Speech and language interventions for young children with communication disorders

Speech and language interventions for young children with communication disorders include
a variety of specific techniques. The specific intervention techniques reviewed in this section
reflect the available scientific literature that met criteria for adequate evidence about
efficacy. There are other techniques used in clinical practice that are not presented in this
guideline.

There are several ways to classify these techniques and an intervention for an individual
child usually incorporates a number of specific techniques. One of the major distinctions
between techniques is the extent to which they are based on a directive or
a naturalistic focus. In techniques with a more directive focus, the professional providing the
intervention controls or directs the intervention. In techniques with a more naturalistic or
non-directive focus, the professional providing the intervention attempts to create learning
opportunities for the child in a less structured environment.

The distinction between a directive and a naturalistic focus for the intervention is not a
dichotomy but rather a continuum, and many speech/language interventions combine
elements of both.

Directive interventions

Directive interventions tend to include the following characteristics:

 providing massed blocks of trials

 having the professional control the antecedents (stimuli) and consequences

(reinforcers)

 using consequences such as verbal praise or tokens that are not related to the child's
current activities

In directive interventions, the professional providing the intervention controls the

antecedents and consequences presented to the child. Directive approaches use specific
techniques such as modeling and prompting to elicit targeted language structures from the
child. An example of modeling is having the professional name an object shown to the child
and then prompting the child to name the object. Prompting involves the professional
presenting a verbal command or question, or some nonverbal cue, to the child to elicit a

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desired verbal response. Directive interventions frequently use blocks of discrete trials or
drills in a controlled environment.

Naturalistic interventions

Naturalistic approaches commonly include the following characteristics:

 providing distributed learning opportunities rather than massed blocks of trials

 following the child's focus of attention or interest

 using antecedent and consequent stimuli naturally associated with a particular

communication response

Naturalistic interventions use specific techniques that create opportunities for the child to
use targeted language structures. This approach utilizes aspects of adult-child interaction
that promote language acquisition. Deciding which techniques to use for an individual child
requires the professional to draw upon knowledge about normal language acquisition and to
be cognizant of the needs of the particular child. A critical aspect of naturalistic interventions
is the professional's ability to read, interpret, and respond appropriately to the child's cues.

Naturalistic and enhanced or modified milieu methods (also called incidental teaching)
involve the professional arranging materials in the environment in a way designed to elicit
targeted responses from the child.

Directive versus Naturalistic Intervention>

[A] = Strong [B] = Moderate [C] = Limited [D1] = Opinion/Studies do not meet criteria [D2] =
Literature not reviewed

Recommendations

Selecting a specific speech/language therapy technique

1. It is important to recognize that no one specific speech/language therapy technique

or approach is best for all young children. [B]

2. When selecting an intervention technique or approach, it is important for the

professional providing the intervention to consider the individual characteristics of
the child, and the child's stage of language development. [B]

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 3. It is often useful to consider the child's conversational skills and verbal style in
deciding whether to use a more directive or a more naturalistic intervention. [D1]

Using a continuum of techniques as the child progresses

4. For some children, more directive interventions may be appropriate, particularly at

the beginning stages of treatment. Directive interventions can be very effective in
eliciting initial structures of speech or gesture. [B]

5. Naturalistic interventions may be more useful than directive interventions in

increasing spontaneous language and generalization to non-treatment settings. [C]

6. It is recommended that intervention methods progress from a more directive

towards a more naturalistic focus. This progression is important as some functional
aspects of language (such as social context and conversational turn-taking) cannot be
established through directive intervention and need to be learned using more
naturalistic approaches. [B]

7. It is important to recognize that a naturalistic approach may help to facilitate long-

term goals for speech/language interventions such as:

 expressing basic needs

 establishing functional use of language

 interacting socially

 acquiring knowledge [D1]

Evaluating the Effectiveness of Specific Techniques for an Individual Child<

Recommendations

Using specific intervention techniques

1. It is important to recognize that:

 Many different specific intervention techniques have been shown to be

effective in improving speech/ language skills in children with communication
disorders.

 Specific techniques that will prove to be most effective for an individual child
will depend upon many factors including the type of communication disorder,
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 the child's personality characteristics, and the presence of other
developmental problems. [A]

Identifying intervention targets

2. It is recommended that the intervention targets for each child be clearly identified
and defined with clear criteria for mastery. [A]

Monitoring treatment progress

3. It is strongly recommended that the degree of effectiveness of a particular

speech/language intervention be assessed on a regular basis for each child. [A]

4. When a child is receiving discrete speech/language therapy sessions, it is

recommended that the child's progress be periodically evaluated and documented
during the course of the intervention. Specifically, it is important to:

 assess and document behaviors and communication skills at baseline

 document progress at the end of each intervention session [A]

5. When a child is receiving a speech/language intervention that is integrated within the

child's daily activities (rather than in discrete sessions), it is still important to
periodically monitor and document the child's progress. [A]

6. It is important to assess the extent to which the speech/language skills acquired with
specific intervention techniques are generalized to non-treatment settings. [A]

7. It is recommended that the professional providing the intervention use information

gathered regularly about the child's progress to assist in choosing and modifying:

 intervention strategies

 intensity, frequency, and duration of intervention [A]

Using information about the child's progress to modify the intervention

8. Elements of single-subject design methodology, when adapted to clinical settings can

be useful for documenting the child's progress and the effectiveness of specific
intervention techniques. [A]

Single-subject design studies provide information about the efficacy of specific techniques as
they are used for an individual child. These studies can also provide information about the

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efficacy of broad general intervention approaches as well as about the efficacy of more
narrow specific elements and variations of these interventions.

Interventions for Children with Speech/Language Problems and Other Developmental

Disorders

For children who have both speech/language and other developmental problems, additional
considerations may apply in planning and carrying out interventions. This section provides
specific recommendations on how intervention may be modified for children with general
developmental delays, hearing problems and oral-motor or feeding problems.
Recommendations are also given for children needing augmentative communication.

Children with general developmental delays or disorders

Children whose communication disorder is only one part of a more general developmental
disorder may require multiple services to address multiple needs. Since the communication
disorder is only one aspect of the overall needs of the child, there are additional intervention
considerations for those children who have a language delay but no other apparent
developmental problems.

Often, similar speech and language intervention strategies are effective for children with
communication disorders regardless of whether these children are affected only in the
communication domain or in other developmental domains as well. In fact, many of the
treatment efficacy studies that were evaluated included subjects whose communication
disorders were embedded in more general developmental disabilities. Some studies
comparing specific treatment approaches found an association between the child's pre-
treatment developmental level and the intervention method. Such an association indicates
that the most effective intervention method differs according to the child's pre-treatment
developmental level.

Children with hearing impairments

When hearing loss occurs at birth or within the first few months of life ("prelingual" onset),
the impact on communication development is usually significant because the loss occurs
during the time considered critical for language development. The effect of even mild
hearing loss can delay speech and language development in a young child. There is strong
evidence that early intervention for an infant or young child with hearing loss or an infant or
young child who is deaf results in optimal development of communication skills (Moeller and
Carney, 1998).

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Many children experience temporary and fluctuating hearing loss associated with otitis
media with effusion (OME), particularly during the first three years of life (AHCPR, 1994).
Children with sensory hearing loss may also have OME resulting in a mixed hearing
impairment. OME is treated medically or, in some cases, surgically. While persistent OME is
considered by most to be a risk factor for a communication disorder, there is controversy as
to whether OME in early life results in long-term communication sequelae.

Many of the general intervention recommendations for children who have only a
communication disorder also apply to children who have a communication disorder
associated with other developmental problems.

Interventions for Children Who Have a Communication Disorder Associated with Other
Developmental Problems

[A] = Strong [B] = Moderate [C] = Limited [D1] = Opinion/Studies do not meet criteria [D2] =
Literature not reviewed

Recommendations

Addressing all areas of concern

1. For children whose communication disorder is combined with disabilities in other

areas of development, it is recommended that interventions address all affected
areas rather than just focusing on communication in isolation. [D2]

Timing of assessment and intervention

2. For children with a developmental disorder diagnosed at birth, it is recommended

that intervention for communication begin at birth. [D2]

3. For newborns with genetic syndromes or conditions with a high probability of

developmental delay (including hearing loss and certain neurological conditions), it is
recommended that communication intervention begin immediately. For example:

 As early as birth to 3 months of age, there may be a need to initiate oral-

motor or feeding therapy or intervention for a hearing impairment.

 As early as 4 to 6 months of age, it is recommended that behavioral

techniques be used to increase the frequency and variety of vocalizations. In
addition, it is important to start training parents and other caregivers for such
procedures. [D2]

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Modifying intervention strategies when children have additional disabilities

4. It is important to be aware that particular communication treatment strategies may

have to be modified when the child's communication disorder is combined with other
disabilities. Reciprocity, responsivity, joint attention, and rhythm may be more
difficult to establish and maintain with a child whose communication is impacted by
other areas of development or medical issues. [D2]

5. It is important to be aware that the expected rate of progress in communication may

be different for a child who has additional areas of impairment. [D2]

6. Strategies which might help in setting up the communication environment for

children with a communication disorder and other developmental problems include
the following:

 adapting materials, equipment, and lessons to the developmental level of the

child

 adapting the home and/or therapy environment so the child has to solve
problems or reinforce skills to do what he or she wants to do

 gearing the level of stimulation in the environment to the individual learning

style of the child

 using preparatory physical or sensory stimulation or alerting activities prior to

or during language stimulation

 presenting learning material in small increments (through the use of task

analysis) and providing sensory, emotional, or physical supports

 presenting language-related concepts concretely, repetitiously, and/or with

multi-sensory input through the use of sensory cues, which may need to be
dramatic or exaggerated (such as large visual pictures, tactile or auditory
cues)

 setting up predictable schedules to help a child transition from one activity to

another

 including parent and peer interactions as part of the communication

environment in order to help foster generalization of communication skills
[D2]

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Coordination of care among professionals and parents

7. Because children whose development is affected in multiple areas require multiple

services, it is important to:

 use an interdisciplinary team approach, involving those professionals with

expertise in the child's specific developmental problems as well as the child's
primary health care provider if appropriate

 coordinate services so interventions are not fragmented and parents are not
put in the role of coordinating their child's services (for example, if services
are provided by more than one professional, have joint planning for
intervention goals, methods, and schedules as well as regular communication
about progress) [D2]

Interventions for Children Who Have a Speech/ Language Problem Associated with a
Hearing Loss

[A] = Strong [B] = Moderate [C] = Limited [D1] = Opinion/Studies do not meet criteria [D2] =
Literature not reviewed

Recommendations

1. It is recommended that communication intervention for young children with hearing

loss follow a developmental approach with a goal of maximizing age-appropriate
communication skills. [D2]

2. Communication intervention goals specifically directed at infants and children with

hearing loss who are learning language through or partly through the auditory
channel, may need to emphasize specific aspects of language (such as phonologic and
syntactic) that often are less salient (less audible, less visible). [D2]

Selecting hearing amplification devices

3. It is recommended that use of personal hearing amplification devices (such as

hearing aids, FM system) be considered a prerequisite for optimal communication
intervention for the children with hearing loss. [D2]

4. It is recommended that hearing amplification devices be individually selected and

fitted for each child's specific type, degree, and configuration of hearing loss.
Prescriptive hearing aid fitting procedures and real-ear measurement are particularly

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 effective for individualizing the fitting of amplification devices to infants and young
children. [D2]

5. It is recommended that there be regular monitoring of the child's hearing loss as well
as effectiveness of the child's hearing amplification devices. [D2]

6. It is recommended that in some cases of profound sensory hearing loss, cochlear

implants be considered an option. [D2]