Early Intervention Early Intervention Strategies for Children with Strategies for Children with

Speech & Language Speech & Language ImpairmentImpairment

Nancy J. Scherer, Ph.D.Nancy J. Scherer, Ph.D.

Overview of PresentationOverview of Presentation

Rationale for early interventionRationale for early intervention Goals for early interventionGoals for early intervention Early intervention modelsEarly intervention models Teaching ParentsTeaching Parents

RationaleRationale

Much of language development occurs Much of language development occurs prior to three years of ageprior to three years of age

Language functioning is requisite for Language functioning is requisite for successful academic performance and successful academic performance and social functioningsocial functioning

Early intervention may lessen risk of long-Early intervention may lessen risk of long-term communication impairmentterm communication impairment

Advances in Early Advances in Early Language InterventionLanguage Intervention

Focus on teaching functional skills for Focus on teaching functional skills for immediate useimmediate use

Attention to generalization, maintenance Attention to generalization, maintenance of newly learned skillsof newly learned skills

Emphasis on naturalistic approaches Emphasis on naturalistic approaches rather that didactic instructionrather that didactic instruction

Empirical evidence of effective intervention Empirical evidence of effective intervention to improve communication skillsto improve communication skills

Implications of These Implications of These AdvancesAdvances

Teach in everyday Teach in everyday contexts where contexts where communication is neededcommunication is needed

Teach specific Teach specific communication forms at communication forms at the moment they are the moment they are usefuluseful

Teach to promote Teach to promote generalization and generalization and maintenancemaintenance

Which teaching Which teaching strategies?strategies?

Who can teach? Who can teach? What should be taught?What should be taught? What evidence of What evidence of

effectiveness?effectiveness? Are developmental changes Are developmental changes

possible?possible? What changes in functional What changes in functional

communication skills?communication skills? Are there effects in other Are there effects in other

developmental domains?developmental domains?

Goals for Early InterventionGoals for Early Intervention

Promote pre-linguistic communicationPromote pre-linguistic communication Communication intention (Communication intention (e.g.,Request, comment,e.g.,Request, comment, protest)protest) Communication modalitiesCommunication modalities

• VocalizationsVocalizations• GestureGesture• SignSign

Early linguistic communicationEarly linguistic communication Early vocabulary developmentEarly vocabulary development Word combinationsWord combinations Syntax/morphologySyntax/morphology ArticulationArticulation Pragmatics Pragmatics

Milieu TeachingMilieu Teaching

Naturalistic language Naturalistic language teaching strategy teaching strategy designed to teach designed to teach communication skills communication skills in everyday in everyday conversational conversational interactions interactions Hart & Rogers-Warren (l978)Hart & Rogers-Warren (l978)

Principles of EMTPrinciples of EMT Children are motivated to practice language Children are motivated to practice language

when there is a functional consequence.when there is a functional consequence. Adults can create opportunities for functional Adults can create opportunities for functional

language by arranging the environment to language by arranging the environment to facilitate requests.facilitate requests.

Adults model target words (Focused Stimulation)Adults model target words (Focused Stimulation) Structured prompting procedures elicit and Structured prompting procedures elicit and

model new words in response to requests.model new words in response to requests. Expansion, praise and access to requested Expansion, praise and access to requested

objects encourages practice of new words.objects encourages practice of new words. Provides functional, social and linguistic Provides functional, social and linguistic

consequences for child’s language production.consequences for child’s language production.

Milieu Teaching has positive effects on Milieu Teaching has positive effects on children’s communication when implemented children’s communication when implemented

by clinicians and teachersby clinicians and teachers Increases child use of targets Increases child use of targets

Vocabulary (Vocabulary (Kaiser et al, l993; Scherer & Kaiser, in press)Kaiser et al, l993; Scherer & Kaiser, in press) Early syntactic/semantic forms Early syntactic/semantic forms (Kaiser & Hester, l994)(Kaiser & Hester, l994) Moderately complex syntax Moderately complex syntax (Warren & Kaiser, l986)(Warren & Kaiser, l986)

Increases child frequency of communication Increases child frequency of communication ((Warren et al, l994; Kaiser et al, l993)Warren et al, l994; Kaiser et al, l993)

Results in Results in generalizationgeneralization across settings, people, and language across settings, people, and language concepts (concepts (Warren & Bambara, l989; Goldstein & Mousetis, l989Warren & Bambara, l989; Goldstein & Mousetis, l989))

Results in maintenance of newly learned targets (Results in maintenance of newly learned targets (Warren & Kaiser, l986)Warren & Kaiser, l986) Is Is more effective than drill-practice methodsmore effective than drill-practice methods for early language for early language

learners (learners (Yoder, Kaiser et Alpert, l991, Kaiser, Yoder, et al,1996)Yoder, Kaiser et Alpert, l991, Kaiser, Yoder, et al,1996)

Findings From Single Subject Research on Findings From Single Subject Research on Parent-Implemented Milieu TeachingParent-Implemented Milieu Teaching

Parents can learnParents can learn a range of strategies to a range of strategies to criterion levelscriterion levels Environmental arrangement (Environmental arrangement (Alpert & Kaiser, l992; Hemmeter & Kaiser Alpert & Kaiser, l992; Hemmeter & Kaiser

l990)l990) Responsive interaction strategies (Responsive interaction strategies (Hancock & Kaiser, 2002;Kaiser et al, Hancock & Kaiser, 2002;Kaiser et al,

l996)l996) Modeling language targets (Modeling language targets (Hancock & Kaiser, 2002Hancock & Kaiser, 2002)) Prompting target production using EMT techniques (Prompting target production using EMT techniques (Kaiser, Kaiser,

Hancock & Nietfeld, 2001) Hancock & Nietfeld, 2001)

Parents can generalizeParents can generalize these strategies to these strategies to home interactions with their children (Hancock home interactions with their children (Hancock & Kaiser, 2002)& Kaiser, 2002)

Parents maintainParents maintain their newly-learned skills their newly-learned skills over 6-18 months (Kaiser, et al 2001).over 6-18 months (Kaiser, et al 2001).

Hybrid: Enhanced Milieu Hybrid: Enhanced Milieu Teaching Teaching (Kaiser, l993)(Kaiser, l993)

ModelingModeling Mand + ModelMand + Model Time DelayTime Delay Incidental TeachingIncidental Teaching

Four Milieu Four Milieu TeachingTeaching ProceduresProcedures

PLUS

Responsive InteractionResponsive Interaction

Environmental Arrangement

BIGBIG Environmental Arrangement Environmental Arrangement Child preferred activities and materialsChild preferred activities and materials Strategies and room arrangements to promote child Strategies and room arrangements to promote child

engagement engagement Strategies and room arrangements to support positive Strategies and room arrangements to support positive

behaviorbehavior RoutinesRoutines

LittleLittle Environmental Arrangement Environmental Arrangement Strategies to promote requestingStrategies to promote requesting

Choose Toys and Materials of InterestChoose Toys and Materials of Interest Developmentally Developmentally appropriateappropriate Promote Promote speech andspeech and languagelanguage targets targets Can be structured to promote Can be structured to promote requestingrequesting Can be used in a Can be used in a playplay routineroutine AdaptAdapt toys and activities to fit the child’s interest and toys and activities to fit the child’s interest and

abilitiesabilities Cause and effect (bubbles, balls on track, shape sorter)Cause and effect (bubbles, balls on track, shape sorter) Routines and simple schemes (cars on track, jumping Routines and simple schemes (cars on track, jumping

spiders, art, playdough, feeding babies)spiders, art, playdough, feeding babies) Moderate schemes (doll house, simple games, Moderate schemes (doll house, simple games,

housekeeping, farm)housekeeping, farm) Child is Child is engagedengaged….but not obsessed….but not obsessed

Sustaining Child EngagementSustaining Child Engagement Actively engageActively engage in play with child in play with child

Mirror child actionsMirror child actions Exchange materialsExchange materials Take turnsTake turns Talk about what child is doingTalk about what child is doing

Add partsAdd parts to materials to materials PraisePraise engagementengagement—let the child know you notice—let the child know you notice BeBe an engaging, an engaging, responsiveresponsive partner partner Manage timeManage time

Anticipate when child is interest in waningAnticipate when child is interest in waning Change before she doesChange before she does Use a timerUse a timer

Responsive InteractionResponsive Interaction (Adapted from Weiss, et al , 1985)(Adapted from Weiss, et al , 1985)

Follow the child’s lead Follow the child’s lead (topic, play, joint attention)(topic, play, joint attention)

Balance verbal turn takingBalance verbal turn taking Treat nonverbal turns as Treat nonverbal turns as

communicativecommunicative Contingent imitation of Contingent imitation of

child actions in playchild actions in play Enter into and expand Enter into and expand

child’s playchild’s play Provide meaningful Provide meaningful

feedback for feedback for communicative behaviorcommunicative behavior

Model talk at the target Model talk at the target level appropriate to the level appropriate to the communicative contextcommunicative context

Model specific language Model specific language targets in contexttargets in context

Expand child utterances Expand child utterances (meaning and lexical (meaning and lexical expansions at target level expansions at target level and using specific and using specific targets)targets)

Provide meaningful Provide meaningful verbal feedback for verbal feedback for communicative behaviorcommunicative behavior

Basic EMT strategiesBasic EMT strategies

Environmental ArrangementEnvironmental Arrangement Responsive InteractionResponsive Interaction Milieu Teaching StrategiesMilieu Teaching Strategies

Strategies for supporting positive behavior and Strategies for supporting positive behavior and engagementengagement

Choosing activities and routinesChoosing activities and routines for teaching for teaching communicationcommunication

Ability to IndividualizeAbility to Individualize to fit children’s to fit children’s communication needscommunication needs

Choosing targets that advance child’s skillsChoosing targets that advance child’s skills Teaching child’s targetsTeaching child’s targets Keeping track of progressKeeping track of progress Changing as the child changesChanging as the child changes

Basic Responsive StrategiesBasic Responsive Strategies

Create a context for conversationCreate a context for conversation Make yourself an available partnerMake yourself an available partner Use routines, activities, child interest, child Use routines, activities, child interest, child

action to define the topicaction to define the topic Follow the child’s leadFollow the child’s lead

Join, follow, focus on the childJoin, follow, focus on the child Maintain positive boundariesMaintain positive boundaries

Imitate child’s actions:MirroringImitate child’s actions:Mirroring

MirroringMirroring Non-verbal Turn-taking Non-verbal Turn-taking

Definition:Definition:Connecting and communicating with the child Connecting and communicating with the child without using words. without using words.

Mirroring occurs when the adult imitates the Mirroring occurs when the adult imitates the child’s nonverbal behaviorschild’s nonverbal behaviors

Mirroring means you wait, watch, and then Mirroring means you wait, watch, and then do exactly what he did if you cando exactly what he did if you can

MirroringMirroring Non-verbal Turn-taking Non-verbal Turn-taking

ExamplesExamples

Imitating/Mirroring the child’s nonverbal, Imitating/Mirroring the child’s nonverbal, appropriate play behaviorsappropriate play behaviors Child rolls his truck on the table; the adult rolls her Child rolls his truck on the table; the adult rolls her

own truck on the tableown truck on the table You can both drive cars on the table without mirroring, You can both drive cars on the table without mirroring,

but when he stops his car and you immediately stop but when he stops his car and you immediately stop your car too, then you are mirroringyour car too, then you are mirroring

When he slices one piece off of the playdough and When he slices one piece off of the playdough and you slice one piece off, you are mirroringyou slice one piece off, you are mirroring

Mirroring Mirroring Verbal Turn-takingVerbal Turn-taking

ExamplesExamples

To balance your turns with the child, you should To balance your turns with the child, you should respond to every child verbal utterancerespond to every child verbal utterance

Talk only when the child talksTalk only when the child talks Be sure to Be sure to pausepause after your response to allow the child to take after your response to allow the child to take

another turnanother turn If more than 5 seconds pass without a verbal or nonverbal If more than 5 seconds pass without a verbal or nonverbal

behavior from the child, you should take another turnbehavior from the child, you should take another turn MirrorMirror the child’s actions and talk about the action the child’s actions and talk about the action MapMap the child’s nonverbal communication with words the child’s nonverbal communication with words

Example of MirroringExample of Mirroring

C/A: (Mirroring)C/A: (Mirroring)

A: We make musicA: We make music

C/A: (Mirroring)C/A: (Mirroring)

C: (Vocalizes)C: (Vocalizes)

A: Say more (Model)A: Say more (Model)

C: (Vocalizes)C: (Vocalizes)

A: Say more (Model)A: Say more (Model)

C: (Vocalizes)C: (Vocalizes)

A: More music (Model)A: More music (Model)

C/A: MirroringC/A: Mirroring

Milieu Teaching Milieu Teaching ProceduresProcedures

Prompt Prompt language use in language use in functional functional communicative contextscommunicative contexts using using

• Model Model • Mand +Model,Mand +Model,• Time Delay,Time Delay,• Incidental TeachingIncidental Teaching

Teach elaborated language forms Teach elaborated language forms ((TARGETSTARGETS) in context) in context

Provide functional consequencesProvide functional consequences for for communication including positive communication including positive feedback and expansionsfeedback and expansions

Model ProcedureModel Procedure Prompts child to imitate modeled language Prompts child to imitate modeled language

response response Response is functional for childResponse is functional for child

• Access to reinforcerAccess to reinforcer• Child does not yet use form spontaneouslyChild does not yet use form spontaneously

Model begins with “SAY”Model begins with “SAY”• Make the prompt clear to the childMake the prompt clear to the child

Adult waits for child responseAdult waits for child response Model is repeated once if child does not respondModel is repeated once if child does not respond Approximations may be accepted Approximations may be accepted

• Criteria for response are predeterminedCriteria for response are predetermined

Examples of Model ProcedureExamples of Model Procedure

C: XC: XA: Say I roll (Model)A: Say I roll (Model)C: I rollC: I rollA: I roll marbles (Expansion)A: I roll marbles (Expansion)C: (reaches for marbles)C: (reaches for marbles)A: Say more marbles (Model)A: Say more marbles (Model)C: More marbleC: More marbleA: More marbles (Expansion)A: More marbles (Expansion)C: (Marbles in track)C: (Marbles in track)A: Marbles roll (Model)A: Marbles roll (Model)C: Me someC: Me someA: Say marbles go (Model)A: Say marbles go (Model)C: Marble goC: Marble go

Model ProcedureModel Procedure

Model a target word that child does not produce Model a target word that child does not produce spontaneouslyspontaneously

Two prompts—unless you lose child interestTwo prompts—unless you lose child interest Focus and move fast—keep the model in the Focus and move fast—keep the model in the

pace of the conversationpace of the conversation Expand, praise, and provide the requested Expand, praise, and provide the requested

objectobject

MandMand A prompt for a communicative response A prompt for a communicative response

RealReal Question Question • What do you want?What do you want?• What are you painting?What are you painting?

An instruction to verbalize preference or give An instruction to verbalize preference or give informationinformation• Tell me what you wantTell me what you want• Tell me when you are readyTell me when you are ready

An opportunity to indicate a choiceAn opportunity to indicate a choice• Do you want milk or tea?Do you want milk or tea?

Test Questions

Example of Mand-ModelExample of Mand-Model

A: Which one? (Mand)A: Which one? (Mand)

C: (Reaches)C: (Reaches)

A: Say give horse (Model)A: Say give horse (Model)

C: Give horseC: Give horse

A: Give me horse (Expansion)A: Give me horse (Expansion)

C: Give horseC: Give horse

A: Give me more horse A: Give me more horse (Expansion)(Expansion)

C: Give me more C: Give me more

A: Say more horseA: Say more horse

C: More horseC: More horse

Time DelayTime Delay …the pause that transitions …the pause that transitions to spontaneous requestingto spontaneous requesting

Set up environment to promote request Set up environment to promote request (routines, needs assistance)(routines, needs assistance)

Look at child expectantlyLook at child expectantly Hold up object or physically interrupt Hold up object or physically interrupt

actionaction WAIT….up to 5 secWAIT….up to 5 sec Reinforce child initiated responses!!!Reinforce child initiated responses!!!

Example of Time DelayExample of Time Delay

A: (Holds car on track)A: (Holds car on track)

C: Go C: Go

A: Say go cars (Model)A: Say go cars (Model)

C: Go carsC: Go cars

ExpansionExpansion

Definition:Definition: Repeat child’s utterance and ADD new Repeat child’s utterance and ADD new

information. information. • Expansions can be lexical, “correcting” the Expansions can be lexical, “correcting” the

sentence by fixing an ending, correcting a word, or sentence by fixing an ending, correcting a word, or replacing a nonspecific word with a specific word replacing a nonspecific word with a specific word

• or meaning expansions—adding new or meaning expansions—adding new words/meanings to the sentence.words/meanings to the sentence.

Expansion ExampleExpansion Example

A: Which one? (Mand)A: Which one? (Mand)

C: XC: X

A: Say yellow block (Model)A: Say yellow block (Model)

C: Yellow blockC: Yellow block

A: Want yellow block A: Want yellow block (Expansion)(Expansion)

A: Stack blocks (Model)A: Stack blocks (Model)

C: Stack blockC: Stack block

A: We stack blocks A: We stack blocks (Expansion)(Expansion)

Summary Summary

ModelModel procedure is the heart of EMT; it is always procedure is the heart of EMT; it is always the fall back correction procedure the fall back correction procedure

Mand-model Mand-model procedure teaches choice making and procedure teaches choice making and response to general instructions (“tell me) and real response to general instructions (“tell me) and real questionsquestions

Time-delayTime-delay helps children transition to initiating helps children transition to initiating verbal communication at target level; its use verbal communication at target level; its use depends on child learning depends on child learning

ExpansionExpansion increases the child’s linguistic increases the child’s linguistic complexitycomplexity Incidental teaching is simply these procedures done in Incidental teaching is simply these procedures done in

response to a child requestresponse to a child request

Choosing TargetsChoosing Targets Each child should have:Each child should have:

Vocabulary targetsVocabulary targets• Specific words or categories with specific wordsSpecific words or categories with specific words• Prelinguistic transition and one-word children will have Prelinguistic transition and one-word children will have

small set of targets with lots of repetitionsmall set of targets with lots of repetition• Vocabulary matches child cognitive skills and linguistic Vocabulary matches child cognitive skills and linguistic

skillsskills• Phonology and articulation also dictate choicesPhonology and articulation also dictate choices

Two semantic/ syntactic target classes above Two semantic/ syntactic target classes above MLU levelMLU level

• One word children will not have theseOne word children will not have these• Plan multiple examples of target classesPlan multiple examples of target classes

ExamplesExamples

Child’s Target LevelChild’s Target Level Potential “Target Types”Potential “Target Types” Target ExamplesTarget Examples

One wordOne word NounsNounsVerbsVerbsProtoverbsProtoverbsRequesting WordsRequesting Words

Car, ball, barn, houseCar, ball, barn, houseGo, push, roll, runGo, push, roll, runIn, out, off, on, up, downIn, out, off, on, up, downMore, help, Mine, WantMore, help, Mine, Want

Two wordTwo word Agent-actionAgent-actionAction-objectAction-objectModifier-nounModifier-noun2 word requests2 word requests

Girl rides; baby criesGirl rides; baby criesCatch ball; drive carCatch ball; drive carBig ball, red carBig ball, red carWant ball; More cars; Help Want ball; More cars; Help meme

Three wordThree word Agent-action object Agent-action object Agent-action-locationAgent-action-locationAction-modifier-nounAction-modifier-nounAgent-preposition-locationAgent-preposition-locationAction-preposition-locationAction-preposition-location3 word requests3 word requests

The farmer drives the tractorThe farmer drives the tractorThe girl jumps down!The girl jumps down!Blow big bubbles!Blow big bubbles!Boy in car!Boy in car!Go down the slide!Go down the slide!I want ____; Want more I want ____; Want more ____; Help me ________; Help me ____

Summary: EMTSummary: EMT

Hybrid model of early language intervention that Hybrid model of early language intervention that utilizes natural language teaching opportunitiesutilizes natural language teaching opportunities

Validated through evidence-based studiesValidated through evidence-based studies Used with wide range of disabilitiesUsed with wide range of disabilities Promotes speech production in addition to Promotes speech production in addition to

languagelanguage Can be applied to prelinguistic children as well Can be applied to prelinguistic children as well

as children using wordsas children using words Parents and teachers can be trained Parents and teachers can be trained