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Improving Clinical Practices for Children With Language and Learning Disorders

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Abstract

Purpose: This lead article of the Clinical Forum addresses some of the gaps that exist between clinical practice and current knowledge about instructional factors that influence learning and language development. Method: Topics reviewed and discussed include principles of learning, generalization, treatment intensity, processing interventions, components of language therapy, grammar goals, and goal prioritization for students with language and learning difficulties. Conclusion: The gaps that exist between current knowledge about learning, language development, and clinical practice often do not receive as much attention as the gaps in the evidence base that addresses the efficacy and effectiveness of language intervention practices and service delivery models. Fortunately, clinicians do not have to wait for future intervention studies to apply their knowledge of learning and language development to clinical practices.
LSHSS
Clinical Forum
Improving Clinical Practices for Children
With Language and Learning Disorders
Alan G. Kamhi
a
Purpose: This lead article of the Clinical Forum addresses
some of the gaps that exist between clinical practice and
current knowledge about instructional factors that influence
learning and language development.
Method: Topics reviewed and discussed include principles of
learning, generalization, treatment intensity, processing
interventions, components of language therapy, grammar
goals, and goal prioritization for students with language and
learning difficulties.
Conclusion: The gaps that exist between current knowledge
about learning, language development, and clinical practice
often do not receive as much attention as the gaps in the
evidence base that addresses the efficacy and effectiveness
of language intervention practices and service delivery
models. Fortunately, clinicians do not have to wait for future
intervention studies to apply their knowledge of learning and
language development to clinical practices.
Key Words: intervention, language, language disorders
Recent systematic reviews of intervention practices
for children with language disorders have revealed
significant gaps in the body of literature that
addresses the efficacy and effectiveness of language inter-
vention practices and service delivery models (Cirrin et al.,
2010; Cirrin & Gillam, 2008; Law, Garrett, & Nye, 2004).
Despite the gaps in the research literature, articles and
textbooks on language disorders indicate a general consensus
on the basic principles and procedures of language therapy
(Ellis-Weismer, 19901991; Fey, Long, & Finestack, 2003;
Lahey, 1988; Paul & Norbury, 2011; Nelson, 2010; Owens,
2014; Reed, 2012). Most clinicians are familiar with the
process of evidence-based practice. They know that clinical
decisions should not be based solely on research evidence;
client values, clinical expertise, internal client-based evi-
dence, and the constraints of the clinical setting also need to
be considered. Many excellent articles have discussed how
the process of evidence-based practice can improve clinical
decision making (see, e.g., Bernstein Ratner, 2006; Cirrin &
Gillam, 2008; Dollaghan, 2004; Gillam & Gillam, 2006;
Kamhi, 2006, 2011a).
The gaps that I am concerned with in this article involve
the frequent disconnect in current knowledge about learning,
language development, and clinical practice. The following is a
short, 10-item, truefalse quiz to help readers familiarize them-
selves with some aspects of learning and language therapy:
1. Learning is easier than generalization.
2. Instruction that is constant and predictable is more
effective than instruction that varies the conditions of
learning and practice.
3. Focused stimulation (massed practice) is a more
effective teaching strategy than varied stimulation
(distributed practice).
4. The more feedback, the better.
5. Repeated reading of passages is the best way to learn
text information.
6. More therapy is always better.
7. The most effective language and literacy interven-
tions target processing limitations rather than
knowledge deficits.
8. Telegraphic utterances (e.g., push ball, mommy sock)
should not be provided as input for children with
limited language.
9. Appropriate language goals include increasing levels
of mean length of utterance (MLU) and targeting
Browns (1973) 14 grammatical morphemes.
10. Sequencing is an important skill for narrative
competence.
a
University of North Carolina at Greensboro
Correspondence to Alan G. Kamhi: agkamhi@uncg.edu
Editor: Marilyn Nippold
Associate Editor: LaVae Hoffman
Received August 12, 2013
Revision received October 8, 2013
Accepted March 4, 2014
DOI: 10.1044/2014_LSHSS-13-0063
Disclosure: The author has declared that no competing interests existed at the time
of publication.
Language, Speech, and Hearing Services in Schools Vol. 45 92103 April 2014 AAmerican Speech-Language-Hearing Association
Clinical Forum: Reflections on Improving Clinical Practice
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Statement 8 is true; all the others are false. The first
five statements consider aspects of instruction that every
practitioner has confronted. Much has been learned in the
past few decades about how people learn and the types of
conditions that optimize long-term retention and transfer
(E. Bjork, 2004; R. Bjork, 1994, 2011; Diemand-Vauman,
Oppenheimer, & Vaughn, 2011). R. Bjork and others have
found in experiments of adult learning that conditions of
instruction that make performance improve rapidly often
fail to result in long-term retention and transfer, whereas
conditions of instruction that appear to create difficulties for
the learner, often slowing the rate of apparent learning,
can actually optimize long-term retention and transfer.
R. Bjork (1994) referred to these conditions as desirable
difficulties.In recent years, there have been a growing
number of studies applying these principles to students with
language and learning difficulties (see, e.g., Austermann
Hula, Robin, Maas, Ballard, & Schmidt, 2008; Riches,
Tomasello, & Conti-Ramsden, 2005).
The statement about treatment intensity has been
addressed by a number of researchers in recent years (see, e.g.,
Fey, Yoder, Warren, & Bredin-Oja, 2013; McGinty, Breit-
Smith, Fan, Justice, & Kaderavek, 2011; Ukrainetz, Ross,
& Harm, 2009). The title of Fey et al.s (2013) article on
the effects of milieu teaching was actually prefaced with
Is More Better?
The four statements about appropriate language
models and goals are arguably the most important ones
on the list. Statement 7 considers the appeal that targeting
processing limitations has for many practitioners. In a
previous article (Kamhi, 2011b), I argued that therapy that
targets basic perceptual or cognitive processes, such as
attention, auditory processing, or memory, are appealing
because they promise more rapid gains than knowledge-
based interventions. In the section on processing interven-
tions, I raise the question about recent research that purports
to show the benefits of working memory training.
The next statement on the list (No. 8) considers
whether clinician language models should be grammatically
correct (in the adult form) or reflect the childs language
level. Clinicians often provide telegraphic speech models
(e.g., baby shoe, mommy sock) to expand childrens one-word
utterance or echo childrens two-word utterances. A poten-
tial problem with ungrammatical language models is that
language learning is facilitated by the presence of weak
syllablestrong syllable alternation patterns (Bedore &
Leonard, 1995). For example, the presence of an adjacent
weak syllable (e.g., the ball) makes the strong syllable stand
out more perceptually.
Statements 9 and 10 consider goals commonly targeted
to improve childrens language. Much has been learned
about grammatical development in the past 30 years but, as
Schuele (2013) recently pointed out, For too many clini-
cians, grammatical development begins and ends with (or
does not move far beyond) MLU and 14 grammatical mor-
phemes(p. 118). Complex syntax is rarely targeted in
therapyin particular with preschoolers. In the same vein,
instruction to improve narrative discourse and comprehension
often focuses too much on sequencing abilities rather than on
conceptual understanding of the topic and ways to improve
discourse cohesion and coherence. In the sections that follow,
I discuss and review the research that addresses these 10
statements. The article concludes with a consideration of
how to prioritize goals for students who have deficiencies in
multiple areas of language and literacy.
Reconceptualizing Learning and Generalization
as Performance and Learning
A key notion in current views of learning is a new twist
on an old distinction in psychologythe distinction between
performance and learning. Performance is the short-term
context-specific occurrence of some behavior, whereas
learning is the long-term context-independent occurrence of
the particular behavior (E. Bjork, 2004). In education and
speech-language pathology, short-term, context-specific
performance typically is characterized as learning, whereas
the long-term, context-independent occurrence of the par-
ticular behavior is viewed as generalization. This outdated
behavioral view of learning mischaracterizes learning prob-
lems as entailing a difficulty with generalization (Kamhi,
1988). It is not particularly useful, theoretically or clinically,
to characterize childrens learning difficulties as a problem
with generalization. A generalization problem implies that
there is some deficiency in the transfer mechanism or in the
ability to transfer knowledge from one domain to another or
from one context to another. However, even young children
have no difficulty transferring broad-based rules and princi-
ples to new situations (Brown, Kane, & Echols, 1986). What
childrenand everyone elsehave difficulty with is transfer-
ring narrow limited rules to new situations. In applying this
notion to language, one sees that language rules with a limited
scope have more of a restricted use than do rules with a
broader scope (see Kamhi, 1988, for examples). Children with
language and learning problems will have difficulty acquiring
broad-based rules and modifying these rules once acquired,
and they also will be more vulnerable to performance demands
on speech production and comprehension (Kamhi, 1988).
As Fey (1988) appropriately noted in his introduction
to an LSHSS Clinical Forum on generalization, there are
two broad issues here: First, is it reasonable to expect chil-
dren to use a language target consistently after a brief period
of intervention? Second, can language intervention be de-
signed to lead children with language disorders to acquire
broad-based language rules?
The answer to the first question is an unequivocal
No,whereas the answer to the second question is We
certainly hope so.The expectation that brief periods of
intervention will lead to widespread use of adult-level
language rules is based on two assumptions: (a) that lan-
guage intervention techniques have enormous, almost mag-
ical, teaching power and (b) that the language learning
abilities in children with language impairments are somehow
better than those of typically developing children (Fey, 1988).
There is no evidence to support either of these assumptions.
Fey (1988) recognized the challenge involved in designing
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language interventions to facilitate the acquisition of broad-
based language rules, but he was optimistic that it is possible.
Indeed, it must be possible because language serves too
many functions, expresses too many meanings, provides
too many lexical and syntactic options, and is formally too
complex for us to teacheverything to a language-impaired
child (sic) that is necessary to be a competent language
user(Fey, 1988, p. 278).
Instructional Factors
As indicated previously, there has been a considerable
amount of research that has examined instructional factors
that influence learning. Five of these factors are considered
in this section.
Varying the Conditions of Instruction and Practice
When instruction occurs under conditions that are
constant and predictable, learning becomes contextualized”—
that is, the learning looks very good in that context, but it
does not transfer well to different contexts (E. Bjork, 2004).
Context change across repetitions of to-be-learned infor-
mation induces forgetting because current cues differ from
prior cues (R. Bjork, 2011). At the same time, changing the
instructional contexts also enhances learning because the
information becomes linked with a greater range of con-
textual cues and encoded in more than one way (R. Bjork,
2011). To enhance long-term learning and transfer to novel
contexts, the conditions of instruction and practice should
be varied.
Clinicians are well aware of the importance of
generalization/transfer. Paul and Norbury (2011), for exam-
ple, described the notion of sequential modification that
happens when the intervention environment is extended from
one place to another until spontaneous generalization/transfer
to new environments occurs. They suggested that one or
two sessions in one of two alternate environments every few
months may be adequate.
Distributing and Spacing Study and Practice
A large body of literature indicates that distributed
practice, which is characterized by long intervals between
learning episodes, is more effective than massed learning (for
reviews, see Dempster, 1988, and Baddeley, 1997). Accord-
ing to Bruce and Bahrick (1992), over the past 100 years,
the benefits of distributed learning have been investigated in
more than 300 studies. Spacing effects have been observed
in a variety of different cognitive domains, ranging from
motor learning (Baddeley & Longman, 1978) to the ac-
quisition of spelling and multiplication tables (Rea &
Modigliani, 1985). The existence of a spacing effect across
different cognitive domains suggests that it exploits fun-
damental domain-general learning mechanisms. Another
interesting characteristic of distributed practice is that, in
addition to boosting initial performance, it leads to better
retention (e.g., Bahrick & Phelps, 1987).
There is reason to believe that spacing and distribution
of teaching episodes might be particularly beneficial for chil-
dren with language learning difficulties (Riches et al., 2005).
Yoder, Fey, and Warren (2012) recently suggested that the
spacing and distribution of teaching episodes have more of an
impact on treatment outcomes than treatment intensity. A
study by Riches, Tomasello, and Conti-Ramsden (2005) on
verb learning in children with specific language impairment
supports this claim. Children with specific language impairment,
like their typically developing peers, performed better in the
distributed condition for initial learning as well as retention in
production and comprehension. The spacing effect was also
greater and more influential than the effect of the number of
presentations. Performance after only 12 presentations in the
distributed training condition was better than performance
after 18 presentations in the massed training condition.
Reducing Evaluative Feedback to the Learner
The idea that reducing evaluative feedback to the
learner during acquisition could be a desirable difficulty seems
counterintuitive. Yet, recent studies have shown that reduc-
tions in evaluative feedback actually may enhance long-term
retention and generalization of motor skills (Schmidt & Bjork,
1992; Schmidt & Young, 1991), including speech produc-
tion (Austermann Hula et al., 2008). Austermann Hula et al.
(2008) found that reduced evaluative feedback led to greater
long-term retention of motor skills than feedback provided
after every trial. There is no reason to believe that language
learning would not also benefit from evaluative feedback that
is spaced out or less consistent. Evaluating every language
production not only disrupts the flow of the conversational
interaction but also may cause students to stop paying atten-
tion to the feedback and tune out.
Retrieval and Recall Facilitate Learning
Retrieval attempts that require a person to recall and
produce information, even when no corrective feedback is
provided, are often more effective for long-term learning
than re-reading texts (E. Bjork, 2004). Most students spend
too much time reading a text over and over again and too
little time trying to retrieve information and discussing it
with someone else. R. Bjork (2011) showed that retrieving
information from memory facilitates long-term retention.
It is important to note that the more difficult the act of a
successful retrieval, the greater the learning benefit (E. Bjork,
2004) and, conversely, the easier it is to retrieve something,
the less long-term learning there will be. The impact that
spelling and writing have on reading supports this principle.
Research has consistently shown that spelling and writing,
which are both difficult retrieval tasks, benefit reading
(Graham & Hebert, 2010; Shahar-Yames & Share, 2008),
but the reverse is not true. For example, spelling has been
shown to be a powerful self-teaching tool for the formation
of word-specific orthographic information necessary for
fluent reading (Shahar-Yames & Share, 2008), and writing
has been shown to have a positive impact on learning to read
(Graham & Hebert, 2010).
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Treatment Intensity
It is generally thought that a higher dose of instruction
(e.g., five 45-min sessions/week) will result in better learning
outcomes than a lower dose (e.g., two 30-min sessions/week).
Brandel and Frome Loeb (2011) found support for this belief in
a survey showing that clinicians in schools provide more
intensive treatment to children with more severe communi-
cation problems. This widespread belief about treatment
intensity is inconsistent, however, with findings of learning
plateaus and threshold effects in language and literacy (e.g.,
Ambridge, Theakston, Lieven, & Tomasello, 2006; Riches
et al., 2005; Scarborough & Dobrich, 1994). For example,
the benefits of joint book reading have a threshold of three
to four times a week (Scarborough & Dobrich, 1994). Beyond
this point, the quantity or quality of joint book reading has
little effect on literacy outcomes.
The prevalence of thresholds and learning plateaus
suggests that the relationship between treatment intensity
and outcomes might not be as straightforward as most edu-
cators and clinicians believe. Indeed, a number of recent
studies (Denton et al., 2011; Fey et al., 2013; Ukrainetz et al.,
2009) have found that increasing the frequency of treatment
did not result in better language and reading outcomes. In
a recent study by McGinty and colleagues (2011) on the
effects of print referencing, higher dose frequencies actually
made outcomes worse under certain circumstances. An
increase in dose frequency from two to four sessions per week
led to better print knowledge outcomes only when print-
referencing teaching episodes were kept low. There was no
significant advantage of frequent sessions without a reduc-
tion in teaching episodes in individual sessions.
Taken together, the body of research on treatment
intensity indicates that more is not always better. More
frequent instructional episodes will not always be associated
with better treatment outcomes. At some point, increased
intensity is likely to be associated with diminishing treatment
benefits. Plateau effects are more likely with repetitive inter-
ventions such as the one used for print referencing. Spacing the
intervention sessions may help, as may the use of less repeti-
tive interventions, but the relationship between intensity
and learning is unlikely to be consistent across individual
children, different areas of development, and different points
in the learning trajectory (McGinty et al., 2011).
The Case Against Processing Interventions
Acquiring the language, conceptual knowledge, and
reasoning skills necessary to be competent language users,
readers, and writers is challenging even for typical learners.
For students with language and learning disabilities, ac-
quiring these skills may often appear insurmountable to
families, teachers, and the individual student. Given these
challenges, it is not surprising that families and teachers are
often attracted to simple solutions to language and learning
problems. Interventions that target processing skills are
particularly appealing because they offer the promise of
improving language and learning deficits without having to
directly target the specific knowledge and skills required to
be a proficient speaker, listener, reader, and writer. The most
appealing processing interventions target auditory skills and
working memory. Because the benefits of auditory inter-
ventions have been addressed in several recent articles (Fey
et al., 2011; Fey, Kamhi, & Richard, 2012; Kamhi, 2004,
2011b; Wallach, 2011), in this section I focus on working
memory training.
Memory is inextricably tied with language, so it should
not be surprising that there is a long history of research re-
lating memory and language (for recent reviews, see Boudreau
& Costanza-Smith, 2011, and Montgomery, Magimairaj, &
Finney, 2010). In the 1960s and 1970s, it was common for
therapy to focus on improving visual and auditory memory
because the Illinois Test of Psycholinguistic Abilities (ITPA;
Kirk, McCarthy, & Kirk, 1968) was used often to diag-
nose language and learning problems. ITPA-driven therapy
was eventually replaced by therapy that directly targeted
language and communication abilities.
The resurgence of interest in memory training in recent
years can be attributed in part to the large body of evidence
showing that children with language and learning disorders
typically perform below age norms on measures of phonolog-
ical short-term memory and working memory (Boudreau &
Costanza-Smith, 2011; Leonard et al., 2007; Montgomery
et al., 2010; Montgomery & Evans, 2009). If working memory
is a primary cause of language and learning problems, it
seemed reasonable to consider the possibility that improve-
ments in working memory would lead to significant changes in
language function. Practitioners thus began to look for work-
ing memory training programs that showed positive results
in improving language and learning.
They didnt have to wait long. About 5 years ago, an
Italian team of researchers (Jaeggi, Buschkuehl, Jonides, &
Perrig, 2008) published a provocative study showing that
training working memory using dual n-back tasks led to
significant improvement in fluid intelligence in adults. Fluid
intelligence is the ability to reason and to solve new problems
independently of previously acquired knowledge. The sig-
nificance of the study is that previous attempts to improve
fluid intelligence by any type of cognitive or memory training
had not been successful. In an n-back task, variable-length
series of items (digits, words, pictures) are presented in which
an item is repeated at specific intervals relative to other
stimuli. Successful performance requires the listener to re-
member short sequences while counting back one, two, or
three letters to identify a letter match. For example, for an
auditory three-back test, the test-taker must indicate which
letters correspond to letters that he or she read three steps
earlier. The letters in boldface type below are the ones that
should be named. The first two letters in bold are Cs because
there is a C three letters back from each of them. The final
letter in bold is an L because there is an L three letters back:
TLHCHOCQLCKLHCQTRRKCHR
Subsequent studies have reported that working mem-
ory training is also effective with typically developing
children and children with attention-deficit/hyperactivity
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disorder (ADHD; S. Beck, Hanson, Puffenberger, Benninger,
& Benninger, 2010; Holmes, Gathercole, & Dunning, 2009;
Klingberg, Forssberg, & Westerberg, 2002). These studies
have found that training improves attention and executive
control abilities in children with ADHD. On the basis of these
findings, speech-language pathologists (SLPs) are being
encouraged to use working memory training programs with
dual n-back tasks to improve phonological short-term
memory and working memory (Boudreau & Costanza-Smith,
2011; Montgomery et al., 2010).
I am not as enthusiastic as some of my colleagues
about the benefits of these training programs. A recent meta-
analysis (Melby-Lervåg & Hulme, 2013) of 23 working mem-
ory training studies found no evidence that memory training
was an effective intervention for children with ADHD or
dyslexia. Most damaging to the previous claims was the
finding that working memory training did not lead to better
performance outside of the tasks presented within the mem-
ory tests. The findings cast strong doubt on claims that
working memory training is effective in improving cogni-
tive ability and scholastic attainment(Melby-Lervåg, 2013,
p. 282). In light of such evidence, it is difficult to justify the use
of working memory training programs for children with
language and reading disorders. As with previous claims
about the benefits of targeting processing limitations, prac-
titioners should be highly skeptical of interventions that
promise quick fixes for language and learning disabilities.
Components of Language Therapy
One of the most important components of therapy is
the models of language provided by the clinician to the client.
Models can vary in intensity and specificity. One end of the
continuum therapy would involve clinician-directed focused
stimulation (mass practice) of specific language structures
such as auxiliary is +/ing/. At the other end, child-directed
therapy would consist of recasts and expansions of child-
initiated language. Clinicians also need to consider whether
language models should always be well-formed grammati-
cally correct utterances. Statement 8 in the quiz listed earlier
in this article questioned whether telegraphic utterances (e.g.,
push ball, mommy sock) were appropriate language models.
Bedore and Leonard (1995) addressed this question by
showing how the prosodic cues of weak syllablestrong
syllable alternation patterns that characterize well-formed
utterances help children identify the boundaries of clauses,
phrases, and even words.
Bedore and Leonard (1995) reviewed research dem-
onstrating that young children pick out strong syllables from
the input that correspond to open-class content words. The
presence of an adjacent weak syllable (e.g., the ball) makes
the strong syllable stand out more perceptually. The problem
with telegraphic utterances is that they may have two or
more syllables (e.g., open door, eat cookie), which means they
have at least one weak syllable that will be associated with
a content word. Although this association might help
children pick out the stressed syllables in an utterance, it could
lead children to associate all weak syllables with content
words, which would make the subsequent learning of func-
tion words very difficult (Bedore & Leonard, 1995). The
weak syllablestrong syllable alternation patterns also may
provide children a way to predict the grammatical category
of new words. For example, strong syllables in the middle
of a sentence with adjacent weak syllables would indicate
main verbs.
The arguments made by Bedore and Leonard (1995)
suggest that clinicians should always provide well-formed
language models. A recent study conducted by Bredin-Oja
and Fey (2014) that directly compared the effects of tele-
graphic versus grammatically complete models supports this
suggestion. Three of the five children with language delay
who were studied produced significantly more grammatical
morphemes when presented with grammatically complete
imitation prompts. The other two children did not include a
function word in either condition. Providing a telegraphic
prompt to imitate thus did not offer any advantage as an
intervention technique. Children were just as likely to respond
to a grammatically complete imitation prompt.
It is important to note that providing grammatically
complete models does not mean that clinicians should not
respond positively to childrens ungrammatical productions.
The following exchange illustrates how appropriate feedback
can be coupled with a grammatically complete language
model.
Child: Ball.
Clinician: You want the ball?
Child: Want ball.
Clinician: Good (or some other praise for the two-word
utterance). Heres the ball.
The other basic components of therapy are the clients
response to the language models, the feedback the clinician
provides to the client after a response, and the events or
actions the clinician provides to maintain the clientsattention
and motivation. Client responses can vary from no response to
an exact repetition of the model. Appropriate responses are
not necessarily verbal. Examples of appropriate nonverbal
responses would include carrying out a requested action (Put
the spoon in the cup) or pointing to the cup after being asked
Where is the cup?Inappropriate or insufficient responses
depend on the targeted goal.
A clinicians response to the clients communicative
attempt can provide an evaluation of the attemptwas it
appropriate and well formed?or it can reflect an appro-
priate communicative response. Examples of evaluative
feedback are I like the way you said thatand That wasnt
quite right; lets try that again.Evaluative feedback is a
common component of therapy but, as discussed earlier,
reducing evaluative feedback to learners has actually been
found to be a desirable difficulty that enhances long-term
retention and generalization of speech (Austermann Hula,
et al., 2008) and language skills (Proctor-Williams & Fey,
2007). These findings suggest that clinicians should consider
reducing the frequency of evaluative feedback and expand
or comment on what clients are saying rather than how
they are saying it. For example, in describing a picture in a
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storybook, a child may say, The elephant looking for her
babies.Instead of responding, No, the elephant IS (stress)
looking for her babies,the clinician would respond Yes,
the elephant is looking for her babies. Where do you think
they are?The clinician might choose to provide added stress
to the auxiliary is in her response to call attention to this
morpheme, but this is not necessary.
Grammar Goals
In previous articles, I have argued that what is treated
is more important than how it is taught (Kamhi, 2006,
2011b). There are two compelling reasons for the primacy of
goals over procedures. First and foremost, targeting the
wrong goal means that the more appropriate goals are not
being targeted. As a result, the client falls farther behind his
or her typically developing peers in language and literacy
skills. Second, as noted at the outset of this article, there are
significant gaps in the body of literature that addresses the
efficacy and effectiveness of language intervention practices
and service delivery models (Cirrin et al., 2010; Cirrin &
Gillam, 2008; Law et al., 2004). There is little that clinicians
can do about the paucity of high-quality treatment studies,
but there is a lot that they can do to better align their clinical
practices with current literature on language development
and learning. Familiarity with current literature, especially
information about the development of complex syntax, is
crucial for selecting the most appropriate treatment goals. As
noted previously, for many clinicians, grammar development
does not go beyond mean length of utterance and Browns14
grammatical morphemes (Schuele, 2013). The effect of this
narrow interpretation of grammatical development is that
the language needs of children with grammatical problems
may not be adequately addressed in therapy. In the next
section, I discuss how common misconceptions about the
development of grammatical morphemes and complex
syntax affect assessment and treatment decisions.
Grammatical Morphemes
Professionals often assume that children with language
impairments have difficulty acquiring all grammatical mor-
phemes. We have known for at least 20 years, however, that
children with language impairments do not have difficulty
learning /ing/, plural /s/, or the locatives in and on. They do
have difficulty learning grammatical morphemes that reflect
tense and agreement (T/A; e.g., Bedore & Leonard, 1998;
Rice, Wexler, & Cleave, 1995). These include third person
singular /s/, past tense /ed/, the auxiliary do forms (do, does,
did), and both finite copula and auxiliary be forms (is, are,
am, was, were).
Productivity of T/A morphemes has been shown to
have good diagnostic accuracy differentiating children with
specific language impairment from their typically developing
peers (e.g., Gladfelter & Leonard, 2013). Gladfelter and
Leonard (2013) found that two T/A measures developed by
Hadley and her colleagues (Hadley & Holt, 2006; Hadley
& Short, 2005) provide clinically useful information about
specific T/A morphemes and major T/A categories. The two
measures are (a) Tense Marker Total, which assesses the
diversity of T/A morpheme use, and (b) Productivity Score,
which assesses the productivity of major T/A categories.
Although it is probably unrealistic to expect that T/A mea-
sures will permeate clinical practice, clinicians should at least
recognize the multiple limitations of continuing to focus
narrowly and individually on Browns 14 morphemes.
Complex Syntax
A common misconception about the production of
complex syntax is that it is a later developing language
achievement that occurs after children have mastered gram-
matical morphology and basic clausal structure (Arndt &
Schuele, 2013). Consistent with this view, the Common Core
State Standards do not expect complex sentences to be used
until third grade. Typical learners, however, begin to produce
complex syntax (utterances with one or more dependent
clauses) when they are 2 years old, soon after they begin
combining words (Limber, 1973). By age 3 they are producing
conjoined sentences and the three categories of subordinate or
dependent clauses: (a) adverbials, (b) relatives, and (c) nom-
inals (Paul, 1981; Tyack & Gottsleben, 1986). This typical
developmental trajectory means that a focus on complex
syntax needs to begin in the preschool years (see Clark, 2009,
and Diessel, 2004, for a review of normal development of
complex syntax). Clinicians should not wait for children to
master basic clause structure and grammatical morphology
before targeting complex syntax.
Having a framework of how sentences become com-
plex would seem to be a prerequisite for targeting complex
syntax in therapy. There are three basic ways to make
sentences more complex: (a) noun phrase elaboration, (b) verb
phrase elaboration, and (c) conjoined and embedded clauses.
Noun phrase elaboration involves the use of determiners and
adjectives to modify a noun (this table; my big, round, bouncy
ball) and prepositional phrases and relative clauses (the
girl with the red dress; the movie that I saw). Verb phrase
elaboration occurs by adding auxiliaries, secondary verbs, and
adverbs (e.g., She likes to walk quickly to school. He had been
studying for a long time. They should have won the game.)
Complex sentences are formed by embedding nominal
and adverbial clauses in main clauses. Nominal clauses can
be object clauses (e.g., John thinks hes getting an A in
the class) or relative clauses (John, who is tall, is getting an
A in the class;Mary wants the book that I read ). Ad-
verbial clauses, also called subordinate or dependent clauses,
modify independent clauses (e.g., They walked to the beach
because there was no parking;If you build it, he will
come). Compound sentences are formed by conjoining
clauses by the coordinating conjunctions and, but, and or.
My general principle for targeting complex syntax
in therapy is this: Target the meanings and/or functions
conveyed by the syntactic structure rather than the structure
itself. For example, rather than targeting the specific syn-
tax of object-modifying relative clauses (NP + VP + NP +
object modifying clause), the focus should be on the function
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or purpose of relative clauses to clarify (object or subject)
nouns. Relative clauses thus serve the same function as ad-
jectives: They specify and disambiguate nouns. To illustrate,
consider the following example. A clinician places three
different-colored cups in front of a student and asks for a cup.
Not knowing which cup the clinician wants, the student
should respond, Which one?The clinician responds,
The blue one/I want the one thats blue.After providing
other examples of adjectives that can go before the noun and
after the noun in relative clauses (e.g., large drink,”“the
drink that is large), the clinician should provide examples
of relative clauses that cannot be turned into adjectives: Give
me the ball thats on the table(*Give me the table ball),
Give me the cup that fell on the floor(*Give me the floor
ball).
In the same vein, rather than targeting the structure of
object clauses or complements (NP + VP + subject), the
focus should be on the expression of various mental state
verbs (e.g., know, hope, wish, think) that lead to object
clauses. This would lead to exchanges such as the following:
Would you like to have a big sister?
Yes, I wish I had a big sister.
Do you want a dog?
Yes, I hope I get a dog for my birthday.
Do you think its raining out?
Yeah, I think it is.
For object clauses with wh-embedding, goals would
focus on the meanings of the wh-wordswhat, where, who,
why, and how. Examples of these sentences are as follows:
I know what youre doing.
I know where youre going.
I know who you are.
I know why youre here.
I know how youre doing.
To increase the use of conjoined and embedded clauses,
the focus should be on expressing the meanings of coordinating
(e.g., and, but) and subordinating conjunctions (e.g., because,
if, so [that], before, when) and conjunctive adverbs (e.g., then,
yet). Using these conjunctions and conjunctive adverbs will re-
quire producing conjoined sentences and adverbial (subordinate/
dependent) clauses, such as the following examples:
Conjoined sentences
I ate dinner and then watched TV.
She wanted to do her homework but was too tired.
Adverbial (subordinate/dependent) clauses
He couldnt play tennis because it was raining.
They walked home after they played in the park.
If you build it, they will come.
The specific goals associated with NP elaboration, VP
elaboration, and conjoining/embedding would look something
like this:
The student will elaborate noun phrases with adjec-
tives and relative clauses given verbal prompts to
describe pictures. For example:
Tell me what the boy is wearing.
Heswearing a blue shirt that has lots of stripes.
The student will elaborate verb phrases with present
and past tense modals (can, could, will, would, may,
might) and catenatives (gonna, gotta, wanna, hafta)
in conversations with an adult and peers.
The student will use the terms and, but, and or to link
clauses in the retellings of stories and relating events.
The student will use the mental state verbs think, wish,
hope, and know with object clauses when asked questions
about the mental states of characters in books.
The student will produce adverbial clauses with the
subordinate conjunctions because, if, when, after, and
before in response to questions about a story, event, or
play situation. For example:
Why is the boy sad?
Because someone stole his favorite toy.
There is no shortage of information on the develop-
ment, assessment, and treatment of complex syntax. Marilyn
Nippold and Cheryl Scott have written books, chapters, and
articles on the topic (Balthazar & Scott, in press; Nippold,
2007; Nippold & Scott, 2010; Scott, 1988). Most recently,
Melanie Schuele (2013) edited an issue of Topics in Language
Disorders on promoting the development of grammatical skills,
including complex syntax. Articles by Arndt and Schuele
(2013) and Eisenberg (2013) provide a wealth of information
about assessment and intervention.
Difficulties with grammar rarely occur in isolation.
Most students who struggle with grammar often have dif-
ficulties in other areas of language and literacy, and it is these
other aspects of languagesemantics, pragmatics, social
skills, narrative/expository discourse, phonological aware-
ness, spelling, reading, and writingthat are typically given
priority in therapy. In the final section of this article, I
consider the problem of prioritizing goals for students who
have deficiencies in multiple areas of language and literacy.
Prioritizing Goals
Since the late 1960s, when SLPs first began to serve
children with language disorders, the knowledge base and our
scope of practice have undergone dramatic changes. Goal
selection decisions were much easier 40 years ago, when the
scope of language was limited to grammatical morphology,
syntax, early semantic relations, and processing abilities
measured by the ITPA. Today, clinicians are faced with an
expanded scope of practice for language that includes not only
pragmatics, different discourses (conversation, narrative,
expository), and processing limitations (working memory,
auditory, attention) but also all of the components of literacy.
How does a clinician prioritize goals for a student who has
deficiencies in syntax-morphology (grammar), semantics,
conversational and narrative discourse, reading, spelling,
writing, and comprehension of spoken and written language?
There is no simple, straightforward answer to this
question because a number of factors influence the prioriti-
zation of goals. Four of these factors include (a) clinician
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experience and competencies; (b) degree of collaboration
with other professionals; (c) type of service delivery model
(pullout, response to intervention, classroom based); and
(d) client/student factors (e.g., nature and severity of the
disorder). For illustrative purposes, let us consider a hypo-
thetical case of a knowledgeable, experienced, collabo-
rative clinician who works in a response-to-intervention
school with like-minded teachers and other professionals.
Working in such an environment changes the question
from How do I decide what to prioritize?to How
can we, the team of professionals, best serve this student?
The team decides that the reading specialist will target
phoneme awareness and word-level reading; the special
educator will target reading comprehension, spelling, and
writing; and the SLP will focus on narrative discourse
and comprehension.
Narrative discourse is an important area of expertise
for SLPs. Producing and understanding narratives provides
an important bridge between spoken and written language
(e.g., Dunst, Williams, Trivette, Simkus, & Hamby, 2012;
Kamhi & Catts, 2012). Telling or writing stories and re-
lating events can be used to teach all aspects of language and
literacy (syntax, morphology, vocabulary, discourse cohe-
sion, narrative structure, reading, writing, and spelling).
Narratives also can be made communicatively relevant by
focusing on scripts and relating events (e.g., going to the
movies on vacation orplaying a soccer game). Recent research
(Gillam, Gillam, & Reese, 2012) suggests that a contextu-
alized language intervention (CLI) approach is an effective
way to improve discourse-level language. CLI provides
a therapeutic focus within a purposeful and meaningful
activity (Ukrainetz, 2006). Topic continuity across activities
is a key component of contextualized intervention (Gillam
et al., 2012). The specific intervention activities in CLI
include listening to stories, answering comprehension ques-
tions, generating inferences, comparing/contrasting char-
acters across stories, discussing and defining meanings of
Tier 2 vocabulary, and brainstorming solutions to prob-
lems in the stories. Tier 2 vocabulary includes words that are
often unfamiliar to children but represent familiar concepts
(cf. I. Beck, McKeown, & Kucan, 2013). Children are also
encouraged to use conjunctions, modals, and question forms
as they discuss and retell the stories.
It is important to note that improving narrative dis-
course and comprehension does not require the targeting
of sequencing abilities. The ability to understand and recall
events in a story or script depends on conceptual under-
standing of the topic and attentional /memory abilities, not
sequencing ability. Sequencing is not a basic cognitive pro-
cess; no model of cognitive processing includes sequencing
as a distinct cognitive process. The idea that sequencing is
a distinct processing skill can be traced to subtests on the
ITPA that measure auditory and visual sequencing ability.
Unfortunately, many educators continue to believe that
sequencing is a distinct processing skill that needs to be
assessed and treated.
To illustrate the knowledge and processing skills
involved in narrative comprehension and recall, consider
these two passages adapted from the Qualitative Reading
Inventory5 (Leslie & Caldwell, 2011):
Summer and Winter
Michael likes summer.
He goes camping.
He plays with his friends.
He swims and plays in the lake.
Michael also likes winter.
He enjoys Christmas and New Years Day.
He likes skiing and sledding.
He likes wearing his hat and gloves.
A Night in the City
It was Saturday night in the city.
Ben and Ruth wanted something to do.
They heard a noise from outside.
They ran to their bedroom window.
They saw people in the street.
A woman was playing a guitar.
A man began playing the harmonica.
The people began to sing.
Which passage is easier to understand and remember?
Both passages are relatively short and seem well within the
memory constraints of young school-age children. The dif-
ference in the two passages is that the first passage has no
conceptual or temporal logic to help with the ordering of the
events. Going camping, playing with friends, and going
swimming have no logical connection. Correctly recalling
the sequence of events thus depends solely on attention and
memory processes. In contrast, the second passagetells a story
with a logical temporal order of events (hear a noise, go to
window, see a woman playing guitar, man with harmonica,
everyone sings). The logical, conceptually coherent order of
events (macrostructure) reduces memory demands and aids
recall. Incorrectly ordering these events (e.g., Ben and Ruth
saw people singing and then went to the window)would
reflect conceptual difficulties rather than attentional/memory
limitations. Attention and memory limitations would result in
the omission of sentences/events and difficulty responding
to comprehension questions about event order (e.g., What
did Michael do first, go camping or play with his friends?
Did the man play the harmonica before the woman played
the guitar?).
To reiterate, ordering and sequencing errors are caused
by limitations in attention, working memory, and/or con-
ceptual knowledge. For assessment, this means that clini-
cians need to consider the logical and temporal connection
of sentences/events in various language tasks. Even some-
thing as routine as following a two-part command is affected
by these connections. The command Put the ball in the box
and the pen in the canis more likely to have an ordering
error than Put the ball in the box and close the lidbecause
you cant put something in a box with the lid closed. The
therapy implications should be clear: There should never be a
separate therapy goal targeting sequencing ability. Goals
should target the specific concepts and language of the
narrative discourse using a therapy approach such as CLI
Kamhi: Improving Clinical Practice 99
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that reduces attentional and memory demands through
activities that engage the learner and facilitate recall.
The use of contextualized language approaches and
narrative interventions are well suited for the Common Core
State Standards (CCSS) that have now been adopted by almost
every state. The CCSS include specific content standards
for speaking and listening; this is the first time that spoken
language skills have been included in the standard course of
study for elementary school children. These standards include
goals for the production and understanding of simple and
complex sentences as well as goals for conversation and
narrative discourse (see the Appendix). The development of
assessments to monitor student attainment of the CCSS is
already underway (Schraeder, 2012). While awaiting these
assessments and full implementationof the CCSS, SLPs should
consider replacing current language goals with standards-
based individualized education plan (IEP) goals. Recent
articles by Power-de Fur and Flynn (2012) and Rudebusch
(2012) provide several case examples of standards-based IEPs.
Developing standards-based IEPs should help all SLPs
recognize that they play an integral role in the implementation
of the CCSS and are not simply a related service provider.
Summary
In this article, I have attempted to address some of the
gaps that exist between current knowledge about learning,
language development, and clinical practice. These gaps
often do not receive as much attention as the gaps in the body
of literature that addresses the efficacy and effectiveness of
language intervention practices and service delivery models.
Fortunately, clinicians do not have to wait for future inter-
vention studies before applying current knowledge of learn-
ing and language development to clinical practices. In the
first half of this article, I provided a reconceptualization of
learning and generalization, reviewed some basic principles
of learning, and discussed the problem with processing
interventions. In the second half of the article, I discussed
the basic components of therapy as well as how to select
grammar goals and prioritize goals for students who have
difficulties in multiple areas of language and literacy.
The response articles that follow provide other examples
of learning principles and language development that can
be applied to clinical practice. These articles also address
important questions, such as the role of evidence-based
practice in the application of learning principles, the role
of learner engagement in learning, and the order in which
goals are selected.
Acknowledgments
I thank Mary Kristen Clark for her helpful comments on an
earlier version of this article.
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102 Language, Speech, and Hearing Services in Schools Vol. 45 92103 April 2014
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Appendix
First-Grade Speaking and Listening Common Core State Standards
1. Participate in collaborative conversations with diverse partners about Grade 1 topics and texts with peers and adults in
small and larger groups. Follow agreed-upon rules for discussions (e.g., listening to others with care, speaking one at a time
about the topics and texts under discussion). Build on otherstalk in conversations by responding to the comments of others
through multiple exchanges. Ask questions to clear up any confusion about the topics and texts under discussion.
2. Ask and answer questions about key details in a text read aloud or information presented orally or through other media.
3. Ask and answer questions about what a speaker says in order to gather additional information or clarify something that
is not understood.
4. Describe people, places, things, and events with relevant details, expressing ideas and feelings clearly.
5. Add drawings or other visual displays to descriptions when appropriate to clarify ideas, thoughts, and feelings.
6. Produce complete sentences when appropriate to task and situation.
7. Use Standard English grammar and usage when writing or speaking. Print all upper- and lowercase letters. Use common,
proper, and possessive nouns. Use singular and plural nouns with matching verbs in basic sentences (e.g., he hops;
we hop). Use personal, possessive, and indefinite pronouns (e.g., I, me, my; they, them, their; anyone, everything). Use
verbs to convey a sense of past, present, and future (e.g., yesterday I walked home; today I walk home; tomorrow I will walk
home). Use frequently occurring adjectives. Use frequently occurring conjunctions (e.g., and, but, or, so, because). Use
determiners (e.g., articles, demonstratives). Use frequently occurring prepositions (e.g., during, beyond, toward). Produce
and expand complete simple and compound declarative, interrogative, imperative, and exclamatory sentences in response
to prompts.
Note. Excerpted from the Common Core State Standards Initiative (n.d.), publicly available at www.corestandards.org/ELA-
Literacy/SL /1/
Kamhi: Improving Clinical Practice 103
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... Generalization has long been considered difficult to achieve for children with developmental language disorder (DLD). Discussions concerning the nature of generalization and the possible conditions supporting generalization are long-standing (e.g., Eisenberg, 2014;Johnston, 1988;Kamhi, 1988Kamhi, , 2014Leonard, 1974;Smith, 1975). Generalization writ large is also multidimensional. ...
... The distinction between performance on trials that occur during treatment sessions and generalization to untreated contexts is critical (Kamhi, 2014). The former may occur solely in the context of clinician-provided cues or after feedback to the learner that may be a part of the treatment method. ...
... Accordingly, a certain amount of learning might be necessary before generalization occurs. Others have argued that generalization is not just the gold standard for learning but is actually the only true evidence of learning (Kamhi, 2014(Kamhi, , 2019. Conceptualized in this way, any treatment effects that do not generalize reflect only superficial "performance" rather than true learning. ...
Article
Background To maximize treatment efficiency, it would be useful to determine how long to continue a treatment approach before concluding that it is not effective for a particular client, whether and when generalization of treatment is likely to occur, and at what point to end treatment once a child is approaching mastery. Method We analyzed aggregate data from 117 preschoolers with developmental language disorder from a decade of treatment studies on Enhanced Conversational Recast therapy to determine whether the timing of treatment response impacts its overall effectiveness and whether certain levels of accuracy during treatment enable 100% accurate generalization after treatment ends. Results We found that children who take longer than 10 days to answer one item correctly during treatment are unlikely to ever respond to the treatment approach. Generalization accuracy closely followed treatment accuracy, suggesting the two are tightly linked for this treatment method. We did not find evidence that attaining a certain level of accuracy below 100% during treatment enabled children to generalize with 100% accuracy after treatment ended. Conclusions Clinicians using Enhanced Conversational Recast treatment can use these markers to help make evidence-based decisions in their practice regarding how long to continue treatment. Importantly, these data suggest that stopping treatment before a child has attained 100% accuracy (for at least three sessions) does not ensure that a child will ever reach 100% accuracy on their own.
... Academic success in school relies on students' speaking, listening, reading, and writing proficiency (Duncan et al., 2007;Kamhi, 2014). Proficient reading and writing are supported by a strong foundation of linguistic knowledge (Catts et al., 2002;Foorman et al., 2018). ...
... For example, Long (1996) suggested that SLP students should know that subject phrases, verb phrases, personal pronouns, and determiners are subcomponents of syntax. Other clinical forum papers (e.g., Fey et al., 2003;Kamhi, 2014) highlight skills that SLPs should utilize in providing intervention. Notably, Fey et al. (2003) identified that SLPs should select an intermediate language target that is based on a broader language category. ...
... For example, an SLP will need to identify syntactic structures in a child's written language that are omitted or used incorrectly or break down a complex sentence in a written passage to facilitate comprehension. Sufficient explicit syntax knowledge also is critical to SLPs' efforts to collaborate with other educators (Archibald, 2017), such as general and special education teachers, and to provide the team with leadership on the assessment and remediation of children's weaknesses in language (American Speech-Language-Hearing Association, 2010, 2014Every Student Succeeds Act, 2015). ...
Article
Full-text available
Children with developmental language disorder (DLD) exhibit weaknesses in the syntactic aspects of language that affect their spoken language (i.e., speaking and listening) and written language (i.e., reading and writing). Speech-language pathologists (SLP) who work with children with DLD are the team member with the greatest expertise in syntax. However, emerging data suggest that speech-language pathology (SLP) students and SLPs have limitations in their explicit syntax knowledge that may affect how they assess and treat the language and literacy knowledge and skills of children with DLD. Additionally, there is a lack of data on the outcomes of professional development specific to syntax. This paper reports on the effects of self-paced, online learning modules on SLP graduate students’ explicit syntax knowledge. Thirty-six SLP graduate students completed online syntax learning modules that taught four pairs of syntactic structures. SLP graduate students experienced a treatment effect from two of the four online training modules. Treatment effects seemed to be influenced by the syntactic skill being treated, by prior knowledge of that particular syntactic structure, and by other environmental factors, including training program. Although future studies should explore these factors further, the outcomes of this pilot study are the first to report on a way to improve SLP graduate students’, and potentially SLPs’, explicit syntax knowledge.
... There are theoretical arguments to be made in favor of each type of input (Bredin-Oja & Fey, 2014;van Kleeck et al., 2010;Willer, 1974), but findings from several recent studies support the benefits of providing grammatical input (Bredin-Oja & Fey, 2014;Sandbank & Yoder, 2016;Venker et al., 2015). In addition, the number of clinical researchers who encourage the use of grammatical input continues to grow (Conklin, 2010;Eisenberg, 2014;Fey, 2008;Kaiser & Hampton, 2017;Kamhi, 2014;Paul et al., 2018). ...
... Despite the increasing support for simplified grammatical input, clinical researchers have observed that telegraphic input use remains common among practicing SLPs (Eisenberg, 2014;Kamhi, 2014;Paul et al., 2018). Consistent with this observation, a recent survey study revealed that 82% of practicing SLPs reported using telegraphic input when speaking to children with language delays (Venker et al., 2019). ...
Article
Purpose It is common for speech-language pathologists (SLPs) to simplify their utterances when talking to children with language delays, but there is disagreement about whether simplified utterances should be grammatical (e.g., Daddy is running, See the cookie? ) or telegraphic (e.g., Daddy running, See cookie? ). This study examined the extent to which SLPs reported grammatical versus telegraphic utterances to sound like something they would say and investigated whether results differed based on SLPs' perspectives about the usefulness of telegraphic input. Method Ninety-three practicing SLPs completed an online survey. SLPs rated the extent to which a list of telegraphic and grammatical utterances sounded like something they would say to a child with a language delay who is prelinguistic or at the one- or two-word stages of spoken language development. Results SLPs who did not view telegraphic input as useful or felt neutral about this issue rated grammatical utterances to sound significantly more like something they would say than telegraphic utterances. However, findings differed for SLPs who viewed telegraphic input as useful. There was no significant difference in the extent to which these SLPs reported grammatical versus telegraphic utterances to sound like something they would say. Conclusions As incorrect language models, telegraphic utterances are counterexamples to the grammatical structure of English that may make it more difficult for learners to detect regularities in the language input they hear. Unless empirical evidence emerges in support of telegraphic input, it may be beneficial to maximize grammatical input provided to children with language delays.
... However, these are both structural elements of language (Verhoeven & van Balkom, 2003) and, as such, are probably easier to manage within the context of research on treatment intensity, compared to syntactic structures, or pragmatic difficulties. Nevertheless, other important aspects of language must be explored for the academic and communicational development of children with DLD (Kamhi, 2014). One such aspect is the narrative discourse, which is a predictor of school success and reading comprehension (Heilmann et al., 2008;Schneider, Hayward, & Dub e, 2006). ...
Article
Full-text available
Purpose Research on treatment intensity in children with developmental language disorder (DLD) has undergone substantial development over the last decade. The aim of the present review was to analyse available publications as related to methodological quality, degree of scientific evidence, and the areas/aspects of language involved. Method A systematic review of the scientific literature was conducted using the PRISMA guidelines. A total of 9 articles from 34 published investigations in the field were selected for review according to our inclusion criteria. Result The articles addressed the effects of treatment intensity primarily considering expressive morphology and vocabulary. The methodological quality and levels of evidence provided by the studies were high. In general, the effect sizes of dependent variables were considered large. Conclusion The number of articles investigating treatment intensity in DLD is scarce. High variability of stimuli was associated with improvements in morphology, whereas vocabulary did not demonstrate the same association. Further research on treatment intensity is needed to address transference and generalisation of the treated abilities.
... The use of untrained verbs, probe kits, and timing of probes prior to treatment ensured that probe performance reflected learning rather than immediate performance effects (cf. Kamhi, 2014). ...
Article
Purpose Enhanced Conversational Recast treatment is an effective intervention for remediating expressive grammatical deficits in preschool-age children with developmental language disorder, but not all children respond equally well. In this study, we sought to identify which child-level variables predict response to treatment of morphological deficits. Method Predictor variables of interest, including pre-intervention test scores and target morpheme production, age, and mother's level of education (proxy for socio-economic status) were included in analyses. The sample included 105 children ( M = 5;1 [years;months]) with developmental language disorder who participated in 5 weeks of daily Enhanced Conversational Recast treatment. Classification and regression tree analysis was used to identify covariates that predicted children's generalization of their trained grammatical morpheme, as measured by treatment effect size d . Results Our analysis indicates that the Structured Photographic Expressive Language Test–Preschool 2 (SPELT-P 2) scores and the Peabody Picture Vocabulary Test–Fourth Edition scores significantly predicted the degree of benefit a child derived from Enhanced Conversational Recast treatment. Specifically, a SPELT-P 2 score above 75 (but still in the impaired range, < 87) combined with a high Peabody Picture Vocabulary Test–Fourth Edition score (> 100) yielded the largest treatment effect size, whereas a SPELT-P 2 score below 75 predicted the smallest treatment effect size. Other variables included in the model did not significantly predict treatment outcomes. Conclusions Understanding individual differences in response to treatment will allow service providers to make evidence-based decisions regarding how likely a child is to benefit from Enhanced Conversational Recast treatment and the expected magnitude of the response based on the child's background characteristics.
Article
This study examined the extent to which early intervention (EI) speech-language pathologists (SLPs) use and recommend language input strategies for caregivers of children with language delays and the child factors associated with these decisions. Participants included 213 SLPs who completed an online survey. Wilcoxon signed-rank tests, Friedman’s analyses of variance, and Spearman correlations were used to determine the extent to which EI SLPs used and recommended language input, child factors that influenced recommendations and input, and relationships between SLPs’ self-reported strategies and recommendations to caregivers. EI SLPs reported recommending expanding on child utterances more than other strategies. EI SLPs reported using grammatical input more than telegraphic input and recommended grammatical phrases as children made gains in spoken language. Language strategies used by SLPs inconsistently aligned with their recommendations to caregivers. Results underscore the importance of evaluating recommendations to caregivers in the context of EI.
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Conversational repair has been found to play a fundamental role in the acquisition of language. This paper describes existing research on conversational repair and its relationship to language learning, whether a first language or a second language, as well as its relevance to augmentative and alternative communication (AAC). A case is made for incorporating prompts to repair in conversation-based language interventions with children learning to use AAC. We argue that interventions targeting linguistic complexity should encourage self-repair in conversation in order to develop linguistic and operational competency as well as increase automaticity when using AAC. Clinical implications and directions for future research are discussed.
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Purpose: To extract key learning from intervention studies in which qualitative aspects of dosage, dose form, have been examined for children with developmental language disorder (DLD) - in vocabulary, morphosyntax and phonology domains. This research paper emerged from a pair of systematic reviews, aiming to synthesise available evidence regarding qualitative and quantitative aspects of dosage respectively. Whilst quantitative aspects had been experimentally manipulated, the available evidence for dose form (tasks or activities within which teaching episodes are delivered) was less definitive. Despite this, the review uncovered insights of value to DLD research. Method: A pre-registered systematic review (PROSPERO ID=CRD42017076663) adhering to PRISMA guidelines was completed. Included papers were: Quasi-experimental, RCT or cohort analytic studies, published in any language between January 2006 and May 2019; oral language interventions with vocabulary, morpho-syntax or phonology outcomes; and participants with DLD (M=3-18 years). The intention was to include papers in which dose form was experimentally manipulated or statistically analysed, while quantitative dosage aspects were controlled, such that definitive conclusions about optimal dose form could be drawn, and gaps in the evidence identified. Results: 224 papers met the above inclusion criteria; 27 focused on dose form. No study controlled for all quantitative aspects of dosage such that we could effectively address our original research questions. Despite this, key points of learning emerged with implications for future research Conclusions: There is tentative evidence of advantages for explicit over implicit instruction, and of the benefits of variability in input, elicited production and gestural and other visual supports. With careful design of dose form, there is potential to design more efficient interventions. SLP research would benefit from an agreed taxonomy of dose form components and standardised reporting of intervention studies to enable cross-study comparisons and a systematic accrual of knowledge to identify optimal dose form for clinical application.
Article
Speech-language pathologists (SLPs) who work in schools are responsible for delivering intervention that improves language abilities but has an impact on academic outcomes. To accomplish this, SLPs need feasible and effective strategies that can be readily incorporated into clinical practice. In this article, we describe two ways that SLPs can deliver intervention that can improve language abilities and academic outcomes: choosing academic language targets and providing language intervention contextualized in the academic curriculum.
Article
Purpose This study provided reference data and examined psychometric properties for clausal density (CD; i.e., number of clauses per utterance) in children between ages 4 and 9 years from the database of the Edmonton Narrative Norms Instrument (ENNI). Method Participants in the ENNI database included 300 children with typical language (TL) and 77 children with language impairment (LI) between the ages of 4;0 (years;months) and 9;11. Narrative samples were collected using a story generation task, in which children were asked to tell stories based on six picture sequences. CD was computed from the narrative samples. The split-half reliability, concurrent criterion validity, and diagnostic accuracy were evaluated for CD by age. Results CD scores increased significantly between ages 4 and 9 years in children with TL and those with LI. Children with TL produced higher CD scores than those with LI at each age level. In addition, the correlation coefficients for the split-half reliability and concurrent criterion validity of CD scores were all significant at each age level, with the magnitude ranging from small to large. The diagnostic accuracy of CD scores, as revealed by sensitivity, specificity, and likelihood ratios, was poor. Conclusions The finding on diagnostic accuracy did not support the use of CD for identifying children with LI between ages 4 and 9 years. However, given the attested reliability and validity for CD, reference data of CD from the ENNI database can be used for evaluating children's difficulties with complex syntax and monitoring their change over time. Supplemental Material https://doi.org/10.23641/asha.13172129
Article
Full-text available
Marilyn A Nippold, Ph.D., is internationally recognized for her scholarship in later language development. Her research serves as the foundation for understanding the protracted course of language development in school-age children, adolescents, and young adults, and for recognizing the difficulties that young people sometimes encounter in attaining linguistic proficiency. A Fellow of the American Speech-Language-Hearing Association (ASHA) and an Endowed Professor, Dr. Nippold has taught in the Communication Disorders and Sciences program at the University of Oregon for over 20 years. She has published two books and 70 articles and chapters, and has made over 100 presentations at state, national, and international conferences. Dr. Nippold's recent research projects have examined morphological analysis, figurative language comprehension, literacy, and spoken and written language development in school-age children, adolescents, and adults. She also has conducted crosscultural and crosslinguistic studies of later language development with colleagues in New Zealand, Australia, and Israel.
Article
Purpose: School-based speech-language pathologists (SLPs) routinely work with team members to make recommendations regarding an intervention program's intensity and method of service delivery for children with speech and language impairments. In this study, student, SLP, and workplace characteristics that may influence SLPs' recommendations were examined. Method: Almost 2,000 school-based SLPs completed an online survey about the factors they consider when making recommendations regarding program intensity and service delivery model that students on their caseloads receive. Results: SLPs reported that student characteristics, rather than SLP or workplace characteristics, were the factors they considered the most when making these recommendations. However, these same SLPs reported that current students on their caseload with severe to moderate disabilities participated in intervention 2-3 times a week for 20-30 min in groups outside of the classroom. Students with the least severe disability received intervention 1 time a week for 20-30 min in groups outside of the classroom. Conclusion: The limited variety of intervention program intensities and service delivery models used suggests that student characteristics may not be the most important factor considered when making intervention recommendations, as reported by the SLPs. Instead, caseload size and years of practice appear to influence SLPs' recommendations regarding which program intensity and service delivery models to use.
Chapter
This chapter highlights the genesis of complex sentences. There are a number of alternative observationally equivalent descriptions or analyses of these utterances that may turn out to be preferable for one reason or another. As an alternative to a structural or performance oriented explanation, the possibility that the observed distribution results from what children of that age talk about, that is, general exigencies of communication rather than as a gap in their knowledge of English syntax can be looked into. The distribution of relative clauses is dependent on that of names and pronouns—an extensive use of names and pronouns in an environment precludes or reduces the observation of relatives in that environment.
Article
Thirty-five individuals who had learned and relearned 50 English-Spanish word pairs were tested for recall and recognition after an interval of 8 years. Two variables, the spacing between successive relearning sessions and the number of presentations required to encode individual word pairs, are excellent predictors of the likelihood of achieving permastore retention. Optimum recall occurs for words encoded in 1-2 presentations and accessed at intervals of 30 days. Both variables yield monotonic retention functions that account for a range of variation from 0% to 23% recall. These variables also have very significant effects on the recognition of unrecalled words.
Article
All theories of language development assume that young children must have some means of identifying the relevant units of the language they hear without explicit instruction from adults. Even if children are born fully equipped to handle abstract units such as phrases and verbs, they need some means of identifying which pieces of the speech stream are examples of these units, because such units are not structured in the same way across languages. In this paper, we discuss two solutions to this problem that children might employ, commonly referred to as "prosodic bootstrapping" and "syntactic bootstrapping." Following a discussion of these processes, their implications for language intervention are considered.