Journal of Communication Disorders 103 (2023) 106326

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Journal of Communication Disorders

journal homepage: www.elsevier.com/locate/jcomdis

Effects in language development of young children with language

delay during early intervention
Bernadette A.M. Vermeij a, c, *, Carin H. Wiefferink a, Harry Knoors b, c, Ron H.
J. Scholte c
a
Dutch Foundation for the Deaf and Hard of Hearing Child (NSDSK), Amsterdam, The Netherlands
b
Royal Dutch Kentalis, Utrecht, The Netherlands
c
Behavioural Science Institute, Radboud University Nijmegen, Nijmegen, The Netherlands

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: In the Netherlands, early language intervention is offered to young children with
Language delay Language Delay (LD). The intervention combines groupwise language intervention, individual
Developmental language disorder speech and language therapy and parent-implemented language intervention. This study tests the
Late talkers
hypothesis that children with LD show progress in their receptive and expressive language during
Early intervention
intervention. Differences in language progress between age groups (< 36 months and ≥ 36
months at intervention start) were expected in favour of the younger group, which might be
due to an earlier intervention start, a longer treatment duration or the potential presence of
late talkers.
Methods: The study included 183 children with LD (45 children < 3 years of age at intervention
start; mean age 32 months, 138 children ≥ 3 years; mean age 40 months). Receptive and
expressive language was assessed with norm-referenced tests at intervention start and ending
using Routine Outcome Monitoring. A repeated measures MANOVA was carried out to examine
language progress and to compare the age groups on receptive syntax, receptive vocabulary,
expressive syntax and expressive vocabulary. The Reliable Change Index was used to study in­
dividual progress.
Results: On average, children in both age groups showed significant improvement in all four
language domains. The younger children showed more language progress than the older children
in all four domains. When examining individual progress, most of the children displayed reliable
improvement for expressive vocabulary. Most children developed in the same pace as their
typically developing peers for receptive syntax, receptive vocabulary, and expressive syntax.
Conclusions: Children stabilized or even improved language proficiency during the intervention,
indicating that the language gap between these children and typically developing children did not
widen further. Younger children displayed more language progress than older children in all four
domains, but it is unclear what might explain this difference.

1. Introduction

The impact of developmental language disorder (DLD) (Bishop, 2017) on language development, social development, and

* Corresponding author: Dutch Foundation for the Deaf and Hard of Hearing Child (NSDSK), Amsterdam, The Netherlands.
E-mail address: bernadette.vermeij@ru.nl (B.A.M. Vermeij).

https://doi.org/10.1016/j.jcomdis.2023.106326
Received 10 March 2022; Received in revised form 13 February 2023; Accepted 7 April 2023
Available online 20 April 2023
0021-9924/© 2023 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).
B.A.M. Vermeij et al. Journal of Communication Disorders 103 (2023) 106326

participation in society is substantial. Language skills are essential for functioning adequately in society (Durkin & Conti-Ramsden,
2010). Difficulties in understanding what others say, or not being able to express oneself clearly, can cause several problems in daily
life. For instance, adults with DLD have a poorer educational attainment, are more often unemployed, and have a higher risk of poor
quality friendships compared with adults without DLD (Conti-Ramsden & Durkin, 2012; Durkin & Conti-Ramsden, 2010). Children
with DLD also experience problems with participating in society. They face more problems in interaction with peers and report more
victimization compared with their typically developing (TD) peers (Mok et al., 2014; van den Bedem et al., 2018).
Language problems early in life increase the risk for difficulties developing later in life, such as problems in educational
achievement and social-emotional functioning (Preston et al., 2010; Yew & O’Kearney, 2013, 2017). To prevent or minimize an in­
crease of language problems and co-occurring problems, early intervention is important (Kaiser et al., 2022; Singleton, 2018). Several
studies indicate that young children with language problems benefit from early intervention: their language proficiency can improve in
several domains (Heidlage et al., 2020; Rinaldi et al., 2021; Roberts et al., 2019). Additionally, early intervention may also result in
improvements in academic and social-emotional behaviours.
Therefore, in the Netherlands, an intensive early language intervention program is offered to two to four year old children with
language delay (LD). The intervention is a countrywide system and consists of a combination of group language intervention, indi­
vidual speech and language therapy, and parent-implemented language intervention. Empirical evidence supports the value of
providing individual speech and language therapy (Boyle et al., 2009; Broomfield & Dodd, 2011) and parent-implemented language
intervention (Heidlage et al., 2020; Roberts et al., 2019). However, evidence for the effectiveness of group language intervention and
particularly for the combination of all three intervention types in one program is largely lacking. Although on theoretical grounds we
expect this comprehensive early language intervention program to be effective, this study is a first step to explore if young children
with LD show progress in their receptive or expressive language proficiency during the course of this intensive early language
intervention program. In this paper, we will use the term LD, although we expect most children to have DLD. At this young age, it is
difficult to unravel if children suffer from DLD or that the language delay has another cause.

1.1. Group language intervention

The intensive early language intervention program includes group intervention (Wiefferink, 2021) because children learn most
effectively within a social context (Hoff, 2006). In a group, social interaction takes place, which plays a fundamental role in the
language development of children (Vygotsky, 1978). By interacting with their environment, children not only develop language skills
but also learn social-communication skills and conversational skills. This is especially important for children with LD, as they
encounter more difficulties communicating with significant others in their environment (van Balkom et al., 2010). Communication
difficulties make it more challenging to start and continue interactions, with fewer opportunities to learn language as a result. In the
early language intervention program, the group language intervention offers opportunities to learn language within a social context. In
these groups, a social learning environment is created where children can practice new language skills in daily situations and routines,
with the help and guidance of professionals. For example, if a child has difficulties expressing himself in interaction with a peer,
professionals guide the interaction and can support the child if needed. The group language intervention is offered three mornings a
week by two preschool teachers, a speech and language therapist (SLT), and a psychologist.

1.2. Individual speech and language therapy

Besides group intervention in the early language intervention program, children also receive individual treatment by an SLT. The
SLT sets treatment goals tailored to the specific language problems of each child. The one-on-one setting with the SLT makes it possible
to treat specific language problems in a more targeted manner. For example, a new sentence structure can more easily be practiced and
repeated with one-on-one guidance of the SLT, compared with a group setting. Several studies report positive effects of speech and
language therapy (and techniques used in this therapy) for receptive language domains (Broomfield & Dodd, 2011; Glogowska et al.,
2000) and expressive language domains (Boyle et al., 2009; Broomfield & Dodd, 2011; Fey et al., 1997; Fey et al., 1993; Law et al.,
2004).

1.3. Parent-implemented language intervention

Not only direct but also indirect intervention is offered by engaging parents. This is important because children spend most of their
time with their parents and parent-child interaction plays a key role in language development (Hirsh-Pasek et al., 2015; Hoff, 2006).
However, as a result of the children’s language problems, parents of children with LD may find it more difficult to adjust their language
to their child’s needs (van Balkom et al., 2010). Teaching parents language support strategies can help them to improve communi­
cation with their child and establish a better language-learning environment at home. The value of parent-implemented language
intervention is supported by three meta-analyses conducted over the past ten years ((Heidlage et al., 2020; Roberts & Kaiser, 2011;
Roberts et al., 2019). These meta-analyses included studies with children with primary and secondary language problems and results
showed that parents indeed changed their communication behavior. Moreover, this change in behavior resulted in positive effects on
expressive language skills (Heidlage et al., 2020) and in some studies on both receptive and expressive language skills (Roberts &
Kaiser, 2011; Roberts et al., 2019).

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1.4. Key intervention techniques

The group language intervention, the individual speech and language therapy, and the parent-implemented language intervention
are offered in different settings (center- and home-based), but basically similar key intervention techniques are used in all three
intervention types. These techniques are applied by parents and professionals and are known to stimulate language development.
Examples of key techniques are ‘observe, wait and listen’ (Pepper & Weitzman, 2004), recasting (Camarata & Nelson, 2006), focused
stimulation (Paul & Norbury, 2012), and using visual input (Pepper & Weitzman, 2004). In ‘observe, wait and listen’, the professional
or parent observes what the child is interested in, waits to give the child a chance to initiate an utterance, and listens to what the child
says. Recasting is used to correctly reproduce the child’s word or utterance and to add new (syntactic, semantic or phonological)
information, while acknowledging what the child meant to say. For example, when the child says: “he running”, the professional can
recast: “yes, he is running”. Focused stimulation involves frequently offering the child input of a sound, word, or utterance in different
meaningful contexts. Examples of visual input are the use of signs, gestures, pictures or objects, to support spoken language input.
Empirical evidence shows that these techniques have a positive influence on language development (Cleave et al., 2015; Fey et al.,
1997; Fey et al., 1993; Kruythoff-Broekman et al., 2019; Paul & Norbury, 2012; van Berkel-van Hoof et al., 2019). A more detailed
description of key techniques used during the early intervention program is available in supplemental material.

1.5. Younger versus older children at intervention start

The early language intervention program is offered to children between 2 and 4 years old. Children can start at different ages,
depending on the age of diagnosis. This means that some children already start with the intervention program when they are about 2;6
years old, while others start after 3 years of age. There are several reasons why children who enroll in intervention at a younger age
may show more language progress during the intervention compared with children who enroll at an older age. First of all, the younger
children start treatment, the sooner they can start improving their language proficiency. Several studies emphasize the importance of
intervening early and advocate to abandon the so-called ‘wait-and-see approach’ (Kaiser et al., 2022; Singleton, 2018) as withholding
treatment may lead to an increase of language problems in children with LD. Early diagnosis is key, as this enables early enrollment in
intervention, which consequently should lead to better language outcomes.
Secondly, because children enroll at different ages and most children complete the intervention around the age of four when
transition to school occurs, treatment duration differs. Therefore, children starting intervention at a younger age are likely to have a
longer treatment duration compared with children who enrolled at an older age, which in turn could affect language outcomes. A
longer treatment duration implies more treatment, which could be beneficial for language outcomes. Several studies emphasize the
importance of taking treatment duration into account when examining intervention effects (Law et al., 2017; Warren et al., 2007).
Thirdly, some children may turn out to be late talkers, that is, children whose language development is delayed but who may
eventually catch up without receiving language intervention (Rescorla, 2011; Rescorla & Dale, 2013). Past research shows that
approximately 13% of children younger than 3 are late talkers (Horwitz et al., 2003; Nouraey et al., 2021; Zubrick et al., 2007). From
these children, 5% to 7% is diagnosed with DLD after three years of age (Norbury et al., 2016; Tomblin et al., 1997). At this young age,
it is hard if not impossible to differentiate between late talkers and children who later turn out having DLD (Bishop, 2017; Sansavini
et al., 2021) and thus it is not possible to set a diagnosis of DLD at this young age. Whereas the language development of late talkers
may show spontaneous improvement, the language problems of children suffering from DLD are more persistent and more difficult to
resolve (Boyle et al., 2010; Law et al., 2004). Therefore, when examining intervention outcomes of young children participating in the
language intervention program, the possible presence of late talkers needs to be taken into account because this may lead to an
overestimation of the intervention effect.
In conclusion, the present study examines the language development of young children with LD following an intensive early
language intervention program consisting of group language intervention, individual speech and language therapy and parent-
implemented language intervention. The intervention is examined as a whole, the components are not being studied independently
to document their contribution to the results. Although we are interested in the language progress of all children, we want to further
explore if younger children benefit in the same way from the intervention as older children. We therefore decided to compare the
results of children younger than 3 years of age at intervention start with children 3 years and older. We chose this cut-off because
several studies state that it is very difficult if not impossible to discriminate between late talkers and children with DLD before the age
of 3 (Bishop et al., 2017; Gerrits et al., 2017; Sansavini et al., 2021). The following research questions are addressed. Firstly, do
children with LD show progress in their receptive and expressive language development during the early language intervention
program? Secondly, do children who started the early language intervention program before the age of 3 differ from children who
started at the age of 3 years or older on receptive and expressive language development during the early language intervention
program?
Because this early language intervention program is much more comprehensive and intensive compared to individual speech and
language therapy or parent-implemented language intervention, we hypothesized that children would improve both their receptive
and expressive language skills. We also hypothesized that children who started intervention at a younger age (< 36 months) would
show more progress in language development compared with children who started at an older age (≥ 36 months). This may be due to
the effect of early intervention, a longer treatment duration, or because of the potential presence of late talkers in the younger group.
Since it is difficult to unravel the contribution of each of these three factors, this study is a first step to examine if younger children
indeed show a different language development trajectory compared with older children. The outcomes of this study may provide more
insight into the importance of early diagnosis and intervention.

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2. Methods

2.1. Design

In this longitudinal and practice-based study, language proficiency was assessed around intervention start and ending by pro­
fessionals in clinical practice. Routine Outcome Monitoring (ROM) was used to gather the data (ROM) (De Beurs et al., 2011; Duncan
et al., 2010; Van Sonsbeek et al., 2014). With ROM, the development of a client can be monitored through the systematic and repeated
gathering of language scores during the intervention. These outcomes are necessary to evaluate the intervention and, if needed, to
adjust the intervention. The advantage of ROM data is that it is clinically relevant information on the language development of a child,
gathered during actual treatment rather than in a fixed research setting.
In this study, a control group is not included. We therefore cannot study the efficacy of the intervention program. This is therefore
an effectiveness study, which aims to explore if the desired results can be achieved in the real world.

2.2. Participants

In the Netherlands, children with language problems are referred to speech and hearing centres for multidisciplinary assessment
(Wiefferink et al., 2020) in order to assess whether these children may suffer from DLD or not, excluding potential causes for DLD such
as hearing loss or low cognitive ability. If DLD is presumed, children are referred to a language intervention center that is specialized in
treating children with DLD. This study included 183 children (149 boys, 34 girls) who were referred from a speech and hearing center
and received intensive language intervention for at least 3 months. All children had a score of − 1 SD or more on at least one of four
language domains, indicating language problems on that domain(s), at the start of the intervention. The four language tests assessed
receptive syntax, receptive vocabulary, expressive syntax, and expressive vocabulary.
The children all had a nonverbal IQ of at least 80, assessed with a Dutch nonverbal intelligence test, the SON-R (Tellegen et al.,
1998). Because the norms of the language tests were only applicable to monolingual Dutch-speaking children, multilingual children
were excluded. Children with serious additional disabilities were also excluded. The mean age at pretest was 38 months (range 26 to 45
months). Of the mothers, 4% did not attend or complete high school education, 52% did complete high school and 44% obtained a
college degree or higher. From the fathers, 2% did not attend or complete high school education, 53% did complete high school and
45% obtained a college degree or higher.

2.3. Early language intervention program

During three mornings a week, two preschool teachers, an SLT, and a psychologist offered language intervention to a group of eight
to ten children. The preschool teachers were always present at the group. The SLT was either present at the group or was offering
individual speech and language therapy. The psychologist would observe the child during the intervention and discuss observation
findings with the team. During this process, the psychologist would advise the team on how to address any problems and how to adjust
the intervention to meet the child’s needs.
The children visited the group intervention, where they also received individual speech and language therapy. Additionally, a
program was offered to the parents. To tailor the intervention to the specific needs of each child, a treatment plan was drawn up
together with the parents. During quarterly meetings, the intervention team and the parents discussed the child’s progress, and any
adjustments to the treatment plan, if required. The language intervention program was evaluated by the Netherlands Youth Institute
(www.nji.nl), who judged that it was based on the latest scientific theories and empirical evidence (Wiefferink, 2021).

2.3.1. Group intervention

Group language intervention is an established program and the main ingredient of the early language intervention program. Three
mornings a week, all children received this intervention from 9.00 until 12.30. Group intervention was offered in a fixed structure of
four different kinds of activities: daily routine activities, educational play, intentional language stimulation, and group speech and
language therapy. Daily activities, such as welcoming and mealtime were a good opportunity for repetition: the preschool teachers and
the SLT used these moments to expose children repeatedly to the same words and sentences. Educational play consisted of free play and
guided play. During free play, the child could choose what he or she wanted to play with. During guided play, however, a specific
playing situation with specific aims was created. Educational play was used to stimulate playing with other children and to practice
turn taking. Activities such as singing and picture-book reading were used for intentional language stimulation, in order to learn new
words or utterances. Speech and language therapy in the group was aimed at improving receptive and expressive language proficiency.
For example, when the SLT aimed at expanding receptive and expressive vocabulary, she selected a number of target words which were
offered in different meaningful contexts. See supplemental material for more techniques used during group intervention.

2.3.2. Individual speech and language therapy

Every child also received 20 min sessions individual language therapy once a week, in a separate room. This therapy was tailored to
the specific language problems of the child, aiming at a variety of aspects of language, such as receptive syntax, receptive vocabulary,
expressive syntax and expressive vocabulary. The SLT used different techniques during the therapy. For instance, when a child had
difficulties in developing a vocabulary, the SLT used techniques such as focused stimulation (frequently offering the same word in
different meaningful contexts) (Paul & Norbury, 2012) or emphasizing a word by placing it at the end of a sentence (Leonard, 2014). In

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supplemental material, more techniques used by the SLT are described.

2.3.3. Parent-implemented language intervention

A parental program was offered to the parents, consisting of group meetings, home visits, and psycho-education (Wiefferink, 2021).
Psycho-education helps people to understand and cope with health conditions. It includes information about the condition, its
symptoms, and how to manage it (see supplemental material for more information). Parents were encouraged to attend two group
trainings: a six-session training in which they learned language stimulating interaction techniques and a six-session training in which
they learned how to use signs and gestures in communication with their child. In the first training, parents learned, for example, how to
observe, wait and listen and how to adjust their language input to the child’s level. They learned how to do this in routine daily
situations, during play, and during picture book reading. In the second training, parents learned to use gestures and signs in routine
daily situations such as mealtime, getting dressed, and going to bed. Not all parents attended these trainings: 37% of the parents
attended four to six sessions of the speech and language training, while 35% of the parents attended four to six sessions of the signs and
gestures training. In total, 58% of the parents attended at least one training. The parents of at least 16 children had already attended a
speech and language training before the start of the early language intervention program.

2.3.4. Treatment quality and fidelity

Treatment was delivered by certified SLT’s, preschool teachers, and psychologists who were qualified to work with preschool
children with LD. For this study, we did not measure treatment fidelity, but we did develop all kinds of activities to improve the quality
of treatment. Firstly, every professional received additional education, tailored to the intervention (such as a training on how to use
signs and visual communication with children with LD). Secondly, collegial consultation of professionals with the same professional
background was organized at least five times a year in small groups. It provided an opportunity for knowledge development for
professionals who share a common challenge or problem. During these sessions, professionals consulted their colleagues to help them
gain valuable new insights (Sharmahd et al., 2018). Together they dissected a problem that had been introduced by a participant. They
did so by asking questions using a method consisting of six steps: preparation, introducing an issue, question round, brainstorming,
recommendations, feedback. If collegial consultation was not sufficient to solve the problem, individual coaching was offered by the
psychologist or the clinical linguist. Thirdly, a licensed clinical linguist contributed to improving treatment quality. She visited all
treatment groups for observation at least once a year. Her observations focussed on the communication between professional and child,
on which techniques were applied, and on how they were applied. The clinical linguist then would discuss her observations with the
intervention team and supported them in enhancing quality of interactions, if necessary.

2.4. Procedure

In this study, ROM data were gathered around the start and the end of the intervention for receptive syntax, receptive vocabulary,
expressive syntax, and expressive vocabulary. For this study, we chose only to include language domains that could be assessed with
norm-referenced and standardized tests. Language proficiency was assessed by SLT’s working in clinical practice. Language testing
took place within three months of starting intervention and within three months of intervention ending. All data were entered into a
web-based database, the BergOp system, version 4.0.8. (Praktikon, 2016). Because all children received care as usual, we were not able
to include a control group who did not receive intervention.
Parents of all 183 children consented to the use of the anonymous ROM data of their child for scientific research purposes. Because
we only used data that were already gathered for clinical aims, ethical approval from a Research Ethics Committee was not required.

2.5. Instruments

This study takes four language domains into account to examine language progress, namely receptive syntax, receptive vocabulary,
expressive syntax, and expressive vocabulary. Development in these four language domains is closely monitored by professionals with
norm-referenced and standardized tests during the early language intervention program. Because norm-referenced and standardized
test for other language domains, such as phonology or pragmatics, were not available for these young children in the Netherlands,
other language domains were not included in this study. To enable comparison with the test norms, raw scores were converted into
standardized Q-scores (mean score: 100, standard deviation: 15). The higher the Q-score, the better the language proficiency.

Table 1
Number and percentage of missings for each imputed domain.
Domain Number of missings %

Receptive syntax pretest 0 0%

Receptive vocabulary pretest 16 9%
Expressive syntax pretest 3 2%
Expressive vocabulary pretest 3 2%
Receptive syntax posttest 73 40%
Receptive vocabulary posttest 98 54%
Expressive syntax posttest 53 29%
Expressive vocabulary posttest 64 35%

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Receptive syntax proficiency was assessed with the “Schlichting Receptive Language Test” in which children had to carry out as­
signments with several objects. The test measures receptive language, with an emphasis on syntax. The test’s internal consistency is
0.93 (lambda-2) and test-retest reliability is 0.82 (Schlichting & Lutje Spelberg, 2010a). Receptive vocabulary was tested with the
“Peabody Picture Vocabulary Test-III-NL” (Dunn et al., 2005). In this test, the child had to match a spoken word to one out of four
pictures. The test’s internal consistency ranges from 0.89 till 0.92 for children 2;3 to 4;5 years old (lambda-2). The test-retest reliability
score is only available for adults (Dunn et al., 2005).
Two subtests of the “Schlichting Expressive Language Test” (Schlichting & Lutje Spelberg, 2010b) were used to measure expressive
language. In the subtest for expressive syntax, children were requested to repeat and complete sentences of increasing grammatical
complexity. The test’s internal consistency is 0.90 (lambda-2) and test-retest reliability is 0.73 (Schlichting & Lutje Spelberg, 2010b).
Expressive vocabulary was measured by naming pictures of objects or actions. The test’s internal consistency is 0.89 (lambda-2) and
test-retest reliability 0.93 (Schlichting & Lutje Spelberg, 2010b).

2.6. Data analyses

The dataset was inspected for missing values at pretest and posttest. The number of missing values for the language domains ranged
from 0 (receptive syntax pretest) to 98 (receptive vocabulary posttest) (Table 1). Data were missing completely at random, which was
confirmed by Little’s MCAR test (p=.132). Single imputation was used to impute the missing Q-scores on the language pretests and
posttests, generating the dataset that was used for all analyses.
To answer the research questions, firstly a repeated measures MANOVA was carried out including the pretest and posttest scores of
receptive syntax, receptive vocabulary, expressive syntax and expressive vocabulary as dependent variables. Time was entered as the
within-subjects factor and age group (< 36 months, ≥ 36 months) as the between-subjects factor.
Secondly, because the results of the repeated measures MANOVA only provide insight in the language development of an entire
group of children, the Reliable Change Index (RCI) (Jacobson & Truax, 1991) was also calculated for each child. It specifies the amount
of change a client must show on a test score between pretest and posttest before that change can be defined as reliable, that is, larger
than the reasonably expected difference due to the standard error of measurement alone. The RCI can also classify children into reliable
change categories for language development and distinguish between children displaying reliable change and children showing a more
stable language development. For both age groups, the number of children in each category were calculated.
The RCI is a standardized z-score with a mean of 0 (indicating no change) and a standard deviation of 1. Three categories can be
distinguished: deteriorated (negative reliable change, RCI < -1.64), unchanged (no reliable change, RCI > -1.65 and < 1.65) and
improved (positive reliable change, RCI > 1.64), based on one-sided testing and a significance level of 5%. The RCI is calculated by
dividing the change scores between the pretest and posttest language scores of an individual by the standard error of the difference.
The test-retest reliability of the instruments was used for calculating the standard error. Because test-retest reliability was not
described in the instruction manual of the PPVT-III-NL, internal consistency was used to calculate the standard error of receptive
vocabulary (0.89 for children aged 3;0–3;5). For each instrument, the minimum difference that defined a reliable change was
calculated. A difference of 15 points was required for receptive syntax, for receptive vocabulary a difference of 12 points, for expressive
syntax 19 points, and for expressive vocabulary 10 points.

3. Results

Table 2 provides the mean pretest and posttest language scores of all 183 children, in the < 36 months group and the ≥ 36 months
group. Although the mean scores at pretest did not differ between the younger and older children, the mean posttest scores on receptive
syntax (t [181] = 2.266, p = .025, d = 0.389), expressive syntax (t [62] = 2.151, p = .035, d = 0.421), and expressive vocabulary (t
[181] = 3.159, p = .002, d = 0.542) significantly differed, with the younger children gaining higher scores at posttest. The < 36 months
and ≥ 36 months group also significantly differed on age at intervention start (t [181] = -17.202, p < .001, d=− 2.953), treatment
duration in months (t [181] = 13.782, p < .001, d = 2.366), and days of attendance (t [59] = -9.446, p < .001, d = 1.925). The < 36
months group was on average 7.5 months younger, their treatment duration on average 6.3 months longer, and their days of

Table 2
The mean pretest and posttest language scores of the total group, children < 36 months, and children ≥ 36 months.
Mean Q-scores (SD) Mean Q-scores (SD) Mean Q-scores (SD)
total group (n = 183) children < 36 months (n = 45) children ≥ 36 months (n = 138)
Pretest Posttest Pretest Posttest Pretest Posttest

Receptive syntax 84.5 (14.0) 89.2 (11.4) 85.2 (16.7) 92.5 (12.0) 84.3 (13.1) 88.1 (11.1)

Receptive vocabulary 93.3 (13.9) 99.8 (9.4) 91.9 (15.9) 101.5 (9.9) 93.7 (13.3) 99.2 (9.2)

Expressive syntax 72.8 (7.1) 79.3 (8.2) 72.1 (6.9) 81.9 (9.7) 73.1 (7.2) 78.5 (7.5)

Expressive vocabulary 70.7 (13.6) 87.9 (15.0) 68.2 (13.3) 93.9 (17.1) 71.6 (13.6) 86.0 (13.7)

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Table 3
The mean age at start intervention, mean treatment duration (months) and mean attendance (days) of the total group, children < 36 months, and
children ≥ 36 months.
Total group (n = 183) < 36 months (n = 45) ≥ 36 (n = 138)

Mean age start intervention 38.1 (4.1) 32.4 (2.4) 39.9 (2.6)

Mean treatment duration in months 8.8 (3.8) 13.6 (3.1) 7.3 (2.5)

Mean child attendance in days 90.6 (36.4) 131.4 (35.6) 77.3 (25.2)

Table 4
Results of the repeated measures MANOVA for children < 36 months old and children ≥ 36 months old.
Mean Q-scores pretest Mean Q-scores posttest df F p η2p

Children < 36 months old (n = 45)

Receptive syntax 85.2 (16.7) 92.5 (12.0) 1.44 22.243 < 0.001 .336

Receptive vocabulary 91.9 (15.9) 101.5 (9.9) 1.44 40.083 < 0.001 .477

Expressive syntax 72.1 (6.9) 81.9 (9.7) 1.44 42.711 < 0.001 .493

Expressive vocabulary 68.2 (13.3) 93.9 (17.1) 1.44 107.750 < 0.001 .710

Children ≥ 36 months old (n = 138)

Receptive syntax 84.3 (13.1) 88.1 (11.1) 1.137 28.721 < 0.001 .173

Receptive vocabulary 93.7 (13.3) 99.2 (9.2) 1.137 50.555 < 0.001 .270

Expressive syntax 73.1 (7.2) 78.5 (7.5) 1.137 101.900 < 0.001 .427

Expressive vocabulary 71.6 (13.6) 86.0 (13.7) 1.137 138.465 < 0.001 .503

Values for Partial eta squared: small effect size = 0.01, medium effect size = 0.06, large effect size = 0.14.

Table 5
Classification of the children < 36 months old and ≥ 36 months old in the three RCI categories.
Children < 36 months (n = 45) Children ≥ 36 months (n = 138)

Deteriorated Unchanged Improved Deteriorated Unchanged Improved

n (%) n (%) n (%) n (%) n (%) n (%)

Receptive syntax 0 (0%) 34 (76%) 11 (24%) 1 (1%) 124 (90%) 13 (9%)

Receptive vocabulary 0 (0%) 28 (62%) 17 (38%) 5 (3%) 106 (77%) 27 (20%)

Expressive syntax 0 (0%) 38 (84%) 7 (16%) 0 (0%) 134 (97%) 4 (3%)

Expressive vocabulary 0 (0%) 7 (16%) 38 (84%) 3 (2%) 56 (41%) 79 (57%)

attendance on average 54.1 days more compared with the older group (Table 3). Treatment duration in months correlated highly with
attendance of the child in days: r = 0.91, p < .001 (multicollinearity). This means the longer the treatment duration, the more days the
children were present.
To gain insight in the language development of all children and to examine the differences between the age groups, a repeated
measures MANOVA was carried out. The multivariate outcomes revealed a significant main effect for time (F [4, 178] = 90.325, p <
.001, η2p = 0.670), which was qualified by a significant interaction effect (F [4, 178] = 7.310, p < .001, η2p = 0.141) between time and
age group. This indicated that children starting the early language intervention program before the age of 3 showed more progress in
language development compared with children starting at or after 3 years of age. Because this analysis did not provide information
about the language development of the age groups separately, a post hoc repeated measures MANOVA was conducted for each age

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group with the pretest scores and posttest scores of the four language domains as dependent variables. Results showed significant
improvements in all four language domains for both age groups, with large effect sizes (Table 4).
Next, RCI scores were calculated for each language domain to examine individual progress (Table 5). In both age groups, the
development of most children was classified as unchanged for receptive syntax, receptive vocabulary, and expressive syntax. This
means for both age groups that the gap with TD peers (based on the test norms) did not increase, but children also did not catch up with
their TD peers on these language domains. Only for expressive vocabulary, most of the children in both age groups showed a reliable
improvement in their language development. A few children showed a decrease in language skills, namely in receptive syntax (1%),
receptive vocabulary (3%) and expressive vocabulary (2%). All these children belonged to the ≥ 36 months group.
When comparing both age groups on language progress on the separate domains, univariate results revealed significant interaction
effects (time * age group) for all four language domains: receptive syntax (F [1181] = 5.445, p= .021, η2p= 0.029), receptive vocabulary
(F [1181] = 6.442, p= .012, η2p = 0.034), expressive syntax (F [1181] = 11.930, p.001, η2p = 0.062), and expressive vocabulary (F
[1181] = 19.226, p < .001, η2p = 0.096). The younger children showed more progress on each language domain compared with the
older ones. When comparing both age groups on the RCI categories not improved (combination of deteriorated and unchanged) and
improved, chi-square was significant for receptive syntax (χ2 (1) = 6.72; p = .010, V = 0.192), receptive vocabulary (χ2 (1) = 6.16; p =
.013, V = 0.184), expressive syntax (χ2 (1) = 9.62; p = .002, V = 0.229), and expressive vocabulary (χ2 (1) = 10.89; p = .001, V =
0.244). This indicated that the proportion younger and older children differed for the RCI categories not improved and improved, with
younger children being classified more often as improved.

4. Discussion

The aim of this study was twofold. First, we wanted to explore if young children with language delay (LD) showed progress in their
receptive and expressive language development during an intensive early language intervention program. Second, we wanted to study
if there was a difference in receptive and expressive language development between children starting the early language intervention
program before the age of 3 and those starting at the age of 3 or later. We hypothesized that children as a group would benefit from the
intervention and that the younger children would show more progress compared with the older ones. Our hypotheses were confirmed,
as we found that children in both age groups displayed significant progress in all four receptive and expressive language domains and
that younger children showed more progress in language development compared with the older ones, on all four language domains.
The RCI scores revealed that most of the children in both age groups developed at the same pace as their (typically developing) TD
peers for receptive vocabulary, expressive vocabulary and expressive syntax, implying that the gaps in language proficiency did not
widen further. For expressive vocabulary though, most children in both age groups showed improvement, implying that the gap in
expressive vocabulary was closing.
As hypothesized, children in both age groups, on average, improved their language proficiency on all four language domains. This
is of interest, because studies examining individual speech and language therapy and parent-implemented interventions did not always
find progress in all four language domains (Glogowska et al., 2000; Heidlage et al., 2020; Rinaldi et al., 2021). This raises the question
if the intensity of the language intervention program may have contributed to these findings. Unfortunately, we are not able to answer
this question.
Although children in both age groups showed considerable language progress, these group results did not always imply individual
reliable progress. For three of the four language domains, most of the children’s language development was classified as unchanged,
meaning that the gap with TD peers did not widen further. The question then arises how this difference between group and individual
results can be explained and how it needs to be interpreted. When examining group results, a clear picture of the development of the
group as a whole is created. However, for professionals, it is relevant to know if children progress on individual basis and how much
they progress (de Beurs et al., 2015; Jacobson & Truax, 1991). This information is provided by the RCI. But because the RCI examines
individual development, it is a more strict measure to define reliable progress in comparison with a group analysis, which may explain
the difference in findings. The RCI takes into account a child will never get the exact same score when testing again because of
changing circumstances like fatigue and inattention (Veerman & Bijl, 2017). The standard error of measurement reckons with these
circumstances. The RCI is therefore a strict and reliable method for measuring individual change. The group results and individual
results are both of importance for interpreting the data and complement each other (de Beurs et al., 2015). On the one hand, the results
of this study show that children as a group display significant improvement in all four language domains. The RCI results, on the other
hand, emphasize that these group results do not mean that all or most children show reliable improvement, except for improvement in
expressive vocabulary. This underlines the importance of examining individual results in addition to group results.
According to the RCI outcomes, the language proficiency in most children developed at the same pace as the language proficiency
of TD children from the test norms, meaning that the children increased their rate of learning with intervention. Before intervention,
they were learning at a slower pace than TD children, hence the gap. This implies that the gap in language proficiency between
children with and without LD did not widen. And the gap even seems to close when it comes to expressive vocabulary. The finding that
most children with LD did show a reliable improvement in expressive vocabulary is in line with the results of two meta-analyses
(Heidlage et al., 2020; Law et al., 2004). The results of these studies indicate that improvement in expressive vocabulary as a result
of language intervention is more common than improvement in other domains. A meta-analysis of Heidlage et al. (2020) and col­
leagues found interventions implemented in play and routines and shared book reading to have a significant effect on the development
of expressive vocabulary. Although Heidlage only studied parent-implemented interventions, learning through play and routines and
shared book reading are key elements of the early language intervention program described in this study and were used in all three
types (Wiefferink, 2021). The use of these methods may have contributed to the language progress displayed. Furthermore, the

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emphasis of the language intervention program was on improving vocabulary, which might explain the progress achieved in this
domain. More focus on improving syntax might be needed to improve skills in this domain as well. Studies of Fey and colleagues for
example (1993; 1997) found positive outcomes for an intervention focussing on stimulating syntax. Children with LD who were be­
tween the ages of 3- to 6 years old who received individual and group speech and language therapy or parent-implemented inter­
vention showed more improvement compared to children with LD who did not receive intervention. To gain more insight in what is
necessary in our intervention program, a new study has recently started with the aim to examine the effectiveness of techniques aiming
at improving syntax. It has to be noted that the tests differed in the amount of gain that was necessary for children to show reliable
change. For expressive syntax for example, it was more difficult for children to show reliable improvement compared to expressive
vocabulary. This was due to differences in the test-retest reliability of the tests. In the Netherlands, these tests are used countrywide to
test these four domains because no other norm-referenced tests are available.
Not all children displayed receptive problems at the start of the intervention, so not all children had to improve on both receptive
domains. The intervention for these children did not explicitly focus on receptive language. It might therefore be that children with
scores within normal range less frequently displayed reliable improvement compared with children with lower scores at intervention
start. We conducted post-hoc analyses to calculate the RCI scores of children with a Q-score < 85 only. This revealed higher per­
centages of improved children for both age groups on both domains (for receptive syntax 45% (n = 9) of children younger than 3 and
17% (n = 9) of the children older than 3 showed reliable improvement; for receptive vocabulary, 87% (n = 13) of children younger
than 3 and 63% (n = 19) of children older than 3 displayed improvement) compared to the RCI percentages when all children were
included. These results suggest that indeed the children who needed to catch up most (the children with scores < 85 at intervention
start) more often showed reliable improvement, especially for receptive vocabulary.
Both age groups displayed significant improvement in language development. The younger children, however, improved most.
Three possible explanations may be underlying. First, this effect might be caused by the presence of more late talkers in the younger
group. If this were the case, we would have expected these younger children to catch up their delay (Rescorla, 2011; Rescorla & Dale,
2013) and be classified as improved according to the RCI. However, for receptive syntax, receptive vocabulary and expressive syntax,
most of the younger children’s language development was classified as unchanged. This means their language development increased
at the same pace as TD peers, but they did not narrow the gap in their language skills. This indicates that children with more severe
language problems were also included in this group and that the presence of late talkers might not completely explain the difference in
language development results between the two age groups. Therefore, we needed to consider other possible explanations.
A second explanation might be that the younger children have benefited from an early referral to the early language intervention
program. This is in line with several studies supporting the importance of early intervention (Kaiser et al., 2022; Nouraey et al., 2021;
Singleton, 2018). In our study, the younger group started the intervention on average 7.5 months earlier than the older group. This
means that the language problems of the older children remained untreated for several months while the younger children were
already receiving intervention. Possibly, because language problems were untreated for a longer period of time, the language problems
of older children were more persistent, and therefore more difficult to diminish.
A third reason might be a difference in the amount of treatment duration between the two groups. Since all children leave the early
language intervention program when they enter elementary school around the age of four, a longer treatment duration was strongly
related to the age of the children at the start of the intervention: the younger they were, the longer the treatment duration. The amount
of treatment duration can be an important aspect of the intervention that may influence results (Law et al., 2017; Warren et al., 2007).
Children may have benefited from a longer intervention time, in which more new skills could be taught. Unfortunately, it is not
possible to unravel the specific contributions of the amount of treatment duration and age at the start of the intervention on subsequent
language development. Both early provision of intervention and the amount of treatment duration may be of importance.

4.1. Limitations

This study has several limitations. Firstly, a control group was not included. This makes it impossible to draw firm conclusions on
whether the language intervention program causally led to language progress. In order to study causal effects, a longitudinal multiple
baseline design might be applied in future research. Although we cannot draw the conclusion that the children improved as a result of
the early language intervention program, we do expect the early language intervention program to have contributed to the language
development of the children because techniques were used that are known to stimulate language development (Camarata & Nelson,
2006; Paul & Norbury, 2012; Pepper & Weitzman, 2004).
Secondly, data were collected using Routine Outcome Monitoring (ROM) (De Beurs et al., 2011; Van Sonsbeek et al., 2014),
meaning they were routinely gathered by different professionals for the purpose of treatment: to set and evaluate intervention aims. As
a consequence, there is variability in timing of assessment. Furthermore, it was not always possible for the SLT to administer all four
tests. We had to deal with tests administered at different ages and with missing data. The main advantage of ROM data, however, is that
it is gathered during actual treatment and is therefore ecologically more valid compared with test scores that would have been
gathered out of context in an experimental setting. Another advantage of ROM data is that it can be gathered for several calendar years,
giving researchers the opportunity to study large samples.
Thirdly, although about 20% of the children visiting the early intervention center is multilingual, this study included only
monolingual Dutch-speaking children. Multilingual children were excluded because language tests are normed for monolingual Dutch-
speaking children and not for multilingual children. Results therefore cannot be generalized to this group.
Fourthly, single imputation was used to handle the missing data. For one of the variables that was imputed (receptive vocabulary
posttest), 54% of the scores were missing. Imputing data is advised when 40% or less of the data is missing (Jakobsen et al., 2017).

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Some caution is therefore necessary with interpreting the data concerning the receptive vocabulary posttest (Jakobsen et al., 2017).
Fifthly, it has to be noted that a relatively low number of parents followed the trainings. This may be due to several reasons. First of
all, not all parents were advised to follow both trainings. For example, the use of signs was not considered equally important for all
children to improve spoken language proficiency. Second, practical reasons played a part in not attaining a training (or more than four
sessions), such as unable to arrange a baby-sitter, the location being too far, or not being able to fit the course in a busy timetable. The
past few years, professionals have tried to lower some boundaries for parents to attain, by offering the trainings more often, on more
locations and on-line.
Lastly, although professionals are trained and supported to maintain and improve treatment quality, treatment fidelity was not
assessed. For future studies, it is of importance to examine whether professionals and parents deliver the intervention as intended (Biel
et al., 2020; Toomey et al., 2020). Several steps are needed for monitoring fidelity, such as monitoring the implementation of the
intervention and trainings that reinforce the skills of professionals and minimize loss of skills or unwanted variation in treatment
delivery. For parent-implemented language intervention, measuring fidelity is more difficult. In the parent trainings, parents are
taught to use key techniques in communication with their child and video-feedback is used to discuss the key techniques delivered by
the parents. After these trainings were finished, there was no structural video-feedback anymore on the parent-child interaction in the
home-situations, which makes it unclear how parents continued to use these techniques at home. Moreover, it is difficult to create a
natural situation at home in which communication can be observed.

4.2. Future studies

This study focussed on children in an early language intervention program, without studying the effects of the separate key
techniques (such as recasting and focused stimulation) used in three different intervention types: group language intervention, in­
dividual speech and language therapy and parent-implemented language intervention. For future studies, it may be of interest to
examine the relation between the used key techniques and language outcome measures, to gain more insight into whether specific key
techniques are more helpful than others to stimulate specific language domains. For example, several studies suggest that the use of
focused stimulation stimulates expressive vocabulary (Alt et al., 2020; Girolametto et al., 1996) and recasting stimulates (morpho)
syntaxis (Cleave et al., 2015; Nelson et al., 1996). It is of interest to examine these relations further.
The RCI is used in this study to gain insight into how many children reliably changed their language proficiency (Jacobson &
Truax, 1991). Although the RCI is used in fields such as mental health care and youth care to study treatment outcomes (de Beurs et al.,
2015; Gevers et al., 2021), it is rarely used in empirical studies examining the effect of interventions for children with LD. It is,
however, an important measure adding information about reliable individual change to group results (de Beurs et al., 2015; Zahra &
Hedge, 2010), because group results do not necessarily reflect progress in all individual children. With the RCI, participants can be
categorized into change groups, which makes it possible to identify possible child characteristics of children showing a reliable
improvement or reliable deterioration. This will provide professionals with more information about what works for whom. Therefore,
it might be of importance to use the RCI more often in studies examining intervention effects of children with LD.
Furthermore, this study examined differences in language development between age groups. The younger children made more
language progress than the older ones. We hypothesized possible factors that could account for this difference, namely early inter­
vention, treatment duration and the presence of late talkers in the younger group. Apart from these three factors that differed between
the age groups, there are more factors that may account for individual variation in language outcomes of the children with LD. These
may be factors such as type of language problem, nonverbal cognitive ability, gender or the stress that parents experience. Gaining
more knowledge in future studies about factors that may account for this variation is of importance, because it can provide pro­
fessionals with insights for which children or under which conditions language progress is more difficult to achieve (McKean et al.,
2017; Short et al., 2020).

5. Conclusions

This study found children with LD showing language progress in receptive and expressive language domains during an early
language intervention program. Younger children showed more language progress than older children in all four domains, but it is
unclear what might explain this difference. In this study, we are not able to disentangle the influence of (a) younger age, (b) earlier
start to intervention, and (c) longer treatment duration. During the intervention, children stabilized or even improved language skills,
indicating that the language gap between these children and TD children did not widen further.

CRediT authorship contribution statement

Bernadette A.M. Vermeij: Conceptualization, Methodology, Formal analysis, Writing – original draft, Writing – review & editing.
Carin H. Wiefferink: Conceptualization, Methodology, Writing – review & editing. Harry Knoors: Conceptualization, Methodology,
Writing – review & editing. Ron H.J. Scholte: Conceptualization, Methodology, Writing – review & editing.

Declaration of Competing Interest

The authors declare that there are no conflicts of interest.

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Acknowledgments

We thank the parents and children who participated in this study and the staff of the Dutch Foundation for the Deaf and Hard of
Hearing Child (NSDSK) who gathered the data.

Supplementary materials

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.jcomdis.2023.106326.

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