucination, disorganized

social reciprocity, communication and speech, delusions, catatonic behavior and
repetitive behaviors or interests, each of can negative symptoms, with the onset before 13
occur at different levels of severity” years

(Wetherby, Prizant.)
Has failure or delay in the development Has loss of reality after development is better
established
 Show relativity steady course Marked by remissions and relapse

Autism vs. ADHD

Features ADHD ASD

Being easily distracted √
Frequently shifting from one topic to other √
Unresponsive to common stimuli √
Difficulty in focusing, concentrating on a singular √
item
Intense focus on single item √
Talking nonstop √
Trouble sitting still √
Features ADHD ASD
Lack of concern or inability to react to others feelings √ √
Repetitive movements, such as rocking twisting √
Avoiding eye contact √
Withdrawn behaviors √
Delayed developmental milestones √
Stereotyped behaviours Not common present
Pre occupation (adherence to specific non functional Not common present
routine)
anxiety present absent
attention Lack of focus and Internal
external distractibility
distractibility

4. SLI (SPECIFIC LANGUAGE IMPAIRMENT)

Feature SLI DYSLEXIA AUTISM

 Echolalia Only in severe cases absent present
Pragmatics Reduced performance with Not affected Affected
respect to acts of speech
(warning, naming, requesting,
questioning)
Phonological Certain phonological errors are Difficulty in Difficulty in
development present (final consonant blending and formatting
deletion, cluster reduction, weak segmenting phonemes
syllable deletion )
Syntax Simplified; omissions are most Constructs Significant
common syntactically poor weakness. Delay
sentences in syntax
acquisition. Uses
memorized pieces
of speech
Lexical Word finding problems and Word finding Extremely
abilities naming errors are present problems and limited; limited
naming errors are vocabulary
present

SLI Vs Late talkers

SLI Late talkers

“It is a form of developmental language Late language emergence is a delay in
disorder, occurring in the absence of language onset with no other diagnosed
mental retardation, sensory deficits, evident disabilities or developmental delays in
neurological damage, serious emotional other cognitive or motor domains. Also
problems and environmental deprivation.” referred as “Late talkers or late language
(Leonard 1998) learners”
(ASHA)
The prevalence of SLI is 7%
Phonology: Not all children have impaired
phonology
Semantics: Greater impairment in
production
Syntax: Slow in developing word
combination.
Pragmatics: Roughly normal
pragmatic development
Prevalence of LLE in 2 year-old children
primarily range between 10% and 20%
(Taylor, Rice, Slegers 2007)
More limited phonetic repertoire and use
fewer consonants than age matched peers.
Semantics: Vocabulary delay seen which
resolves by 3-4 years of age
Produce ungrammatical utterances at
higher rates
Poor pragmatic development
 c) General principles and approaches to management in child language disorders

1. GENERAL PRINCIPLES IN THE INTERVENTION OF CHILD LANGUAGE

DISORDERS:

In 2000, Rose and Meyer put forth a framework based on the premise that every individual,
regardless of physical, cognitive, sensory, learning, or other type of disability, is entitled to
universal access to information and to learning. Their model is characterized by three universal
design principles for learning (UDL): multiple means of representation, multiple means of
expression, and multiple means of engagement.

As applied to educational and clinical settings, it is meant to be a theoretical framework for

providing the most appropriate supports for children and adults and includes:

■ Multiple Means of Representation:  There must be multiple methods available by which

individuals can access and learn important information and skills (e.g., traditional textbook
supplemented by CD-ROM, speech-to-text media)

■ Multiple Means of Expression: Various methods and modalities must be available for
individuals to demonstrate their mastery of information and skills

■ Multiple Means of Engagement:  Individuals must be provided with enough successful

learning opportunities and meaningful interactions to maintain adequate motivation for learning

UDL includes accommodations, modifications, and assistive technology.

Accommodations are changes that help clients overcome or compensate for their disability, such
as preferential seating or allowing written rather than spoken communication.
Modifications are changes in informational content or expectations of an individual’s
performance. Examples include decreased amount of classwork/ homework or reduced goals for
productivity or learning.

Also inherent in UDL is the use of assistive technology (AT) as supports for students and adults
with disabilities (Dalton, Pisha, Eagleton, Coyne, &Deysher, 2002; Hall, Meyer, & Rose, 2012;
Ralabate, 2011; Strangman, 2003). AT may include speech-to-text software that converts speech
into text documents, translation software for English language learners, and Internet access as a
means of information gathering.

The basic principles of effective intervention are consistent with a UDL framework and apply
to clients of all ages and disorders. These include:

■ Intervention is a dynamic rather than static process in which the clinician continuously
assesses a client’s progress toward established goals and modifies them as necessary

■ Intervention programs should be designed with careful consideration of a client’s verbal and
nonverbal cognitive abilities. Knowledge of a client’s level of cognitive functioning is critical to
making decisions about eligibility for treatment and selecting appropriate therapy objectives

■ the ultimate goal of intervention is to teach strategies for facilitating the communication
process rather than teaching isolated skills or behaviors (to the extent possible). Whereas skills
are required to achieve specific outcomes in given situations, strategies enable the individual to
know when and how to use these skills in new and varied learning contexts

■ Speech and language abilities are acquired and used primarily for the purpose of
communication and therefore should be taught in a communicative context. To the extent
possible, therapy should occur in realistic situations and provide a client with opportunities to
engage in meaningful communicative interactions

■ Intervention should be individually oriented, based on the nature of a client’s specific deficits
and individual learning style

■ Intervention should be designed to ensure that a client experiences consistent success

throughout all stages of the therapy program

■ Intervention is most effective when therapy goals are tailored to promote a client’s knowledge
one step beyond the current level

■ Intervention should be terminated once goals are achieved or the client is no longer making
demonstrable progress

■ Intervention practices must be based on the best scientific evidence available

 ■ Intervention should be sensitive to a client’s values and beliefs as well as cultural and
linguistic background.

To provide effective intervention for any type of communication disorder, speech language
pathologists must acquire certain essential clinical skills. These skills are based on fundamental
principles of human behavior and learning theory.

The following categories of clinical skills are the building blocks of therapy and serve as the
foundation for all disorder-specific treatment approaches:

■ Programming: Selection, sequencing, and generalization of therapy targets

■Behavior modification: Systematic use of specific stimulus-response-consequence procedures

■ Key teaching strategies: Use of basic training techniques to facilitate learning

■ Session design: Organization and implementation of therapy sessions, including interpersonal

dynamics

■ Data collection: Systematic measurement of client performance and treatment efficacy

Successful intervention requires the ability to effectively integrate these five parameters into a
treatment program.

2. APPROACHES TO MANAGEMENT IN CLD

Interventions can vary along a continuum of naturalness (Fey, 1986), ranging from contrived or
drill-based activities in a therapy room (clinician directed) to activities that model play or other
everyday activities in more natural settings (child centered), to those that use activities and
settings that combine both approaches (hybrid)

Various approaches in the intervention of child language disorders

a) Clinician centered approach
b) Client centered approach
c) Hybrid approach
d) Functional approach
THE CLINICIAN-DIRECTED APPROACH

In clinician-directed approaches, the clinician specifies materials to be used, how the client will
use them, the type and frequency of reinforcement, the form of the responses to be accepted as
correct, and the order of activities—in short, and all aspects of the intervention. Clinician-
directed approaches, also referred to as drill (Shriberg& Kwiatkowski, 1982a) or discrete trial
intervention (DTI). Attempt to make the relevant linguistic stimuli highly salient, to reduce or
eliminate irrelevant stimuli, to provide clear reinforcement to increase the frequency of desired
language behaviors, and to control the clinical environment so that intervention is optimally
efficient in changing language behavior.

Clinician directed approaches tend to be less naturalistic than other, because they involve so
much control on the part of the clinician and because they purposely eliminate many of the
natural contexts and contingencies of the use of language for communication.

An advantage of clinician-directed approaches is that they allow the clinician to maximize the
opportunities for a child to produce a new form, producing a higher number of target responses
per unit time than other approaches allow. This gives opportunities for the child to get extended
practice using a new form or function.

Three major varieties of clinician-directed activities that can provide some of these structured
opportunities: drill, drill play, and modeling.

 Drill

Shriberg and Kwiatkowski (1982a) defined several types of clinical activities in terms of their
degree of structure. The most highly structured in their framework is drill, which makes use of
the classic DTI format. In a drill activity, the clinician instructs the client concerning what
response is expected and provides a training stimulus, such as a word or phrase to be repeated.
These training stimuli are carefully planned and controlled by the clinician. Often they contain
prompts or instructional stimuli that tell the child how to respond correctly, for example by
imitating the clinician. These prompts are gradually reduced or faded on a schedule
predetermined by the clinician.

 In drill activities, the clinician provides a stimulus, or antecedent (shows an object or

picture, for example), the client provides a response to the clinician’s stimulus, with or
without prompting
 If this response is the one the clinician intended, the child is reinforced with verbal praise
or some tangible reinforcer, such as food or a token. A motivating event also may be
provided
 If the client’s response is an incomplete attempt at the target, the clinician attempts to
shape the response by reinforcing the production of parts of the complete target
 Once the client can produce the full form of the intended target, the clinician begins
lowering the level of prompting provided, until the client can produce the form
independently, without any support from the clinician

Drill is the most efficient intervention approach in that it provides the highest rate of
stimulus presentations and client responses per unit time.
One problem with drill in Shriberg and Kwiatkowski’s (1982a) study was that neither the clients
nor the clinicians liked it very much. The clients did not find it very motivating, and the
clinicians were uncomfortable with its high degree of structure and low level of motivation.

 Drill play

Drill play is another clinician-directed approach, which differs from drill only in that it attempts
to provide some motivation into the drill structure. It does this by adding an antecedent
motivating event, that is, one that occurs not only after the target response is reinforced but also
before it is even elicited.

Thus there are two motivating events in drill play, one that goes along with the original training
stimulus the (antecedent motivating event) and one that follows the reinforcement (the
subsequent motivating event).

For example, if the activity is to name clothing items and for correct response, a sticker is
provided to client as a motivation. Then as an antecedent motivating event, the client may be
allowed to choose any sticker from a sheet of clothing stickers that he or she would like to put in
the album. The training stimulus would elicit the name of clothing item represented by the
sticker. After reinforcement for correct labeling (such as getting a cereal piece to eat), the client
would be allowed to put the sticker in the album, as a subsequent motivating event.

Shriberg and Kwiatkowski (1982a) found drill and drill play to be equally efficient and effective
in eliciting responses in phonological intervention.

 Modeling

Fey (1986) presented a second clinician-directed alternative to straight drill procedures. This
arises from social learning theory and involves the use of a third-person model—thus the name,
modeling approach. Like drill, modeling uses a highly structured format, extrinsic reinforcement,
and a formal interactive context. But here, instead of imitating, the child’s job is to listen. The
client listens as the model provides numerous examples of the structure being taught. Through
listening, the child is expected to induce and later produce the target structure. In Leonard’s
(1975a) modeling procedure, a “confederate,” such as a parent, is used by the clinician as a
model.

Advantages and disadvantages of clinician centered approach:

The authors share the advantages these approaches provide:

 specification of linguistic stimuli,

 clear instructions and criteria for appropriate responses,
 reinforcement designed to increase the frequency of correct responding,
 high levels of efficiency in evoking maximal numbers of responses per unit time, and
  Proven effectiveness in eliciting new language behaviors
They all share certain disadvantages too.

 They are relatively “unnatural” and are dissimilar to the pragmatic contexts in which
language is used in everyday conversation
 Perhaps as a result, their targets are not always spontaneously incorporated into everyday
language use, even when they reach criterion levels in the structured intervention
situation
 These facts imply that clinician-directed approaches ought to be considered in some
phases of intervention to evoke use of forms that the child is not using very often or at all
in spontaneous conversation, because of their great efficiency for this purpose
 Because of their drawbacks, though, clinician-directed approaches should be combined
with other modalities to effect the transition from use in formal intervention contexts to
use in everyday interactions
CHILD-CENTERED APPROACHES

Child centered approaches go by several names, including indirect language stimulation,

language facilitation (Fey, 1986), facilitative play (Hubbell, 1981), pragmaticism (Arwood,
1983), and developmental or developmental/pragmatic approaches (Prizant&Wetherby, 2005a).
In using a child-centered approach, a clinician arranges an activity so that opportunities for the
client to provide target responses occur as a natural part of play and interaction. From the child’s
point of view, the activity is “just” play or conversation. A clinician may use a variety of
linguistic models as instructional language when they seem appropriate in the context of the
child’s activity. There are no tangible reinforcers, no requirements that the child provide a
response to the clinician’s language, and no prompts or shaping of incorrect responses when they
do occur.

Child-centered intervention puts the child in the driver’s seat. Apart from choosing the materials
with which the child will play, the clinician does not direct the activity. Rather, we follow the
child’s lead, doing what he or she is doing and talking about what he or she is talking about or
doing. This has a great many advantages for both obstinate and unassertive clients. Rather than
spending all their energy resisting, in the case of the obstinate child, or passively complying, as
the unassertive one will do, clients engaged in a child centered activity spend their time in
natural, enjoyable play with a very accepting and responsive adult who makes a consistent and
salient match between what they are doing and the language used to talk about it. And all clients
can benefit from opportunities to see how actions and objects are mapped onto words in the
context of fun, familiar activities.

The key to this approach is to respond to the client. To do this, we have to wait for the client to
do something. Ideally, that something is to talk. If it is, we can respond to the child’s language
with one of several specific verbal techniques. Sometimes, though, we must interpret some
action of the child’s and act as if it were intended to communicate, even though the client may
not truly have had such an intention. Once the child has said or done something that we can
interpret as communicative, we then respond to the behavior in a way that models
communicative language use. Unlike in the clinician-directed approach, we are not trying to
elicit specific structures from the client. Instead, we react to the child’s behavior, placing it in a
communicative context and giving it a linguistic mapping. The clinician does this mapping by
using a variety of techniques that constitute the language facilitation approach. These techniques
can be summarized as follows:

1. Self-talk and parallel talk: In self-talk, we describe our own actions as we engage in
parallel play with the child. If the child is building a block tower, we copy the tower with
our own blocks, saying as we do, “I’m building. I’m building with blocks. See my
blocks? I’m building.” Self-talk provides a clear and simple match between actions and
words. By using the child’s actions and matching our own words and actions to them, we
model how to comment on our actions with language.
In parallel talk, we provide self-talk for the child. Instead of talking about our own
actions, we talk about the client’s, providing a running commentary, something like the
play-by-play at a sporting event. To take the same block-building example we used
before, parallel talk might sound like, “You’re building. You put on a block. You did it
again. You put on another block. Now it’s big! You’re building a big one!”
Parallel talk also can help us make connections to children with severe disorders whose
choice of actions may not be typical. For example, children with autism, if given a set of
toys, may use them in unconventional ways. Instead of building a tower with blocks, a
child with autism may smell them or focus on the texture of the rug underneath the
blocks. Parallel talk allows us to share this child’s focus. Again, we talk about the child’s
focus of attention; for example, “You see the rug. It’s green. It’s a green rug. It’s soft.
Can you feel it? It’s soft. The blocks are on the rug. They’re on the soft, green rug.”
Self-talk and parallel talk are helpful for children who are not talking at all in the clinical
setting. The clinician’s use of these techniques maximizes the chances that the child will
use the model in producing a spontaneous utterance. Once the child does, the clinician
can respond with other techniques included in the indirect language stimulation approach.
These techniques are designed to provide a verbal response that is highly contingent on
the child’s own utterance.

2. Imitations: We often ask children to imitate what we say in intervention. But instead, we
can turn the tables and imitate what the child says. Research suggests that children who
imitate show advances in language development (Carpenter, Tomasello, &Striano, 2005).
The more the child says, the more the opportunities there are for practice of phonological,
lexical, and syntactic forms and the more opportunities there are for feedback. If the child
repeats our imitation, we can go on to use some of the other forms of contingent
responses available in indirect language stimulation to provide more focused and
extensive feedback. Or, alternatively, we can use the child’s imitation to initiate a
 repeated back-and-forth exchange that will help the child develop this basic turn-taking
structure for conversation.

3. Expansions: In expanding the child’s utterance, we take what the child said and add the
grammatical markers and semantic details that would make it an acceptable adult
utterance. For example, if the child puts a toy dog in a dollhouse and says “doggy,” or
“doggy house,” this could be expanded as “The doggy is in the house.”
Expansions have been shown to increase the probability that a child will spontaneously
imitate at least part of the expansion (Scherer & Olswang, 1984). Moreover, Saxton
(2005) reviewed literature to suggest that expansions specifically have been associated
with grammatical development for a number of structures in a number of diagnostic
groups. In more current literature, these are sometimes called recasts (Camarata& Nelson,
2006).

4. Extensions: Some writers call these responses expatiations (Fey, 1986). They are
comments that add some semantic information to a remark made by the child. In our
“doggy house” example, saying “He went inside” or “Yes, he got cold” could extend this
remark. Cazden (1965) and Barnes, Gutfreund, Satterly, and Wells (1983) showed that
adults’ extensions are associated with significant increases in children’s sentence length.

Owens (2009) called the latter three kinds of responses— imitation, expansions, and
extensions—consequating behaviors on the part of the adult. This is important because
anything that increases the rate of child talk has positive consequences for language
development. In particular, these consequating remarks provide the child with
information about how to encode in a more mature linguistic form the ideas they are
already expressing.

5. Buildups and breakdowns: We start by expanding the child’s utterance to a fully

grammatical form. Then we break it down into several phrase-sized pieces in a series of
sequential utterances that overlap in content. Let’s take the “doggy house” example
again. To do a buildup and breakdown on this utterance, we might respond, “Yes, the
doggy is in the house. The house. He’s in the house. In the house. The doggy is in the
house. The doggy. The doggy’s in the house.” Cross (1978) found that these types of
responses, too, are associated with language growth in normally developing children.

6. Recast sentences: These are similar to expansions. Expansions, elaborate the child’s
utterance into a grammatically correct version of the intended sentence type. In recasting,
we expand the child’s remark into a different type or more elaborated sentence. If the
child makes the statement “doggy house,” we can recast it as a question, “Is the doggy in
the house?” or a negative sentence (used as a playful denial of the child’s utterance),
 “The doggy is not in the house!” or even a negative question, “Isn’t the doggy in the
house?”
HYBRID APPROACHES

According to Fey (1986), hybrid intervention approaches have three major characteristics.
Unlike child-centered approaches, which focus on general communication, hybrid approaches
target one or a small set of specific language goals. Second, the clinician maintains a good deal
of control in selecting activities and materials but does so in a way that consciously tempts the
child to make spontaneous use of the types of utterances being targeted. Finally, the clinician
uses linguistic stimuli not just to respond to the child’s communication but to model and
highlight the forms being targeted. Several forms of hybrid intervention are: focused
stimulation, vertical structuring, milieu teaching, and script therapy.

 Focused stimulation

In this approach, the clinician carefully arranges the context of interaction so that the child is
tempted to produce utterances with obligatory contexts for the forms being targeted. The
clinician helps the child succeed in this by providing a very high density of models of the target
forms in a meaningful communicative context, usually play. The child is not required to produce
the target forms, however—only tempted. Because the clinician provides many models of the
target form in a meaningful context, this approach is very effective for improving comprehension
of a form, as well as production (Weismer, Venker, & Robertson, 2016).

 Vertical structuring.

Vertical structuring is a particular form of expansion used like focused stimulation to highlight
target structures.

Example of Vertical Structuring:

A picture of children visiting a zoo is shown to the child.

Clinician: Look at this. What do you see? (If the child does not respond or makes a remark
unrelated to the picture, the clinician directs the child’s attention to a specific referent in the
picture and asks again, “What do you see here?”)

Client: Lion.

Clinician: Yes, and what is the lion doing?

Client: Roar.

Clinician: Yes, he’s roaring. The lion is roaring.

There we see that the clinician responds to a child’s incomplete utterance with a contingent
question. The child responds to the question with another fragmentary remark. The clinician then
takes the two pieces produced by the child and expands them into a more complete utterance.
The child is not required to imitate this expansion. The fact that children often imitate adult
expansions of their own utterances in normal development is the basis for the hope that children
with language impairments will take these expanded models of their own intended utterances as
a cue for spontaneous imitation. If they don’t, the clinician simply goes on to elicit another set of
related utterances from the child and offers the vertically structured expansion again.

Vertical structuring is obviously less naturalistic than standard language facilitation techniques in
that it involves the clinician’s providing a specific nonlinguistic stimulus (such as a picture),
targeting a particular form, and attempts to elicit particular language behavior from the child. But
it does use a naturalistic response on the part of the clinician and takes the child’s spontaneous
utterance as the basis for the clinician response, rather than requiring an imitation.

 Milieu communication training

Milieu teaching includes several different techniques that apply operant principles to quasi-
naturalistic settings. Hancock and Kaiser (2006) discuss three major components that
characterize this approach:

(1) Environmental arrangement,

(2) Responsive interaction, and

(3) conversation-based contexts,

That use child interest and initiation as opportunities for modeling and prompting
communication in everyday settings. These methods make use of imitative cues and extrinsic
reinforcement but do so during interactive activities that have been carefully arranged by the
clinician to elicit child initiations, necessitate social communication on the part of the client, and
provide natural consequences for the communication.

Hart and Risley (1975) called this approach incidental teaching.

In their variation of the method, the clinician arranges the setting so that things the client wants
or needs to complete a project are visible but out of reach. The child selects the topic of
conversation by making some kind of request, such as gesturing or looking toward the desired
item. The clinician responds first with focused attention. This involves moving toward the child,
making eye contact, and waiting expectantly to see whether the child offers a more elaborated
request. If not, the clinician asks a question. The question form varies, depending on the
clinician’s goal. “What?” may be used if the target is simply for the client to produce verbal
requests? “Which one do you want?” could attempt to elicit sentences with adjectives. “Why do
you want it?” might be used if the goal is sentences with “because” clauses. If this question
produces the target response, the clinician provides a confirmation, which includes a model of
the target form (Client: “Want red marker.” Clinician: “Oh, you want the red marker. Here it
is.”).

If the question fails to produce the target response, a prompt is provided. Prompts can be general
requests for the target, such as “You need to tell me.” Or they can be requests for partial
imitations, such as “Say, ‘I need a marker because . . .’” They can also be requests for complete
imitations, such as, “Say, ‘I want a red marker.’” If the child responds appropriately to the
prompt, a confirmation is provided and the communicative goal is achieved (the child gets the
marker). If not, one more attempt to prompt is made. If this also fails, the child still gets what he
or she wants. The clinician tries again to elicit more elaborated language on the child’s next
attempt at communication.

A similar method is the mand-model approach of Rogers-Warren and Warren (1980).

There are two major differences between this and incidental teaching. The first is that the
clinician does not need to wait for the child to initiate communication. The clinician carefully
observes the child, and when the child seems to show some interest in some aspect of the
environment, the clinician “mands” (requests) an utterance with a stimulus, such as “What’s
that?” or “Tell me what you need.”

The second difference is that the goals are stated very generally. Rather than specific form or
meaning targets, the clinician is merely trying to elicit one-word utterances from some clients,
two-word sentences from others, or complete grammatical sentences from more advanced
clients.

In this way, the mand-model approach can be easily adapted to work with groups of clients,
where each might have his or her own set of goals, and prompts are individualized to the goals of
each client. If the child provides the target response, he or she is verbally reinforced and given
the desired item (“Good talking! You asked for the marker, so here it is!”). If the child does not,
prompts similar to those used in incidental teaching are used.

Franco, Davis, and Davis (2013), Fey, Warren, Bredin-Oja, & Yoder (2016), Warren and
colleagues (2006), and Yoder and Warren (2001; 2002) discuss an additional variation:
prelinguistic milieu teaching (PMT).

This method is designed for children not yet using spoken language, at developmental levels of 9
to 18 months old, although they may be of chronological ages up to 6 years old. The goal of
PMT is to develop the basic intentional communication skills necessary for early language
development by increasing the frequency, maturity, and complexity of nonverbal communicative
acts. It has been used effectively with preverbal children with autism, developmental disorders,
language delays, and augmentative and alternative forms of communication (AAC) users.

Finally, Kaiser and Wright (2013), Kaiser and Hampton (2016), and Hancock and Kaiser (2006)
discuss enhanced milieu teaching (EMT).

This method has been shown to be especially effective for children who meet the following
criteria:

(1) Produce some verbal imitation,

(2) Have at least 10 productive words, and

(3) Are in the early stages of language development, with MLUs from 1 to 1.5.

The approach has been used with clinicians, parents, and teachers as agents of intervention, but
most of the research on EMT has focused on parent-delivered therapy. It incorporates methods
from both incidental teaching and the mandmodel approach.

 Script therapy

Olswang and Bain (1991) discussed script therapy as a way to reduce the cognitive load of
language training by embedding it in the context of a familiar routine. Here the clinician
develops some routines or scripts with the child in the intervention context.

For example, a clinician may institute a routine of placing a name tag on a peg when the client
enters the room or always passing out supplies for snacks in the same sequence. Alternatively,
the clinician reenacts scripts the child already knows. These already known scripts could include
eating at a fast-food restaurant, for example.

In the intervention activity, the known script is disrupted in some way, challenging the child to
communicate, to call attention to, or to repair the disruption. For example, the teacher can begin
to give out cookies before the napkins have been distributed. The clinician can withhold turns,
passing over one child when she is distributing drawing supplies. The clinician can violate the
normal uses of objects in routines. For example, she can wear the clients’ name tags on her head
one day, or she can hide objects needed to complete routines. If she locks the classroom each day
as the class leaves for recess, she can hide the key and pretend to leave without locking up.

Owens proposed a functional approach in the intervention of language disorders.

FUNCTIONAL APPROACH

A functional language intervention model attempts to target language features that a child uses in
the everyday context, such as the home or the classroom, and to adopt that context so that it
facilitates the learning of language. The functional approach recognizes a need to orient language
training toward the inclusion of family members and teachers as language facilitators and toward
the use of everyday activities for encouraging functional communication.

Principles:

 The language facilitator as reinforce.

As communicators, we continue to interact with those individuals who provide positive
feedback and reinforcement. Each of us avoids communicating with certain individuals
who are nonresponsive, caustic, or overly critical. Children respond most readily to adults
who convey genuine caring and respect for them. As much as possible, intervention
should be nonintrusive, with facilitators providing supportive, evaluative feedback to a
child. By reducing the authority-figure persona, demonstrating an attentiveness and a
willingness to adopt a child’s topics, and remaining accepting while providing evaluative
feedback, an SLP can send message of acceptance of the child as a partner
 Close approximation of natural learning
Language intervention strategies should approximate closely the natural process of
language acquisition. The strategy should be communicative in nature and should use
language as it naturally occurs (Mahoney and Weller, 1980). Teaching language devoid
of its communicative function deprives a child of intrinsic motivation and of one essential
element of generalization
 Following developmental guidelines
The language development of typical children can guide the selection of training targets.
From the normal developmental chart we will get to know the level of the child and what
next level of language should be taken as the goal. So we can plan in that hierarchical
order.
 Follow the child’s lead
 Active involvement of the child

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