Improving Clinical Practices for Children
With Language and Learning Disorders
Alan G. Kamhi
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
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, 1990–1991; 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, true–false 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
4. The more feedback, the better.
5. Repeated reading of passages is the best way to learn
6. More therapy is always better.
7. The most effective language and literacy interven-
tions target processing limitations rather than
8. Telegraphic utterances (e.g., push ball, mommy sock)
should not be provided as input for children with
9. Appropriate language goals include increasing levels
of mean length of utterance (MLU) and targeting
Brown’s (1973) 14 grammatical morphemes.
10. Sequencing is an important skill for narrative
University of North Carolina at Greensboro
Correspondence to Alan G. Kamhi: email@example.com
Editor: Marilyn Nippold
Associate Editor: LaVae Hoffman
Received August 12, 2013
Revision received October 8, 2013
Accepted March 4, 2014
Disclosure: The author has declared that no competing interests existed at the time
Language, Speech, and Hearing Services in Schools •Vol. 45 •92–103 •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 child’s language
level. Clinicians often provide telegraphic speech models
(e.g., baby shoe, mommy sock) to expand children’s one-word
utterance or echo children’s two-word utterances. A poten-
tial problem with ungrammatical language models is that
language learning is facilitated by the presence of weak
syllable–strong 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 children’s 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
therapy—in 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 psychology—the 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 children’s 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
children—and everyone else—have 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
Kamhi: Improving Clinical Practice 93
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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 ‘teach’everything to a language-impaired
child (sic) that is necessary to be a competent language
user”(Fey, 1988, p. 278).
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
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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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 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 didn’t 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:
Subsequent studies have reported that working mem-
ory training is also effective with typically developing
children and children with attention-deficit/hyperactivity
Kamhi: Improving Clinical Practice 95
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 syllable–strong
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 syllable–strong 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
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 children’s ungrammatical productions.
The following exchange illustrates how appropriate feedback
can be coupled with a grammatically complete language
Clinician: You want the ball?
Child: Want ball.
Clinician: Good (or some other praise for the two-word
utterance). Here’s the ball.
The other basic components of therapy are the client’s
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 client’sattention
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 clinician’s response to the client’s communicative
attempt can provide an evaluation of the attempt—was 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 that”and “That wasn’t
quite right; let’s 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
96 Language, Speech, and Hearing Services in Schools •Vol. 45 •92–103 •April 2014
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.
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 Brown’s14
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.
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 Brown’s 14 morphemes.
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 he’s 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
Kamhi: Improving Clinical Practice 97
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 that’s 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 that’s on the table”(*Give me the table ball),
“Give me the cup that fell on the floor”(*Give me the floor
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 it’s 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 you’re doing.
I know where you’re going.
I know who you are.
I know why you’re here.
I know how you’re 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:
I ate dinner and then watched TV.
She wanted to do her homework but was too tired.
Adverbial (subordinate/dependent) clauses
He couldn’t 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
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.
He’swearing 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 language—semantics, pragmatics, social
skills, narrative/expository discourse, phonological aware-
ness, spelling, reading, and writing—that 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.
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
98 Language, Speech, and Hearing Services in Schools •Vol. 45 •92–103 •April 2014
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
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
Inventory—5 (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
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 can”is more likely to have an ordering
error than “Put the ball in the box and close the lid”because
you can’t 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
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.
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.
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 •92–103 •April 2014
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 others’talk 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
Note. Excerpted from the Common Core State Standards Initiative (n.d.), publicly available at www.corestandards.org/ELA-
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