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Effectiveness of intervention for grammar in school-aged children with primary language impairments: A review of the evidence

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Effectiveness of intervention for grammar in school-aged children with primary language impairments: A review of the evidence

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This article summarizes the evidence as regards the effectiveness of therapy for grammar for school-aged children with language impairments. I first review studies focusing on specific areas of grammar (both expressive and receptive targets) and then studies aiming to improve language more generally, several of which focus more on the effectiveness of different methods of delivery. I conclude that while there is a growing body of evidence in this area, there are still many gaps. The most concerning gap is the small amount of evidence of effectiveness of intervention for children with receptive as well as expressive language impairments. The evidence to date seems to indicate that these children need specialist, intensive help in order to make progress with their language. Further research is also needed to consider the relative impact of different types of interventions (or their combination) on children of different ages and with different language profiles, including establishing the most effective and/or cost-effective methods of delivery of these interventions.
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Child Language Teaching and Therapy
2014, Vol. 30(1) 7 –40
© The Author(s) 2013
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DOI: 10.1177/0265659013512321
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Effectiveness of intervention for
grammar in school-aged children
with primary language impairments:
A review of the evidence
Susan Ebbels
Moor House School and University College London, UK
Abstract
This article summarizes the evidence as regards the effectiveness of therapy for grammar for
school-aged children with language impairments. I first review studies focusing on specific areas
of grammar (both expressive and receptive targets) and then studies aiming to improve language
more generally, several of which focus more on the effectiveness of different methods of delivery.
I conclude that while there is a growing body of evidence in this area, there are still many gaps.
The most concerning gap is the small amount of evidence of effectiveness of intervention for
children with receptive as well as expressive language impairments. The evidence to date seems
to indicate that these children need specialist, intensive help in order to make progress with
their language. Further research is also needed to consider the relative impact of different types
of interventions (or their combination) on children of different ages and with different language
profiles, including establishing the most effective and/or cost-effective methods of delivery of
these interventions.
Keywords
Evidence base, grammar, intervention, language impairment, review, school-aged children,
therapy
I Introduction
Children with language impairments often have difficulties in many areas of language, but gram-
mar is particularly affected. These children often produce short, simple sentences containing gram-
matical errors and have difficulties understanding longer and more complex sentences. Language
difficulties which are still present by school entry are likely to persist (Stothard et al., 1998), espe-
cially if children have receptive as well as expressive language difficulties (Clark et al., 2007).
Corresponding author:
Susan Ebbels, Moor House School, Mill Lane, Hurst Green, Oxted, Surrey RH8 9AQ, UK.
Email: ebbelss@moorhouseschool.co.uk
512321CLT30110.1177/0265659013512321Child Language Teaching and TherapyEbbels
research-article2013
Article
8 Child Language Teaching and Therapy 30(1)
Such difficulties are likely to affect their ability to do well at school (Nippold, 2010) and hence
their employment prospects (e.g. Law et al., 2009). Thus, there is a need to establish the best ways
to help school-aged children with language impairments improve their language abilities and hence
their educational and life prospects. Improving their use and understanding of grammar is likely to
be one aspect of this.
This review concentrates on intervention studies that aim to improve understanding and use
of grammar in school-aged children (over five years) with language impairments. Some studies
investigate improvements in general language abilities (of which grammar is a major part) but
do not specifically consider grammar. These may use a specific approach (e.g. Fast ForWord,
Scientific Learning Corporation, 1998) or a therapy package containing many different ele-
ments. The outcome measures of these studies are usually quite general, although some meas-
ures more closely related to the intervention itself may also be included. I will consider these
studies after examining those that use more specific intervention methods and outcome measures
related to grammar.
The majority of published language intervention studies indicate that intervention is generally
successful, regardless of the targets or methods used. However, a few important exceptions exist;
these are often the studies with more rigorous designs. Many gaps in the evidence persist, where
relatively little has been published; this is particularly the case for receptive language. Indeed,
previous reviews of the effectiveness of therapy for children with language impairments have con-
cluded that ‘the most substantial single gap in the literature … is the lack of good-quality literature
about intervention for children with severe receptive language difficulties’ (Law et al., 2004) and
that there is ‘an overall lack of evidence for approaches to effective treatment for children with
RELI [receptive and expressive language impairment]’ (Boyle et al., 2010).
II Important variables in intervention studies
The ultimate goal of intervention research is to establish which method is the most effective, for
which areas of language, for which children, using which method of delivery. The most important
variables within the children are likely to be: age, severity and pervasiveness of language difficul-
ties and any co-occurring difficulties. When considering different methods of delivery, the varia-
bles include: who or what delivers the therapy – e.g. speech and language therapist (SLT), SLT
assistant, teaching assistant (TA), teacher, parent, computer – and whether the therapy is delivered
1:1 (one-to-one) or with other children. If the therapy is delivered with other children: how many
others (e.g. in a pair, small group, large group) and who are the other children (in terms of age,
diagnosis, etc)? The duration and distribution of therapy are also important variables as, of course,
is the precise nature of the therapy itself.
When appraising a particular study, it is important first to consider the research design. Some
designs are much more robust than others, and this depends on the degree of experimental control
provided by the study and hence how many other possible factors can be ruled out. For further
discussion of these factors see Ebbels (2008: 150–52).
Practitioners are aided in their appraisal of the evidence by searchable websites, which rate
articles or interventions according to the strength of their research design and hence the reliability
of their findings. The SpeechBITE website http://www.speechbite.com (accessed September 2013)
has the facility to search for published articles on all areas of speech and language therapy. The
resulting studies are listed in order of the strength of their design, although single case experimen-
tal designs have not yet been rated. The recently launched What Works website https://www.
thecommunicationtrust.org.uk/whatworks (accessed September 2013), hosted by the
Communication Trust complements the SpeechBITE website as it allows searches for particular
Ebbels 9
intervention methods or packages. The evidence for each is reviewed and rated as strong, moderate
or indicative.
Another factor to consider when evaluating intervention studies is how specific or general the
outcome measures are and how closely related they are to the intervention. The effectiveness of an
intervention is also indicated by whether positive effects are maintained after intervention ceases
and whether they generalize to similar linguistic targets and to spontaneous use and comprehension
of language in a range of settings.
In this review, I start by considering studies specifically focused on grammar and review the
evidence for different methods of intervention. Tables 1–3 show the key features of all the studies
discussed; I therefore leave out many of these details from my discussion as the information can be
found in the tables. The studies are grouped into tables by target area and sorted within each table
according to the level of experimental control. This is so that practitioners wishing to focus on a
particular area of language can quickly find the evidence relating to that area. More confidence can
be placed in studies higher up the tables due to their stronger designs. Table 1 includes studies
focusing on specific expressive language targets, and Table 2 includes studies focusing on specific
receptive language targets. The studies in Table 3 also focus on expressive language, but not on
specific targets. The tables do not include studies teaching artificial rules or novel linguistic forms.
Following this, I review studies with more general language outcome measures that would be
influenced by changes in grammatical ability, but include other areas of language.
III Intervention approaches aimed specifically at grammar
Two main approaches to improving grammar in school-aged children with language impairments
have been studied: grammar facilitation and meta-linguistic methods. Grammar facilitation
approaches are predominantly implicit and meta-linguistic approaches predominantly explicit (and
usually involve visual support). In practice, a mixture of explicit and implicit approaches may be
used, and the balance between the two may change as the child moves through therapy. Some stud-
ies have examined the effectiveness of primarily implicit or explicit approaches, and some involve
a combination. A few aim to compare the relative effectiveness of these two methods.
1 Implicit approaches
a Grammar facilitation methods. Grammar facilitation methods are the most widely investigated
in intervention research studies. These aim to make target forms more frequent, which is hypoth-
esized to help the child identify grammatical rules and give the child practice at producing forms
they tend to omit. The studies are mostly with pre-school or early school-aged children, many of
whom have expressive language difficulties only. Indeed, the focus of grammar facilitation meth-
ods is on improving expressive language; receptive language is rarely mentioned. The most com-
mon grammar facilitation approaches are: imitation, modelling or focused stimulation, and
recasting.
(i) Imitation. Imitation approaches usually involve the adult providing a non-verbal stimulus
(e.g. a picture) and a target form, which the child then imitates, receiving reinforcement for correct
productions. The adult model and reinforcements are gradually reduced until the child produces
the target in response to the non-verbal stimulus only. Two early randomized control trials (RCTs)
showed that imitation approaches can be effective for improving production of syntax in general
(Matheny and Panagos, 1978) and yes/no questions in particular (Mulac and Tomlinson, 1977).
However, in the latter study, progress only generalized to other settings for those children who
10 Child Language Teaching and Therapy 30(1)
Table 1. Studies targeting specific expressive language targets.
Specific targets Study Number of
participants
Age Diagnosis Grammar
intervention
method
Method of
delivery
Controls? Total hours
therapy
Results Progress
maintained?
Progress
generalized?
Expressive
argument
structure
Ebbels et al.
(2007)
18t (9t: Shape
Coding, 9t: verb
semantics), 9c
11;0–16;1 SLI (receptive
and expressive)
metalinguistic:
Shape Coding
vs. verb
semantics
direct 1:1 yes RCT: 2
therapy
groups plus
control group
1 × 30 minutes
per week (=
4.5 hours)
both therapy groups
improved more than
controls
after 3 months to control verbs
yes/no question
formation
Mulac and
Tomlinson
(1977)
6t (3t: grammar
facilitation,
3t: grammar
facilitation
+ transfer
programme),
3c (articulation
training)
4;4–6;3 language
delayed, plus
failure to use is
interrogative
grammar
facilitation:
imitation
(plus transfer
programme
for 3t)
direct 1:1,
plus 3t
parents
given tasks
to do, but
no mention
of training
parents
yes RCT: 2
grammar
therapy
groups plus
control group
(articulation
therapy)
2.8 hours
(plus 1.92
hours transfer
programme
for 3t)
both grammar therapy
groups improved in the
clinic situation
20–26 days
after end of
therapy
to other
settings only
if extended
transfer training
given
wh-question
formation
Wilcox and
Leonard
(1978)
12t, 12c 3;8–8;2 language
disordered,
all below 10th
percentile of
expressive
measure,
comprehension
not mentioned
grammar
facilitation:
modelling
direct 1:1 yes therapy
vs. delayed
treatment
group, RCT
except for 3
children
not stated therapy group improved
more than waiting
controls; performance
of waiting controls after
therapy not discussed
not measured is inversion
generalized to
wh-questions
finite morphemes Tyler et al.
(2002)
20t (10t:
morphosyntax
then
phonology, 10t:
phonology then
morphosyntax),
7c
3;0–5;11 expressive
language and
phonological
impairment (7t
RELI)
grammar
facilitation:
focused
stimulation
and elicited
production,
recasts and
expansions
direct 1:1 plus
group (1:3)
with graduate
student SLT
interns
yes 2 therapy
groups
(randomly
assigned) +
control group
(not randomly
assigned)
2 × 30 minutes
1:1 plus 45
minutes 1:3
per week for
12 weeks
initially, then
another 12
weeks (=
20 hours
morphosyntax
+ 20 hours
phonology
therapy)
after 12 weeks,
morphosyntax therapy
group made more
progress than controls
on morphosyntax (as
did phonology group on
phonology); phonology
therapy did not improve
morphosyntax although
reverse was true; after
24 weeks, no effect of
order of therapy
not measured morphosyntax
intervention
generalized to
spontaneous
speech and also
to phonological
skills
Ebbels 11
Specific targets Study Number of
participants
Age Diagnosis Grammar
intervention
method
Method of
delivery
Controls? Total hours
therapy
Results Progress
maintained?
Progress
generalized?
finite morphemes Tyler et al.
(2003)
40t (10t: block
of morphosyntax
then phonology,
10t: block of
phonology then
morphosyntax,
11t: alternating
weekly, 9t:
simultaneous
phonology and
morphosyntax),
7c
3;0–5;11 language and
phonological
impairment
(all expressive
impairment,
some also
receptive)
grammar
facilitation:
focused
stimulation
and elicited
production,
recasts and
expansions
direct 1:1 plus
group (1:3)
with graduate
student SLT
interns
yes 4 therapy
groups
(randomly
assigned) +
control group
(not randomly
assigned)
2 × 30 minutes
1:1 plus 45
minutes 1:3
per week for
24 weeks
(= 20 hours
morphosyntax
+ 20 hours
phonology
therapy)
after 12 weeks,
morphosyntax and
alternating therapy
groups made more
progress than controls
on morphosyntax; after
24 weeks: greatest
gains in morphosyntax
in alternating therapy
group with large
effect (d > 1) (changes
in phonology not
significant)
not measured morphosyntax
intervention
generalized to
spontaneous
speech
is, don’t Leonard
(1975)
4t, 4c 5–9 years deficiencies in
grammatical
expression
with no use of
is or don’t
grammar
facilitation:
modelling
direct 1:1 yes therapy
vs. delayed
treatment
group (not
randomly
assigned)
1.25 hours therapy group improved
more than waiting
controls; performance
of waiting controls after
therapy not discussed
not measured not measured
wh-question and
passive formation
Ebbels and
van der Lely
(2001)
4t 11–14
years
SLI (receptive
and expressive)
metalinguistic:
Shape Coding
direct 1:1 yes Multiple
baseline
2 × 30 minutes
per week for
10 weeks (=
10 hours) on
passives, for
20 weeks (=
20 hours) on
wh-questions
3/4 children showed
significant progress with
passives, all progressed
with wh-questions
at 30 weeks:
passives for
2 children,
wh-questions
for 1 child
not measured
(Continued)
Table 1. (Continued)
12 Child Language Teaching and Therapy 30(1)
Specific targets Study Number of
participants
Age Diagnosis Grammar
intervention
method
Method of
delivery
Controls? Total hours
therapy
Results Progress
maintained?
Progress
generalized?
subject pronouns
he and she,
possessive -s, past
tense -ed
Smith-Lock et
al. (2013a)
19t, 15c 5 years SLI (on
average both
expressive
and receptive
language
affected)
direct teaching
plus grammar
facilitation:
focused
stimulation,
recasting and
imitation
small group
(3–5 children)
work with
SLT, teacher
and assistant
(who had
received
training and
manual)
yes matched
control group
(not randomly
assigned)
and multiple
baseline
1 × 1 hour
weekly for 8
weeks (= 8
hours)
experimental group
improved more than
controls, but only
when received therapy,
not during baseline;
effect specific to
targeted structures; at
single-case level, 10/19
showed a significant
treatment effect, 3/19
a non-significant effect
in favour of treatment;
6 made no progress,
but 5 of these had
articulation difficulties
which would interfere
with production of the
targeted grammatical
construction
not measured not measured
to other
situations. Did
not generalize
to control items
regular past tense Kulkarni et al.
(in press)
2t 8;11 and
8;10
participant
A: language
disorder,
participant B:
ASD (both
had expressive
and receptive
impairments)
Shape Coding
plus grammar
facilitation
(recasting
and elicited
imitation)
phase 1: 1:1
with SLT;
phase 2:
generalization
therapy:
activities and
advice given
to teachers
and parents
for carryover
yes multiple
baseline
design
phase 1: 1 ×
30 minutes per
week with SLT
for 10 weeks
(= 5 hours),
plus 3.5 hours
with TA for
participant
A (total =
8.5 hours;
0.5 hours for
participant B
(total = 5.5
hours); phase
2: SLT carried
out 4 sessions
in class, parent
meeting and
session at
participants’
homes.
participant A: stable
baseline, then significant
progress on sentence
completion for treated
and untreated verbs
after phase 1, progress
on conversation task
only after phase 2;
no change in control
structure; participant
B: stable baseline, then
significant progress
with conversation after
phase 1, progress in
sentence completion
task only significant
after phase 2; no change
in control structure
participant
A: yes for 6
weeks; not
measured in
participant B
yes; for
participant B,
generalization
occurred to
conversation
during phase
1; participant
A needed
generalization
therapy (phase
2) for progress
to generalize to
conversation
Table 1. (Continued)
Ebbels 13
Specific targets Study Number of
participants
Age Diagnosis Grammar
intervention
method
Method of
delivery
Controls? Total hours
therapy
Results Progress
maintained?
Progress
generalized?
subject and
possessive
pronouns,
present and past
tense
Smith-Lock et
al. (2013b)
31t: (13t:
distributed
therapy, 18t:
concentrated
therapy)
5 years SLI (17/31t
had RELI,
remainder
expressive
only)
direct teaching
plus grammar
facilitation:
focused
stimulation,
recasting and
imitation
As Smith-Lock
et al. (2013a),
but compared
weekly vs.
daily therapy
yes matched
control group
(not randomly
assigned) and
single baseline
1 × 60 minutes
either weekly
or daily (= 8
hours)
distributed group
made significantly
more progress with
therapy than during
baseline; concentrated
group made similar
progress in baseline
and with therapy,
regardless of whether
measured immediately
after therapy or after
8 weeks (to match
post-therapy testing
period of distributed
group); individual
analyses showed 6/13
of distributed group
showed significant
treatment effect while
3/18 of concentrated
group did so
not measured not measured
grammatical case
in German
Motsch and
Riehemann
(2008)
63t, 63c
(modelling
approaches,
standard
therapy)
8;6–10;1 SLI (84/126
had receptive
difficulties)
‘Context-
optimization’
(incorporates
grammar
facilitation and
metalinguistic
approaches and
writing)
within regular
lessons by
dual trained
teacher-SLT
yes therapy vs.
‘control’
group
(assigned
according
to whether
teacher
signed up for
additional
training)
experimental
group:
12 hours
incorporated
in regular
lessons (on
average 17
minutes, 4 ×
per week);
control group:
time not stated
experimental group
improved more on use
of dative case; both
groups improved on use
of accusative case
yes, for 3
months
not measured
(Continued)
Table 1. (Continued)
14 Child Language Teaching and Therapy 30(1)
Specific targets Study Number of
participants
Age Diagnosis Grammar
intervention
method
Method of
delivery
Controls? Total hours
therapy
Results Progress
maintained?
Progress
generalized?
verb argument
structure
Bolderson et
al. (2011)
6t 5;3–6;6 expressive
difficulties
that included
word order
and omission
problems, and
poor verb
knowledge and
use
metalinguistic:
Colourful
Semantics
direct 1:1 yes group study,
single baseline
30–45 minutes,
2 × per week
for 8 weeks (=
4–6 hours)
specific verb test and
TROG: improved
during baseline and
therapy (not significantly
different); RAPT
(both grammar and
information) and bus
story (information and
mean sentence length):
no progress during
baseline, but significant
progress after therapy
not measured to standardized
tests
expression and
comprehension of
passives
Riches (2013) 2t 8;1 and
8;2
SLI (receptive
and expressive)
usage-based
principles, using
‘construction
grounding’ and
‘conspiracy’
direct 1:1 yes 2 case studies,
single baseline;
control
measure
(relative
clauses) for
one child
20–30 minutes
per week for
6 weeks (=
2 hours, 30
minutes)
both children
significantly improved
both comprehension
and production of
passives; child with
control measure did not
improve on this
not measured not to control
measure
they Courtwright
and
Courtwright
(1976)
8t (4t: imitation,
4t: modelling)
5–10
years
disordered in
use of ‘they’
(used ‘them’
instead)
grammar
facilitation:
modelling vs.
imitation
direct 1:1 no 2 therapy
groups (not
randomly
assigned)
3 × 20 minutes
(= 1 hour)
Modelling group
improved more than
imitation group
not measured to spontaneous
speech
regular past tense
and plurals
Seeff-Gabriel
et al. (2012)
1t 5;1 Speech and
language
difficulties
past tense:
grammar
facilitation
(modelling and
elicitation) +
metalinguistic
(visual symbols);
plurals:
phonology
therapy
direct 1:1 +
carryover
from mother
and school
no treated vs.
untreated
verbs
1 × 30 minutes
per week for
10 weeks (=
5 hours) +
carryover from
mother and
school
past tense: significant
progress; plurals: /s/ and
/z/ produced correctly
in monomorphemic
words after phonology
therapy; /s/ generalized
to plurals; /z/ plural
produced as [d] and
then after further
phonological therapy
as [dz]
yes, for past
tense for 8
weeks
to untargeted
regular verbs,
but not to
irregular verbs
Table 1. (Continued)
Ebbels 15
Specific targets Study Number of
participants
Age Diagnosis Grammar
intervention
method
Method of
delivery
Controls? Total hours
therapy
Results Progress
maintained?
Progress
generalized?
use and inversion
of aux is (3
children), use of
he (one child)
Ellis-
Weismer
and Murray-
Branch (1989)
4t 5;5–6;11 expressive
language delay
(one also had
phonological
and
comprehension
difficulties)
grammar
facilitation:
modelling vs.
modelling
+ evoked
production
direct 1:1 no 4 case studies:
alternating
treatments,
not multiple
baseline
4.67–7.5 hours both approaches
effective for is (children
with expressive
language delay), no
progress with ‘he’ for
child with additional
difficulties
not measured not measured
expressive
language,
especially
argument
structure
Spooner
(2002)
2t 6;3 and
9;9
expressive
and receptive
language
disorder, plus
word finding
difficulties and
dyspraxia
metalinguistic:
Colourful
Semantics
direct 1:1 no pre- vs. post-
test, including
some
standard
scores
approx 22
hours
one child progressed
in argument structure;
both children improved
other areas of
expressive language
not measured to general
language tests
past tense
morphology
Ebbels (2007) 9t 11–13
years
SLI (RELI) metalinguistic:
Shape Coding
direct group
+ (for 2
children) 1:2
no pre- vs.
post-test,
not standard
scores
1 hour per
week for 16
weeks (=
16 hours)
+ approx 4
hours for 2
children
6 children improved
with group therapy; 2
improved only after
additional paired
therapy
not measured to spontaneous
writing
expressive
argument
structure
Bryan (1997) 1t 5;10 expressive
language
disorder
metalinguistic:
Colourful
Semantics
direct 1:1 no pre- vs.
post-test,
not standard
scores
approx 22
hours
most sentences
contained correct
argument structure
after therapy
not measured to a general
language
test and
spontaneous
speech in class
Notes. At number of participants, t = treated and c = control; 1:1 = one-to-one; ASD = autistic spectrum disorder; RAPT = Renfrew Action Picture Test (Renfrew, 2003); RCT = random-
ized controlled trial; RELI = Receptive and Expressive Language Impairment; SLI = specific language impairment; SLT = speech and language therapist; TA = teaching assistant.
Table 1. (Continued)
16 Child Language Teaching and Therapy 30(1)
Table 2. Studies targeting specific receptive language targets.
Specific targets Study Number of
participants
Age Diagnosis Grammar
intervention
method
Method of
delivery
Controls? Total hours
therapy
Results Progress
maintained?
Progress
generalized?
comprehension
of coordinating
conjunctions
Ebbels et
al. (2013)
14t (7
were
waiting
controls)
11;3–
16;1
primary
language
impairments
(RELI)
metalinguistic:
Shape Coding
1:1 with
SLT
yes RCT: therapy
vs. waiting
control group
1 × 30
minutes per
week for 8
weeks (= 4
hours)
significant
progress
with therapy
on targeted
conjunctions
yes for 4
months
yes to
TROG-2,
not to
passives
reversible
sentences
(passives,
comparatives
and sentences
including
prepositions)
Bishop et
al. (2006)
24t (12t:
modified
speech,
12t:
unmodified
speech) 9c
8–13
years
receptive
language
impairment
acoustically
modified vs.
unmodified
speech
computer
1:1
yes 2 therapy
groups plus
control
group:
minimization
method
1.5–7.25 hours no differences
between
groups
n/a n/a
comprehension
of passives and
wh-questions
Ebbels
and van
der Lely
(2001)
4t 11;8–
12;9
SLI (RELI) metalinguistic:
Shape Coding
direct 1:1 yes 4 case
studies,
multiple
baseline
2 × 30
minutes per
week for 10
weeks (= 10
hours) on
passives, for
20 weeks (=
20 hours) on
wh-questions
3/4 children
progressed
with passives,
2/2 progressed
with wh-
questions
at 30 weeks not
measured
comprehension
of dative and
wh-comparative
questions
Ebbels
(2007)
3t 11;8–
12;9
SLI (RELI) metalinguistic:
Shape Coding
direct 1:1 yes 3 case
studies,
multiple
baseline
2 × 30
minutes per
week for 10
weeks (= 10
hours)
2/3 children
progressed
with dative,
2/2 progressed
with wh-
comparative
questions
not
measured
not
measured
Ebbels 17
Specific targets Study Number of
participants
Age Diagnosis Grammar
intervention
method
Method of
delivery
Controls? Total hours
therapy
Results Progress
maintained?
Progress
generalized?
expression and
comprehension
of passives
Riches
(2013)
2t 8;1
and
8;2
SLI (RELI) usage-based
principles, using
‘construction
grounding’ and
‘conspiracy’
direct 1:1 yes 2 case
studies, single
baseline;
control
measure for
one child
20–30 minutes
per week for
6 weeks (= 2.5
hours)
both children
significantly
improved both
comprehension
and production
of passives;
child with
control
measure did
not improve
on this
not
measured
not
measured
comprehension
and production
of structures
involving
syntactic
‘movement’
(relative
clauses and
topicalization)
in Hebrew
Levy and
Friedmann
(2009)
1t 12;2 syntactic SLI
(RELI)
metalinguistic
(colour-coded
verbs and their
arguments and
explicitly taught
to move them
to different
positions in the
sentence)
1:1 with
researcher
no pre- vs.
post-test
(not standard
scores)
20–60 minutes
× 16 sessions,
over 6 months
(= ?11 hours)
significant
progress in
most areas
targeted
not
measured
yes, to wh-
questions
(which were
not directly
targeted)
Notes. See notes at Table 1.
Table 2. (Continued)
18 Child Language Teaching and Therapy 30(1)
Table 3. Studies targeting improvements in expressive language (not target specific).
Study Number of
participants
Age Diagnosis Grammar
intervention
method
Method of
delivery
Controls? Total hours
therapy
Results Progress
maintained?
Progress
generalized?
Fey et al.
(1993)
(phase 1)
21t (11t:
clinician
group, 10t:
parent group),
9c (waiting
controls, who
later got: 4
clinician, 4
parent)
3;8–5;10 clinically
significant
impairment
of expressive
grammar; 13
had RELI and 5
had non-verbal
IQ in 70s
grammar
facilitation:
modelling/
focused
stimulation
plus recasting
(plus imitation
for clinician
group)
clinician
group:
direct: 1:1
+ group
(4–6
children);
parent
group:
indirect
through
parent
groups and
individual
parent
sessions
yes RCT: 2
therapy
groups plus
control
group
clinician group:
60 hours
(children);
parent group:
56 hours
(parents)
both therapy
groups improved
more than controls
(who showed
no change) on
developmental
sentence scores
(DSS); waiting
controls showed
similar progress
when they
received clinician
therapy, but not
parent therapy;
more reliable
progress in
clinician group
not measured
(but see Fey et
al., 1997)
to
spontaneous
speech
Fey et al.
(1997)
(phase 2)
18t (9t:
clinician group,
9t: parent
group), 10c
(dismissed
group who
had received
intervention in
phase 1)
not
stated:
?4;1–6;3?
marked delays
in grammar
development
grammar
facilitation:
modelling/
focused
stimulation
plus recasting
(plus imitation
for clinician
group)
as for Fey
et al. (1993)
yes RCT: 2
therapy
groups plus
control
group
clinician group:
60 hours
(children, in
addition to 60
in first study),
parent group:
15 hours
(parents, in
addition to 56
in first study)
both therapy
groups improved
more than controls
dismissed
group showed
no change;
therefore
progress
from previous
phase 1 study
maintained for
5 months
to
spontaneous
speech
Matheny
and
Panagos
(1978)
16t (8t: syntax
therapy, 8t:
articulation
therapy), 8c
5;5–6;10 ‘functional
articulatory
and syntactic
problems’
grammar
facilitation:
imitation
direct 1:1 yes RCT: 2
therapy
groups plus
control
group
unspecified
over 5 months
both groups made
significant progress
in both syntax
and articulation;
control group
made no progress
not measured to general
language
test
Ebbels 19
Study Number of
participants
Age Diagnosis Grammar
intervention
method
Method of
delivery
Controls? Total hours
therapy
Results Progress
maintained?
Progress
generalized?
Gillam et
al. (2012)
16t (8t: CLI,
8t: DLI), 8c
6;0–9;0 language
impaired
CLI vs. DLI
grammar
facilitation:
drills, focused
stimulation
and recasts
small
groups (3/4
children)
with SLT
yes 2 therapy
groups
randomly
assigned;
non-
randomly
assigned
control
group
3 × 50 min
per week for
6 weeks = 15
hours
both CLI and DLI
improved more
than controls on
sentence-level
measures; CLI
(but not DLI)
also improved
general narrative
comprehension
and expression
(although not
on specific
macrostructure
measure); CLI
had larger effect
sizes than DLI on
both sentence and
narrative measures
not measured not
measured
Nelson et
al. (1996)
7t 4;7–6;7 SLI, < 1.25
SD on MLU
and sentence
imitation
grammar
facilitation:
imitation vs.
recasting
direct 1:1 yes Individual
targets
assigned to
2 therapy
methods vs.
no therapy
mean of 18.1
sessions
(length not
stated)
treated targets
better than
untreated areas;
targets produced
quicker and
generalized more
with recasting
not measured to
spontaneous
speech at
home
Culatta
and Horn
(1982)
4t 4;6–9;2 language
disordered,
primarily
expressive only
grammar
facilitation:
modelling/
focused
stimulation
plus recasting
direct 1:1 yes 4 case
studies:
multiple
baseline
14.25–20.25
hours
90% accuracy
reached on
trained targets,
little progress
on second target
during baseline
period.
yes, for at least
3.5 weeks
to
spontaneous
speech
(Continued)
Table 3. (Continued)
20 Child Language Teaching and Therapy 30(1)
Study Number of
participants
Age Diagnosis Grammar
intervention
method
Method of
delivery
Controls? Total hours
therapy
Results Progress
maintained?
Progress
generalized?
Camarata
et al.
(1994)
21t 4;0–6;10 SLI, primarily
expressive
grammar
facilitation:
recasting vs.
imitation
direct 1:1 no 2 targets
per child
randomly
assigned to
2 therapy
methods
20 hours success of methods
varied between
children; imitation
led to quicker
elicited production
not measured to
spontaneous
speech,
quicker with
recasting
than
imitation
Camarata
and Nelson
(1992)
4t 4;9–5;11 SLI (receptive
language
unaffected)
grammar
facilitation:
recasting vs.
imitation
direct 1:1 no 2 or 4
targets
per child
randomly
assigned to
2 therapy
methods
16–32 hours success of methods
varied between
targets
not measured to
spontaneous
speech,
quicker with
recasting
than
imitation
Tyler and
Watterson
(1991)
12t (6t:
language
intervention,
6t:
phonological
intervention)
3;7–5;7 language and
phonologically
impaired (all
expressive;
comprehension
varied although
generally better
than expression)
grammar
facilitation:
stories read
and re-told
including
targets, role-
play including
targets,
elicitation and
modelling
direct
1:2 with
student
SLT
no 2 therapy
groups (not
randomly
assigned),
no control
group.
2 × per week
for 9 weeks
(length of
session not
stated)
no significant
differences in
MLU between
groups pre- or
post-therapy; no
significant changes
in MLU
n/a n/a
Guendouzi
(2003)
2t 7;0 and
6;10
SLI metalinguistic:
similar to
Colourful
Semantics
not stated,
direct 1:1
implied
no 2 case
studies pre-
vs. post-test,
no standard
scores
not stated one child made
progress on MLU;
one did not
not measured to
spontaneous
speech
Notes. See notes at Table 1; CLI = contextualized, literature-based narrative intervention; DLI = decontextualized language intervention; MLU = mean length of utterance.
Table 3. (Continued)
Ebbels 21
received additional sessions with the clinician and parent, where the target form was elicited in the
context of conversation and stories.
(ii) Modelling / focused stimulation with or without evoked production. In modelling and focused
stimulation approaches, the child is not required to respond, merely to listen to examples of the
target structure. Modelling approaches direct the child’s attention to the stimuli but do not give
explicit guidance on which particular features to attend to. Focused stimulation, in contrast, does
not direct the child’s attention to the model in any way. Evoked production may follow the model-
ling or focused stimulation period. In this case, the child produces a novel utterance that uses the
same rule as the model and then receives feedback. The degree of modelling is gradually reduced
as the child begins to use the new rule productively.
One study showed that modelling without evoked production was effective in teaching auxiliary
is and auxiliary inversion to three children with expressive language delays, but the addition of
evoked production led to a more stable learning pattern (Ellis-Weismer and Murray-Branch, 1989).
However, neither method was successful in teaching he to a fourth child with both expressive and
receptive language difficulties.
Two studies found modelling with evoked production improved the ability of an experimental
group to produce is and don’t (Leonard, 1975) and wh-questions accurately (Wilcox and Leonard,
1978). The delayed therapy groups made no progress until they too received therapy. The latter
study showed generalization of is inversion to other wh-constructions requiring inversion.
Courtwright and Courtwright (1976) compared the effectiveness of modelling vs. imitation
methods for teaching correct use of they in subject position (as opposed to them). The children in
both groups improved on their initial performance, but those in the modelling group showed greater
progress. They found a similar advantage for modelling when teaching children to produce an
artificial grammatical rule (Courtwright and Courtwright, 1979). However, two studies (Connell,
1987; Connell and Stone, 1992) showed that modelling alone seemed to be less effective for teach-
ing novel derivational morphemes to children with Specific Language Impairment (SLI) than just
imitation or modelling plus imitation, particularly if they were required to produce the new form.
The differing results of these studies may be due to the nature of the invented rules, which for the
Connell studies involved derivational morphology, but for the Courtwright and Courtwright (1979)
study involved a novel sentence structure.
(iii) Recasting. Recasting methods are designed to be non-intrusive conversational procedures.
The adult does not initiate teaching directly, but manipulates play activities to increase the chances
of the child using targeted grammatical forms. When the child fails to use the target form or makes
an error, the adult immediately follows his or her utterance with a modified version that includes
the target form (a ‘recast’). The theory behind this approach is that the child is more likely to be
interested in what the adult is saying if it links semantically to the situation and the child’s own
prior utterance. The immediate contrast between the two forms should also focus the child’s atten-
tion on the features of the utterances that differ. In addition, the child does not need to parse the
adult’s meaning and thus should have more processing resources available for analysing the target
form in the recast.
Three studies compared the effectiveness of recasting vs. imitation for increasing production of
a range of morphosyntactic structures in children with SLI (Camarata and Nelson, 1992; Camarata
et al., 1994; Nelson et al., 1996). These found targets treated with either type of intervention
improved more than untreated targets, but Camarata et al. (1994) found target forms occurred
spontaneously after fewer presentations using recasting than imitation. In contrast, imitation led to
faster elicited production of the target. However, there is evidence of an interaction of target type,
22 Child Language Teaching and Therapy 30(1)
child and intervention method. Camarata and Nelson (1992) found that children acquired the pas-
sive construction faster with recasting, whereas they acquired the gerund faster with imitation.
Individual variation was revealed in Camarata et al. (1994) when three of the 21 participants only
acquired targets with imitation and three only with recasting.
More recent studies have begun to unpack the necessary features for recasting approaches to be
effective. This includes: the density of recasts, the similarity of the recast to the original sentence,
whether they serve a corrective function, and whether the child’s initial levels of use of the target
matter. I discuss these studies below as they have clinical implications for recasting therapy, but
they do not appear in the tables because they are either with pre-schoolers, or use novel linguistic
forms or are not intervention studies.
The original studies demonstrating the efficacy of recasting by Camarata, Nelson and colleagues
(discussed above) used recast rates of between 0.7 and 1.8 recasts per minute. Subsequent studies
have shown that lower levels (0.47; Proctor-Williams and Fey, 2007) and conversation-like densi-
ties (Proctor-Williams et al., 2001) do not seem to benefit children with SLI (unlike typically
developing children). Another study (Fey and Loeb, 2002) with recasting densities similar to the
original studies (one per minute) found no effect of recasting on the ability of 3-year-old children
with SLI to produce auxiliaries or modals. They suggested the children may not have been ready
to benefit from recasts and that recasting may be best when the children are already using the target
form to a certain extent rather than for encouraging use of a new form. Indeed, Saxton (2000)
showed that typically developing children need to use a grammatical form above 50% of the times
required before they can benefit from corrective recasts. It appears that recasts do not necessarily
need to be corrective. Hassink and Leonard (2010) found that conversationally relevant recasts
containing a new form were facilitative for pre-schoolers with SLI even when the recasts served no
direct corrective function.
Thus, it seems that for recasting to be maximally effective, the recasts need to be of high density
and the children need to already use the target to a certain extent. It does not seem to matter
whether or not the recast corrects an error.
(iv) Combined grammar facilitation approaches. Some intervention studies have used a combi-
nation of the methods discussed above. In particular, modelling with evoked production together
with recasting has been shown to be effective for generalization of newly learned grammatical
rules to spontaneous discourse (Culatta and Horn, 1982) and for increasing grammatical accuracy
and range (Fey et al., 1993; 1997; Gillam et al., 2012; Tyler et al., 2002). The studies by Fey and
colleagues also investigated the role of parents in the delivery of intervention. These revealed a
significant effect of intervention, whether delivered by parent or clinician, although the children in
the clinician groups made more reliable progress.
A series of studies by Tyler and colleagues investigated the effectiveness of grammar facilita-
tion (and phonological therapy) approaches with children with both language and phonological
impairments. An early study (Tyler and Watterson, 1991) found no significant effect of grammar
facilitation therapy on the mean length of utterance (MLU) of these children. However, two later
studies (Tyler et al., 2002, 2003) showed that children receiving a block of grammar facilitation
therapy focused on morphosyntax, improved their production of finite morphemes (and indeed
their phonology) more than a control group who received no therapy. Tyler et al. (2002) addition-
ally showed that the amount of progress in finite morphemes was the same regardless of whether
the children received morphosyntactic therapy before or after phonological therapy. However,
Tyler et al. (2003) showed that the largest gains were found in children receiving therapy that alter-
nated weekly between a focus on phonology and morphosyntax. The children were assigned ran-
domly to groups, thus there was no consideration of the extent to which each child’s morphological
Ebbels 23
difficulties were due to phonological factors. This may have contributed to the highly variable
responses to therapy in this study.
Indeed, a study including both implicit and explicit therapy (Smith-Lock et al., 2013a, discussed
below) found that children whose articulation difficulties interfered with production of targeted
grammatical constructions made no progress with grammatical therapy. A single case study (Seeff-
Gabriel et al., 2012) considered the impact of phonology on the targeted morphosyntactic struc-
tures and varied the therapy accordingly. Phonology was not considered to affect his production of
past tense and, indeed, grammatical therapy (mostly using grammar facilitation methods) improved
his production of the regular past tense. However, phonology was considered to affect his produc-
tion of plurals, as he could not accurately produce /s/ or /z/. In this case, phonological therapy led
to increased marking of plurals.
A recent study (Gillam et al., 2012) found combined grammar facilitation approaches were
more effective when embedded in a story context than when presented in a decontextualized way.
However, a large scale RCT (Gillam et al., 2008; see Table 5 for details) compared grammar facili-
tation approaches with two other interventions: Fast ForWord (reviewed below) and computer-
based language games and also with a control intervention: ‘academic enrichment’ (computer
games focusing on Maths, Science and Geography). They found no significant advantage for any
group. Indeed, the language intervention groups only showed greater progress than the ‘academic
enrichment’ group on blending words. Thus, the grammar facilitation group fared no better on
language measures than the other groups, including the ‘control’ academic enrichment group.
b Usage-based approach. Riches (2013) evaluated an alternative implicit approach (a usage-based
approach; e.g. Tomasello, 2003), which takes into account the gradual development of grammati-
cal structures in typically developing children. Riches evaluated this approach with reference to
passives. The intervention gradually built up to a full event passive, starting with state passives
(e.g. I like my sausages chopped) which could be interpreted as an adjective, via ambiguous pas-
sives (e.g. I want my sausages chopped) to event passives (e.g. the sausages were chopped by the
cat). He found that two children with receptive and expressive SLI significantly improved their
comprehension and production of passives, but not the control structure (relative clauses).
c Summary of implicit approaches. The effectiveness of implicit methods has been investigated in
a range of studies including some RCTs. These generally indicate that these methods are effective
for improving expressive morphology and syntax in pre-school and early school-aged children
with expressive language delays and disorders when delivered 1:1 by an SLT or parent. However,
the study by Gillam et al. (2008) indicates that this may be no more effective than ‘academic
enrichment’. For children with co-occurring phonological impairments, the impact of these on
specific grammatical targets should be considered, as should delivering an alternating phonologi-
cal and grammatical approach.
2 Explicit approaches
Meta-linguistic approaches provide predominantly explicit teaching of language, often in the con-
text of specific visual cues. Once the child has learned a new rule, some grammar facilitation
methods (especially recasting) may be used alongside visual templates and explicit references to
the child’s errors, and more context may begin to be added. These approaches are based on the
hypotheses that children with primary language impairments have difficulties learning grammar
implicitly and benefit from explicit teaching of the rules (for further discussion, see Ebbels et al.,
2013).
24 Child Language Teaching and Therapy 30(1)
a Colourful semantics. Colour coding is frequently used in meta-linguistic approaches. Colourful
Semantics (Bryan, 1997) colour codes thematic roles in sentences in order to help children identify
thematic roles and create a variety of argument structures. Several uncontrolled case studies have
been carried out using this or similar methods (Bryan, 1997; Guendouzi, 2003; Spooner, 2002).
Also, a group study (Bolderson et al., 2011) found improved expressive language after therapy,
compared with no progress during a baseline period. Progress on receptive language was seen both
during baseline and the therapy period and thus the changes could be due to maturation or practice
at the tests.
b Shape coding. A related meta-linguistic approach (Shape Coding, Ebbels, 2007) uses a combi-
nation of shapes, colours and arrows to indicate phrases, parts of speech and morphology respec-
tively. It was originally conceived as a combination of the ‘Colour Pattern Scheme’ (Lea, 1970)
and ‘Colourful Semantics’ systems, but was further developed so that it can also show complex
sentence structures and verb morphology. Each shape is linked to a question word and colour.
An RCT (Ebbels et al., 2007) investigated production of verb argument structure and compared
therapy using Shape Coding with therapy focusing on verb semantic representations and a control
therapy (focused on inferencing, which was not predicted to have any effect on verb argument
structure). Both the Shape Coding and verb semantic methods were based on detailed hypotheses
regarding the underlying reasons for the participants’ difficulties with verb argument structure and
both groups made significant progress, particularly in linking arguments to the correct syntactic
positions (i.e. reducing errors such as ‘she is filling the water into the glass’). Progress generalized
to control verbs and was maintained three months after intervention ceased. The Shape Coding
group also used more optional arguments after therapy. The control group showed no progress in
verb argument structure.
A second RCT (Ebbels et al., 2013) focused on comprehension of coordinating conjunctions
(but not, neither nor, not only but also). We found that those receiving Shape Coding therapy
improved their comprehension of the targeted conjunctions significantly more than the waiting
controls, who then also made progress when they too received therapy. Progress also led to
increased scores on the Test of Reception of Grammar (TROG-2, Bishop, 2003). However, we
found no generalization to comprehension of passives. Analyses of child-related factors showed no
predictors of which children would improve the most with the therapy. The predictors considered
including non-verbal and visual processing abilities, which while correlated with each other, were
not correlated with any language measure or progress with therapy.
Ebbels and van der Lely (2001) investigated the efficacy of Shape Coding for improving expres-
sion and comprehension of passives and wh-questions. Three of the four participants showed sig-
nificant progress in both their comprehension and production of passives. Two had difficulties
comprehending wh-questions pre-therapy and both showed significant progress in this area. All
four participants showed short-term progress with the production of wh-questions, but only one
participant maintained this at a significant level by follow-up. The three participants who responded
best participated in a follow-up study (Ebbels, 2007) targeting comprehension of the dative con-
struction (e.g. the boy is giving the girl the rabbit) and wh-comparative questions (e.g. what is
bigger than a cat? vs. what is a cat bigger than?). All three received intervention on datives, but
only two received intervention for wh-comparatives due to a change of SLT. Two of the three par-
ticipants showed significant progress in their comprehension of dative constructions. The third was
hypothesized to have additional short-term memory difficulties that made progress on this area
more difficult, due to the need to remember the order of three key nouns. However, this participant
made significant progress in comprehension of wh-comparative questions, as did the other partici-
pant who was taught this structure.
Ebbels 25
The studies of Shape Coding discussed above all involved individual therapy sessions. However,
an uncontrolled study on the use of the past tense in writing (Ebbels, 2007) involved group teach-
ing. A class of nine pupils (aged 11–13 years) were taught using the Shape Coding system during
English lessons. Six used the past tense more after the class sessions, but two more made progress
only when they received additional intervention in a pair. Possible explanations are either that they
merely needed more intervention time, or that they needed a more individualized approach which
could be provided in a pair, but not in a group of nine.
Until recently, all the studies of Shape Coding have been with secondary-aged children.
However, Kulkarni et al. (in press) investigated its effectiveness for improving oral use of the past
tense by two younger children (8-year-olds) in both structured tasks and conversation. We also
considered whether additional generalization therapy was required for participants to use target
forms in their spontaneous speech. One participant improved markedly in sentence completion but
required the generalization therapy before gaining in the conversational task. The other made more
modest gains in both areas without recourse to the generalization therapy.
c Other explicit approaches. The effectiveness of an explicit meta-linguistic approach has also
been investigated in Hebrew in a single uncontrolled case study (aged 12;2). Levy and Friedman
(2009) investigated its effectiveness for improving the comprehension and production of structures
involving syntactic ‘movement’ (relative clauses and topicalization) in Hebrew. Their method was
similar to Colourful Semantics and Shape Coding in that they colour coded verbs and their argu-
ments (as in Colourful Semantics) and they explicitly taught movement showing the link between
the moved item and its trace (as in Shape Coding; see Ebbels and van der Lely, 2001). They found
significant progress in most areas targeted and also generalization to areas not targeted, such as
wh-questions.
d Summary of explicit approaches. Studies of metalinguistic approaches indicate that they can be
effective for school-aged children with language impairments, including those of secondary age
and those with receptive language difficulties. There is no evidence of whether these approaches
are effective when delivered by anyone other than an SLT.
3 Comparison of explicit and implicit approaches
A few studies have compared the effectiveness of implicit vs. explicit therapy for improving
expressive language. These have found conflicting results, which may be due to the age of the
children, the target of therapy, or the design of the studies. One study (Swisher et al., 1995) found
that younger children with SLI (age 4–6 years) learned to generalize novel bound morphemes
trained in a story context to untrained vocabulary stems better with implicit than explicit training.
In contrast, Finestack and Fey (2009) found that children with language impairment (aged 6–8
years) learned to use novel verb inflections better with explicit than implicit training. Motsch and
Riehemann (2008) found German children with SLI (aged 8–10 years) learned the dative case bet-
ter with explicit than implicit intervention, whereas both methods were equally effective for
improving the accusative. However, there were several possible biases in this study; for example,
the more willing and knowledgeable teachers carried out the explicit intervention. It is also unclear
whether the two groups received equal amounts of intervention.
These three studies together appear to indicate that implicit approaches may be more effective
for younger children (under 6 years) while explicit approaches may be more appropriate for older
children. However, given the limited range of targets and the fact that all the targets involved
expressive morphology, much more work needs to be done to draw any firm conclusions.
26 Child Language Teaching and Therapy 30(1)
4 Combination of explicit and implicit approaches
In a study of the effectiveness of grammar therapy in a school setting, Smith-Lock et al. (2013a)
showed a significant effect of direct explicit teaching combined with grammar facilitation tech-
niques on the ability of 5-year-olds with SLI to produce subject pronouns, possessive s and past
tense -ed. Their experimental group improved more than the control group, but only when they
received intervention (in a group), not during baseline. The effects did not generalize to untreated
grammatical targets. At a single-case level, most children showed a treatment effect. Six made no
progress, but five of these had articulation difficulties. A follow-up study (Smith-Lock et al.,
2013a) showed that this approach was only effective when provided in eight weekly sessions rather
than eight daily sessions.
Some of the studies discussed above (e.g. Kulkarni et al., in press), while predominantly using
explicit methods, also used some grammar facilitation methods. Indeed, in clinical practice, the
two are often combined. Given that 50% usage of a targeted structure may be required before
recasting can be effective, it may be that explicit methods could be used for initial teaching and
then recasting could be used thereafter. However, further research is needed to establish whether a
combination of approaches is more effective than purely implicit or explicit therapy and, if so, how
and when the two methods should be combined.
Several studies have focused on both narrative and grammar abilities in parallel. These are
shown in Table 4. These tend to have an explicit approach to narrative structure and an implicit
approach to grammar. Specifically, the ‘narrative based language intervention’ (NBLI) used in
Swanson et al. (2005) and Fey et al. (2010) explicitly taught narrative structure while using gram-
mar facilitation approaches to teach grammar. Swanson et al. (2005) found their intervention
improved the quality of the children’s narratives, but not their grammatical abilities. The authors
suggest this could be due to limited processing resources, such that children with SLI only focus
on explicit targets. Fey et al. (2010) also found NBLI did not yield significant improvements in the
grammatical production of children with SLI, but did improve their narrative comprehension (as
this study primarily focused on the effectiveness of Fast ForWord, it is shown in Table 5).
Some other studies (Davies et al., 2004; Petersen et al., 2008, 2010) used explicit therapy to
focus mainly on narrative production, but also included some work on expressive grammar. These
found progress on narrative ability and grammar. However, the scores for narrative and grammar
were often conflated, so it is difficult to know whether the positive change was in both areas.
IV Language interventions not specific to grammar
1 Acoustically modified speech (including Fast ForWord, FFW; Scientific Learning
Corporation, 1998)
Intervention studies using acoustically modified speech have focused mainly on receptive rather
than expressive language and are shown in Table 5. They are based on the theory that children with
SLI have difficulty processing rapid or brief stimuli (Tallal et al., 1985) and aim to improve this
underlying deficit by training the auditory system using acoustically modified speech. The chil-
dren’s general language abilities are hypothesized to improve as a direct consequence of their
improved temporal processing abilities. An early study of FFW reported that children’s language
comprehension improved significantly (Tallal et al., 1996). However, there were several problems
with the design of this study.
Independent case study investigations of FFW (Friel-Patti et al., 2001; Gillam et al., 2001; Loeb
et al., 2001) showed the majority of children made some progress with some areas of language,
Ebbels 27
Table 4. Studies targeting narrative and grammar together.
Study Number of
participants
Age Diagnosis Intervention method Method of
delivery
Controls? Total
hours
therapy
Results Progress
maintained?
Progress
generalized?
Petersen
et al.
(2010)
3t 6;3, 6;5,
8;1
neuromuscular
impairment and
co-morbid RELI
‘literate narrative
intervention’,
emphasized
macrostructure
and some aspects
of narrative
microstructure,
particularly causal
and temporal
subordinating
conjunctions
1:1 with
SLT (75% of
sessions) and
psychologist
(25%)
yes multiple
baseline
10 × 60
minutes, 4
days per
week (= 10
hours)
macrostructure: better
narratives produced
during intervention than
during baseline; targeted
microstructure: improved
use of marked and unmarked
causal relations, but no
change in temporal adverbial
subordinate clauses; social
validity: 15 undergrads rated
baseline narratives as poorest
at least 67%, 93% and 100% of
time for the three participants
macrostructure:
maintained for
one child, possibly
for another, no
data for third;
causal relations:
for one child
macrostructure:
to verbally
prompted
narratives;
microstructure:
to most non-
targeted areas
for 2 children
and to a few
areas for other
child
Petersen
et al.
(2008)
12t 6;4–9;1 language impaired explicitly taught
story grammar
components, plus
causality, temporal
concepts and dialogue
groups of 3–4 yes therapy vs.
baseline
period
4 × 90
minutes
per week
for 4
weeks (=
24 hours)
significant increase in story
complexity with intervention,
none during baseline (score
included points for story
grammar, causality, temporal
markers and dialogue)
not tested not tested
Davies
et al.
(2004)
31t mean
age: 5;11
teachers
identified children
with difficulty
describing,
explaining and
conveying events
(only one on SLT
caseload)
metalinguistic using
colour coding for wh-
words, plus practice
at re-telling and
generating stories
group (1 ×
per week
with SLT, 2
× per week
with a learning
support
assistant)
no pre- vs.
post-test,
not standard
scores; used
age equivalent
scores to
control for
maturation
3 × 40
minutes
per week
for 8
weeks (=
16 hours)
participants improved their
descriptions of pictures
and narratives in terms
of information, grammar
(including connectives) and
story quality; more progress
in terms of age equivalent than
months which had passed
not tested teachers
reported
increased
confidence in
class and better
able to listen
and contribute
appropriately
in class
Swanson
et al.
(2005)
10t 6;11–8;9 SLI (of whom 7
RELI)
NBLI: addresses both
narrative (explicit
teaching plus story re-
telling and generation)
and grammar
(implicitly using
imitation, modelling
and recasting); cyclical
goal attack strategy: 2
weeks on each target
direct 1:1 with
SLT
no pre- vs.
post-test,
not standard
scores
3 × 50
minutes
per week
for 6
weeks (=
15 hours)
8/10 made clinically significant
progress in narrative quality;
1/0 made clinically significant
progress in number of
different words; no significant
gains for any grammatical
outcomes
not measured not measured
Notes. See notes at Table 1; NBLI = narrative based language intervention.
28 Child Language Teaching and Therapy 30(1)
Table 5. Studies targeting improvement in general receptive and/or expressive language (assessing effectiveness of Fast ForWord, FFW).
Study Number of
participants
Age Diagnosis Intervention
method(s)
Method of
delivery
Controls? Total hours therapy Results Progress maintained? Progress generalized?
Cohen et
al. (2005)
50t (23t: FFW,
27t: other
computer
programs), 27c
6–10
years
SLI (receptive and
expressive)
FFW vs. other
computer programs
computer 1:1 yes RCT: 2 therapy
groups plus
control group
6–60 hours (FFW),
2–82 (other
programs)
therapy groups improved
no more than control
group
n/a n/a
Gillam et
al. (2008)
162t (54t: FFW,
54t: CALI, 54t:
ILI),
54c: AE
6–9
years
normal nonverbal
skills, language
abilities 1.2 SDs or
more below mean
FFW vs. other
computer programs
(language and non-
language) vs. ILI:
language facilitation
approaches, some
in context of
stories
all 1:1. FFW,
AE and CALI:
computer,
ILI: SLT
yes RCT: 3 language
intervention
groups, plus
‘control group’
(who had AE)
100 minutes × 5
days per week,
for 6 weeks (= 50
hours)
all groups made
significant progress on
CASL, token test and
backward masking, no
effect of group; only
effect of group on
blending words subtest
of CTOPP where
language groups > AE
yes, further progress
after 6 months for
all groups for CASL
and token test;
blending progress
also showed further
progress, but this
was significantly
higher for CALI and
FFW, than ILI and AE
yes, to general
language tests.
Effect sizes greatest
on CASL (mainly
expressive language);
smaller effects on
token test suggesting
expressive language
improved more
Fey et al.
(2010)
30t (23
completed
study and
analysed: 7t:
FFW/NBLI, 7t:
NBLI/FFW, 9t:
Wait/NBLI)
6–8
years
12/23 SLI, 11/23
NLI
FFW vs. NBLI
included story
retell, sentence
imitation and story
generation (recasts
for stories)
FFW:
computer
1:1, NBLI:
SLT 1:1
yes RCT: Three
therapy groups
(one acted as
waiting control
in phase 1)
FFW: 100 minutes
per day for 24
sessions (= 40
hours), NBLI: 5
× 100 minutes
per fortnight for
12 sessions (= 20
hours)
most children had
difficulties progressing
through FFW games;
no significant difference
between groups on
grammar measures;
after phase 1: two
therapy groups improved
narrative comprehension
but only significantly
better than waiting
controls when two
groups combined; over
whole study: narrative
improved most in NBLI/
FFW group and least
in FFW/NBLI group,
suggesting that NBLI
improves narrative
comprehension, but only
if not preceded by FFW
not measured to standardized
narrative
comprehension test
Gillam et
al. (2001)
4t (2t: FFW, 2t:
other computer
programs, two
identical
6;11–
7;6
language
disordered (two
with borderline
receptive
FFW vs. other
computer programs
computer 1:1 no children
randomly
assigned to each
100 minutes per
day, 5 days a week
for 4 weeks (= 33
hours)
All children made some
progress
not measured to spontaneous
speech and general
language tests for
Ebbels 29
Study Number of
participants
Age Diagnosis Intervention
method(s)
Method of
delivery
Controls? Total hours therapy Results Progress maintained? Progress generalized?
twins assigned
to different
programs)
language, two with
moderate-severe
receptive language
difficulties)
type of therapy,
pre- vs. post-
test including
standard scores
one FFW child and 2
on other programs
Loeb et al.
(2001)
4t 5;6–8;1 speech-language
impairment (2/4
had receptive
difficulties)
FFW computer 1:1 no pre- vs. post-
test, including
standard scores
30–50 sessions
(hours unclear, but
probably 50–84
hours)
3/4 (less impaired)
children completed
programme; all children
made gains on some
standardized tests, but
many language areas
showed no change
after 3 months, 61%
of gains maintained
to some general
language tests.
Little change in
spontaneous speech,
few differences
reported by parents
and teachers
Friel-Patti
et al.
(2001)
5t 5;10–
9;2
language learning
disabled (2
also attention
deficit disorder);
only 1/5 had
receptive language
difficulties
FFW computer 1:1 no pre- vs. post-
test, including
standard scores
100 minutes × 5
days a week for 31–
32 weeks for 4/5
(= 52–53 hours).
One (less impaired)
participant reached
dismissal criteria
after 16 days (= 27
hours).
3/5 children showed
modest improvements
on a few measures; these
included the two less
impaired children who
had reached dismissal
criteria from FFW
not measured to some general
language tests for
3–5 children. Not to
spontaneous speech.
Tallal et
al. (1996)
(study 2)
22t (11t: FFW,
11t: unmodified
speech)
5;2–
10;0
language learning
impaired
(receptive and
expressive)
FFW vs. unmodified
speech
computer 1:1 no 2 therapy
groups (not
randomly
assigned), no
control group,
not standard
scores
3 hours × 5 days
per week + 1–2
hours a day, 7 days
a week for 4 weeks
(= 88–116 hours)
both groups improved
comprehension;
significantly more with
modified than unmodified
speech
not measured to general language
tests
Tallal et
al. (1996)
(study 1)
7t 5;9–9;1 language learning
impaired
(receptive and
expressive)
FFW computer 1:1 no pre- vs.
post-test, not
standard scores
3 hours × 5 days
per week + 1–2
hours a day, 7 days
a week for 4 weeks
(= 88–116 hours)
language comprehension
improved significantly
not measured to general language
tests
Notes. See notes at Table 1; AE = academic enrichment; CALI = computer assisted language intervention; CASL = Comprehensive Assessment of Spoken Language; CTOPP = Comprehensive Test of Phonological
Processing (Wagner et al., 1999); FFW = Fast ForWord; ILI = individualized language intervention; NBLI = narrative based language intervention.
Table 5. (Continued)
30 Child Language Teaching and Therapy 30(1)
although the children with the most severe language impairments appeared to benefit the least.
However, recent independent large-scale RCTs (Cohen et al., 2005; Fey et al., 2010; Gillam et al.,
2008) found control groups showed equal progress to those receiving FFW (or similar acoustically
modified speech; see Bishop et al., 2006; details shown in Table 2) and a recent meta-analysis,
which is the strongest form of evidence (Strong et al., 2011) has concluded ‘there is no evidence
… that FFW is effective as a treatment for children’s oral language or reading difficulties’ (p. 224).
2 Language intervention packages
Several recent studies have considered the effectiveness of intervention packages delivered in dif-
ferent ways and are shown in Table 6. These studies include a range of intervention approaches and
targets with the aim of improving language generally, and their main focus is on establishing
whether non-SLTs can effectively provide intervention.
Studies by Boyle and McCartney and colleagues of commonly used interventions delivered in
mainstream schools found that children with ELI made more progress than controls in expressive
language on the Clinical Evaluation of Language Fundamentals-3 (CELF-3, Semel et al., 2006)
when they received intervention by an SLT or SLT assistant employed by the research project
(Boyle et al., 2007, 2009). This contrasted with children with RELI who made no progress relative
to controls with either receptive or expressive language. Indeed, on the Receptive Language Scale,
children receiving therapy (whether or not they had receptive language difficulties) showed no
greater progress than controls.
However, a follow-up study (McCartney et al., 2011), using the same intervention but delivered
by school staff (teachers, deputy head teachers, language support teachers and classroom assis-
tants), found no effect of intervention for either receptive or expressive language relative to the
Boyle et al. (2009) historical controls. The most likely reason for this is probably the limited
amount of intervention actually delivered. However, this model of working through education staff
is one followed by many SLT services.
The major difference between the Boyle et al. (2007; 2009) and McCartney et al. (2011) studies
was in the background and employment those delivering the intervention. In Boyle et al. (2007;
2009), they were employed by the researchers running the study and were psychology graduates.
In the McCartney et al. (2011) study, they were school staff, with many other demands on their
time. Indeed, 54% of the teachers who had implemented the intervention in this study agreed or
strongly agreed that ‘this method of working expects too much of the teacher’ (McCartney et al.,
2010: 362). Even after modification of the language therapy support model and revision of the
manual (now called the Strathclyde Language Intervention Programme, SLIP) following feedback
from some of the teachers, potential users (teachers who had not been involved in earlier studies)
were unsure whether implementing the model and delivering the language-learning activities
would be realistic (McCartney et al., 2010). These studies are extremely worrying as they indicate
that a very common model of therapy in the UK may be unrealistic and ineffective.
Nevertheless, an ‘enhanced consultative model’, using SLT assistants employed by the SLT
service (Mecrow et al., 2010), was effective. Progress on targets (both speech and language, recep-
tive and expressive) was significantly greater than progress on control areas. They also found sig-
nificant change on the CELF-Preschool receptive and expressive language scales. However, they
did not split the analyses to see if the effectiveness of therapy varied between target areas or
between different groups of children.
It is not the case that school staff cannot effectively deliver intervention if they are well enough
trained, supported and monitored. A small-scale study (Hutchinson and Clegg, 2011) indicates that
language groups delivered by well-trained and supported education professionals can improve
Ebbels 31
Table 6. Studies assessing different models of service delivery (targets and intervention method not the focus).
Study Number of
participants
Age Diagnosis Language
Intervention
method
Method of delivery Controls? Total hours
therapy
Results Progress
maintained?
Progress
generalized?
Boyle et al.
(2009)
131t (34t:
direct 1:1,
31t: direct
group, 33t:
indirect 1:1,
32t: indirect
group), 31 c
6;0–11;5 primary
language delay
IQ > 75 (86
RELI, 75 ELI)
manualized
intervention
programme
covering
comprehension
monitoring,
vocabulary
development,
grammar and
narratives
direct 1:1 with SLT
vs. direct group with
SLT vs. indirect 1:1
SLTA vs. indirect
group with SLTA
yes RCT: 4 therapy
groups plus
control group
(normal
therapy)
3 × 30–40
minutes per
week, over 15
week, average
38 sessions (=
19–25 hours)
no significant difference
between types of
delivery; project
therapy > control for
expressive language for
ELI; children with RELI
no more progress than
controls; no group
made more progress
than controls on
receptive measures;
non-verbal IQ not
significant predictor of
language outcomes
yes 12
months
later for ELI
children on
expressive
measures
progress on
standardized tests
McCartney
et al. (2011)
38t 6–11yrs
(mean:
8;9)
language
impairment, IQ
> 75 (including
some with
RELI)
same
intervention
programme
as Boyle et al.
(2009)
by school staff, via
‘consultative model’,
activities from
manual; planned 3
× per week for 15
weeks
yes progress
compared
retrospectively
to controls
in Boyle et al.
(2009) study
mean number
contacts 26
(range: 8–70),
length of
contact not
recorded.
no change on any
measures; no difference
between therapy group
and Boyle et al. (2009)
controls
n/a n/a
Mecrow et
al. (2010)
35t 4;2–6;10 14 RELI, 7
speech and
RELI, 5 speech
and ELI, 3
speech only,
1 speech and
RELI
varied
according to
specific targets
‘enhanced
consultative approach’
STA (like SLTA, work
under guidance of
specialist teacher or
teacher/SLT made
available to schools)
provided 1:1 therapy;
STA also trained
school staff
yes compared
change between
treated and
untreated
behaviours
(within
participants).
aim: 4 × 1
hour sessions
per week for
10 weeks.
Actual: mean
of 39 sessions,
45–60 minutes
each (= 29–39
hours)
target behaviours
improved significantly
more than control
behaviours; replicated
with second set of
targets
for 3–12
months
significant gains
on CELF-pre-
school receptive
and expressive
standard scores,
but not on DEAP;
generalization to
other settings and
conversation not
measured
Hutchinson
Clegg
(2011)
12t, 6c mean:
6;9
language
difficulties
identified by
school staff,
not on SLT
caseload
activities
addressing
listening,
memory,
comprehension
and expression
trained teacher or TA
in groups of 6
yes therapy vs.
control group
(not randomly
assigned, from
different school)
1 × 30 minutes
per week for
8 weeks (4
hours)
No progress on
BPVS. Children in
intervention school
(but not controls)
improved on all aspects
of Bus story
not measured progress on
standardized test
(Bus story)
(Continued)
32 Child Language Teaching and Therapy 30(1)
Study Number of
participants
Age Diagnosis Language
Intervention
method
Method of delivery Controls? Total hours
therapy
Results Progress
maintained?
Progress
generalized?
Bowyer-
Crane et al.
(2008)
151t
(76t: oral
language, 75t:
phonology
and reading)
mean
4;9
children
with lowest
vocabulary
and word
reasoning
in each
school (not
all language
impaired)
oral language:
work on
vocabulary,
narrative,
question
answering and
generation;
grammatical
errors re-cast
alternating 1:1 and
group with trained
and supported TAs
following a manual
no RCT: 2 therapy
groups, no
control group
daily
alternating 1:1
(20 minutes)
and group (30
minutes) for
20 weeks (=
45 hours)
oral language group
improved significantly
more than phonology
and reading group on
taught vocabulary and
RAPT grammar; trend
towards more progress
on Bus story; no
difference on listening
comprehension
progress
maintained
for 6 months
progress on
standardized tests
Bowyer-
Crane et al.
(2011)
68t (31t: oral
language, 37t:
phonology
and reading)
mean
4;8
language
impaired (29
SLI and 39
general delay)
oral language:
work on
vocabulary,
narrative,
question
answering and
generation;
grammatical
errors re-cast
daily, alternating
1:1 and group with
trained and supported
TAs following a
manual
no RCT: 2 therapy
groups, no
control group
alternating 1:1
(20 minutes)
and group (30
minutes) for
20 weeks = 45
hours
oral language group
improved significantly
more than phonology
and reading group on
taught vocabulary and
RAPT grammar (both
SLI and general-delay
children); no difference
on comprehension or
narrative
progress
maintained
for 6 months
on taught
vocabulary,
but not on
grammar
progress on
standardized tests
Notes. See notes at Table 1; CELF = Clinical Evaluation of Language Fundamentals; DEAP = Diagnostic Evaluation of Articulation and Phonology (Dodd et al., 2002); SLTA = speech and language
therapy assistant.
Table 6. (Continued)
Ebbels 33
expressive language. In this study, a teacher from a collaborative team of specialist teachers and
SLTs who initially delivered a whole-school training package was in the school for two days a
week during the project. Thus, the education professionals delivering the intervention were well-
supported and their provision was closely monitored.
Several studies from the education literature (e.g. Bowyer-Crane et al., 2008) have also shown
that, if well-supported and closely monitored, TAs can successfully deliver intervention that
improves expressive language, taught vocabulary and literacy in children with literacy difficulties.
Follow-up analyses (Bowyer-Crane et al., 2011) of only the children from the Bowyer-Crane et al.
(2008) study who had language impairments showed that intensive intervention from a highly
trained and well supported TA can improve understanding of taught vocabulary and expressive
grammar (although not comprehension) in children with language impairments, regardless of their
non-verbal IQ level.
V Variables in intervention
1 Targets of intervention
Implicit, grammar facilitation methods have focused on production of a wide range of morphologi-
cal and syntactic targets; however, language comprehension has been largely ignored as a focus of
intervention (with the exception of the usage-based approach by Riches, 2013). Studies using
acoustically modified speech have focused on general language abilities, not specific morphologi-
cal or syntactic targets (with the exception of Bishop et al., 2006). Studies of explicit methods have
mainly focused on specific areas of grammar (both comprehension and production). The few stud-
ies that have considered maintenance of progress generally show that progress is maintained but
does not usually continue after intervention has ceased.
2 Child factors
The majority of studies of implicit grammar facilitation methods reported here either do not mention
the receptive language status of their participants (seven studies), or state that the majority of their
participants have age appropriate comprehension (four studies). Eight of the studies reviewed
included children with RELI, but of those, three showed no greater progress than controls. The other
five did not investigate whether those with vs. without receptive language difficulties differed in the
amount of progress they made, but analysed them as a whole group which may mask any differences
between them. However, a case series (Ellis-Weismer and Murray-Branch, 1989) found that the
three children with expressive difficulties only made progress, but the one with RELI did not.
The participants in studies of explicit meta-linguistic methods have usually had both receptive
and expressive language difficulties (regardless of whether the targets of intervention were recep-
tive or expressive). However, these different participant profiles could be a function of age, as
those children whose language difficulties persist are often those who have more pervasive diffi-
culties (Bishop and Edmundson, 1987). The majority of grammar facilitation studies have been
carried out with children under the age of seven, often with pre-schoolers, although a few studies
using these methods include children up to 10 years of age. In contrast, studies of explicit approaches
have involved a wider age range, but have tended to focus on older children.
Direct comparisons of explicit and implicit methods indicate that explicit methods may be bet-
ter for older children and implicit for younger, but differing responses by age have not been meas-
ured in a single study. Also, the relationship between age, severity and response to different
intervention approaches remains to be considered. Ebbels et al. (2013), did look for correlations
34 Child Language Teaching and Therapy 30(1)
between progress and age (and indeed non-verbal abilities) and found no correlations, but all par-
ticipants were over 11 years. Direct comparisons of the two main approaches (explicit vs. implicit)
with different age groups and different levels of severity (especially as regards expressive lan-
guage) are therefore now required.
3 Methods of delivery
The overwhelming majority of studies aiming to directly improve children’s grammatical abilities
involve 1:1 delivery of intervention by an SLT or (for the modified speech studies) by a computer.
However, several recent studies have focused on the effectiveness of education staff delivering
intervention. These have found that well-trained and supported assistants employed directly by the
SLT service, or research teams, or very closely monitored, can improve the expressive language of
children with expressive language difficulties only, whether the intervention is delivered 1:1 or in
groups. However, a ‘consultative model’, where a programme is left for school staff to carry out
with little support and monitoring, does not seem to be effective.
Disappointingly, standard therapy packages (whether delivered by an SLT or assistant, 1:1 or in
groups) do not seem to improve the receptive or expressive language abilities of children with
RELI. However, several studies indicate that explicit therapy methods, either alone, or in combina-
tion with more implicit methods, delivered by an SLT can be effective for improving both receptive
and expressive language in this group. Implicit therapy methods alone may be effective for this
group, but we cannot evaluate this until analyses of progress of children with RELI have been car-
ried out separately from those with purely expressive difficulties.
VI Implications
1 Future research
Many areas of grammar have been targeted in intervention studies but many gaps remain. In par-
ticular, grammar facilitation methods have focused only on expressive language, primarily with
younger children, many of whom do not have receptive language difficulties. In contrast, metalin-
guistic methods have focused on both comprehension and production skills, but mostly with older
children. Thus, both these methods should be investigated further with different age groups and
receptive language status, for both comprehension and production of language.
The relative benefits of the two main approaches, and indeed their combination, also needs to
be investigated with different age groups and with those with and without receptive language dif-
ficulties. Such studies will require large numbers of participants. Even if age and receptive lan-
guage skills are held constant, the effect size of a difference between two interventions is likely to
be much smaller than between an intervention and control (where significant effects can be found
in quite small studies). Varying age and receptive language status will require even larger numbers
of participants in order to find significant effects within different groups.
Children with receptive language difficulties appear to be the least likely to progress with ther-
apy, but also are those the most in need. Therefore studies are urgently needed with this group to
establish which aspects of intervention are crucial in enabling these children to make progress.
2 Clinical implications
The intervention research base needs further development before clinicians can make reliable
judgements regarding the appropriateness of different intervention approaches and methods of
Ebbels 35
delivery for individual children for particular grammatical targets. However, it is important for
clinicians to make informed decisions using the evidence available. I would suggest that clinicians
who wish to target the grammatical difficulties of a school-aged child, should first establish which
areas of grammar are causing difficulties. Then, they should decide which areas they wish to treat
and in which order. These decisions should be based on factors such as functional importance (e.g.
the impact on access to the curriculum and friendships), typical developmental order of acquisition
and a plan of how to proceed from one target to another, as one target may require prior learning of
another.
Having decided on the targets, they should then consider whether any particular method of
intervention has been shown to be effective (preferably in a study including experimental control)
for that target, for children of a similar age, diagnosis and level of severity to the child they wish to
treat. The tables in this paper are grouped by language target and sorted by level of experimental
control to aid clinicians in this process.
The final step is to choose the method of delivery. The research evidence is primarily based on
1:1 delivery of therapy by an SLT. For a variety of reasons, clinicians may not be able or wish to
offer this method of delivery, but they should be aware that a change in the method of delivery may
affect the effectiveness of the intervention. It seems that delivering therapy via assistants and/or in
groups can be effective for improving expressive language in children with ELI, but only if the
assistants are well trained, supported and closely monitored to ensure that they do actually carry
out the intervention. Indeed, McCartney et al. (2011) recommend that ‘SLT and school services
adopting a consultancy model require a careful activity audit to be undertaken’ (p. 80).
However, for children with RELI, the limited evidence to date of effective intervention indi-
cates that progress may only be made when intervention is delivered by an SLT, as in the studies of
explicit therapy methods which mostly involve such children (even when focusing on expressive
targets). However, if a clinician decides to use other methods of delivery for children with RELI,
they should evaluate closely what they have done and share their findings with the rest of the SLT
community.
VII Conclusions
In recent years, the quality and quantity of studies investigating the effectiveness of intervention
for grammar in school-aged children has greatly improved. We can have reasonable confidence in
the effectiveness of some interventions for particular types of children, but we have yet to compare
directly the effectiveness of these different approaches with different types of children in order to
establish which method is the most effective for which children using which method of delivery.
A parallel challenge is using this evidence wisely in clinical practice. Clinicians and services are
under pressure to deliver effective interventions at the lowest possible cost, and at times effective-
ness and cost may indicate different intervention or methods of delivery. A balance has to be struck.
However, clinicians should ensure they do not waste everyone’s time and money providing inter-
vention which has been shown to be ineffective, even if it is the cheapest option. Providing inef-
fective intervention benefits nobody.
We also need to be very clear about the difference between:
evidence that an intervention is ineffective; and
no evidence that an intervention is effective.
In the former case, we should not provide the intervention, even if we / the children / their parents
/ schools / commissioners like it. In the latter case, the intervention may be effective or ineffective:
36 Child Language Teaching and Therapy 30(1)
we just do not know. If there is evidence that another intervention is effective, then that should be
used. But if there is no evidence, we should use a best-fit approach combined with clinical experi-
ence and then evaluate its effectiveness for the particular combination of target and child factors
with which we are faced.
All clinical work has the potential to be a research project with the addition of experimental
control. This can be achieved, for example, by use of waiting lists as waiting controls, using school
holidays as baseline periods, or having control areas for each targeted area (for discussion of the
value of case studies, see Vance and Clegg, 2013). Small group studies and even small-scale RCTs
can also be carried out within clinical services, involving children with a profile relevant to that
particular service and targeting priority areas. If the effect sizes are large enough (and hence clini-
cally important), these can be significant even with relatively small numbers of participants.
Indeed, the small-scale clinically-based RCTs that I have led have had only 14 (Ebbels et al.,
2013), 15 (Ebbels et al., 2012) and 27 participants (Ebbels et al., 2007). All showed significant
differences between intervention and controls (although not between interventions), because the
effect sizes were large. Thus, RCTs need not require huge amounts of money to run (unless small
effects are expected, such as comparisons of interventions) and should be possible for SLT services
to carry out with appropriate support. If research becomes more embedded in our clinical practice,
we have the potential to improve our evidence base dramatically, which will benefit both the SLT
profession and the children we serve.
Declaration of conflicting interest
The author declares that there is no conflict of interest.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit
sectors.
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Background Children with Developmental Language Disorder (DLD) have a significant deficit in spoken language ability which affects their communication skills, education, mental health, employment and social inclusion. Aim The present study reports findings from a survey by EU network COST ACTION 1406 and aims to explore differences in service delivery and funding of SLT services for children with DLD across Europe and beyond. Methods and procedures The survey was completed by 5024 European professionals. COST countries were grouped into Nordic, Anglo-Saxon, Continental, Mediterranean, Central/Eastern and Non-European categories. The use of direct, indirect and mixed interventions, and their relationship to funding available (public, private or mixed) were considered for further analysis. Outcomes and results The results revealed that for direct therapy, there were more cases than expected receiving private funding. For indirect therapy, fewer than expected received private and more than expected public funding. For mixed therapy, fewer cases than expected received private funding. Conclusions and implications The results implies that other factors than evidence-based practices, practitioners experience, and patient preferences, drive choices in therapy. More research is needed to gain a better understanding of factors affecting the choice of therapy.
... There is evidence of positive effects of direct therapy delivered by an SLT for children with DLD (see e.g., Ebbels, 2014;Ebbels et al., 2017, Ebbels et al., 2019Lowe, 2018;Wales, Skinner, & Hayman, 2017). However, there has been a growing interest in indirect therapies (Mecrow, Beckwith, & Klee, 2010). ...
Chapter
Early intervention is recognized as providing the best chances for children who come to school disadvantaged to leverage chances of successful learning. Over the past decade, there has been an emphasis on the use of “evidence-based” programs that aim to promote children’s development and prevent disorders. However, in school settings, there is a dearth of scientific evidence on what works to foster children’s language skills at an early age, especially in non-WEIRD (Western, educated, industrialized, rich, democratic) populations. In this chapter, we review the existing scientific evidence on the theme to identify key factors related to the success of early language intervention. Specifically, we explore contextual factors that seem to be related to the success of language intervention, such as environmental differences, child characteristics, school features, and the nature of the intervention itself. Possible explanations and implications on what works to foster children’s language development are discussed.KeywordsLanguage developmentEarly interventionEducationalLanguage disordersSocial environmentBiological factors
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England This paper reports a longitudinal follow-up of 71 adolescents with a preschool history of speech-language impairment, originally studied by Bishop and Edmundson (1987). These children had been subdivided at 4 years into those with nonverbal IQ 2 SD below the mean (General Delay group), and those with normal nonverbal intelligence (SLI group). At age 5;6 the SLI group was subdivided into those whose language problems had resolved, and those with persistent SLI. The General Delay group was also followed up. At age 15–16 years, these children were compared with age-matched normal-language controls on a battery of tests of spoken language and literacy skills. Children whose language problems had resolved did not differ from controls on tests of vocabulary and language comprehension skills. However, they performed significantly less well on tests of phonological processing and literacy skill. Children who still had significant language difficulties at 5;6 had significant impairments in all aspects of spoken and written language functioning, as did children classified as having a general delay. These children fell further and further behind their peer group in vocabulary growth over time.
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This study investigated the influence of interventive programs for syntax and articulation on the articulatory and syntactic skills of public school children with multiple-linguistic problems. One group received a program of syntax exclusively, a second received a program of articulation exclusively, and a third received no intervention. Pre- and posttesting revealed that the two experimental groups made significant gains in both syntax and articulatory skills, while the control subjects made no significant gains.