The impact of enhanced Milieu teaching with phonological emphasis (EMT + PE) on the speech and language outcomes for toddlers with cleft palate in Brazil and the United States of America.

PURPOSE: The purpose of this study was to compare the speech and language outcomes of children with cleft palate with or without cleft lip (CP+/-L) in the USA to children with CP+/-L in Brazil who underwent intervention with enhanced Milieu teaching with phonological emphasis (EMT + PE), as there are few cross-country intervention comparisons for children with CP+/-L. METHOD: This is a retrospective analysis of 29 participants from the USA and 24 participants from Brazil who were matched on age. The US participants were between the ages of 13-35 months (M = 23.76), spoke Standard American English in the home, and were recruited from East Tennessee State University and Vanderbilt University. The Brazilian participants were between the ages of 20-34 months (M = 25.04), spoke Brazilian Portuguese in the home, and were recruited from the Hospital de Reabilitação de Anomalias Craniofaciais-Universidade de São Paulo. All treatment participants received EMT + PE from trained speech-language pathologists in hospital-university clinics. RESULT: The treatment groups demonstrated greater gains than comparison groups in percent consonants correct, number of different words, and expressive/receptive vocabulary. There was no main effect nor interaction by country. CONCLUSION: The application of EMT + PE in a second culture and language is a viable early intervention option for participants with CP+/-L.

EMT en Español Para Autismo: A Collaborative Communication Intervention Approach and Single Case Design Pilot Study.

The primary purpose of the current pilot study was to test the effects of an adapted and collaborative intervention model with a systematic teaching approach on Latina Spanish-speaking caregivers' use of EMT en Español Para Autismo strategies with their young children on the autism spectrum. A multiple baseline across behaviors single case design was replicated across two dyads. A series of family interviews and a direct therapist-child intervention phase supported individualization of the intervention. Families were provided speech generating devices as part of their children's intervention protocol. Caregivers were taught to use EMT en Español Para Autismo strategies with aided language input. Strategies included contingent target-level and proximal target-level language modeling, linguistic expansions, and communication elicitations. Secondary variables measured included generalization of strategy use to unsupported interactions and at a 2-month follow-up, child communication outcomes, and social validity. There was a strong functional relation for one dyad between the adapted and collaborative intervention and caregiver use of EMT strategies. The functional relation was weakened by behavioral covariation for the other dyad. Children increased the quantity and diversity of their communication during the study. Caregivers generalized their use of most EMT strategies and reported most aspects of the approach to be socially valid. The current study provides an initial demonstration of an effective model for adaptation and individualization of naturalistic developmental behavioral interventions for Latino Spanish-speaking families with children on the autism spectrum.

Just-in-Time: A Caregiver-Mediated Intervention for Toddlers With Autism.

PURPOSE: We investigated effects of an adaptive telehealth coaching model on caregiver implementation of enhanced milieu teaching (EMT) with newly diagnosed toddlers with autism. METHOD: Three caregiver-child dyads participated in a multiple-baseline-across-behaviors, single-case design. Caregivers were taught EMT via telehealth using the teach-model-coach-review approach. EMT strategies were taught sequentially in four components corresponding to design tiers. Caregivers reported their needs for support and adaptation via weekly surveys. Primary outcomes were measures of caregiver's implementation, including (a) a fidelity checklist for wholistic use of EMT and (b) a percentage of correct use of a subset of key EMT strategies (e.g., matched turns, target talk, expansions, play actions, milieu episodes). Generalization and maintenance of caregiver strategy use in uncoached home activities were measured. The number of different words used by children was measured as a secondary, descriptive outcome. Social validity data were collected through ratings and interviews at the end of the study. RESULTS: There was a functional relation between the intervention and caregiver's implementation of EMT for all dyads. Caregiver's use of EMT strategies often generalized and maintained post-intervention. Child response to intervention was variable. Social validity data indicated that the model was beneficial to caregivers and children. CONCLUSIONS: An adaptive telehealth coaching model is effective for teaching caregivers of toddlers with autism to implement EMT and potentially helps to bridge the gap between diagnosis and comprehensive intervention. Further exploration of the relation between caregiver fidelity and dosage of active ingredients and child spoken language outcomes is needed. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.25156223.

Long-Term Effects of Early Communication Interventions: A Systematic Review and Meta-Analysis.

PURPOSE: Early language and communication interventions for children with language impairments have been shown to be effective in assessments administered immediately after treatment. The purpose of the current systematic review and meta-analysis was to assess the overall durability of those effects over time and whether durability was related to outcome type, etiology of child language impairments, implementer of intervention, magnitude of posttest effects, time between intervention and follow-up, and study risk of bias. METHOD: We conducted a systematic search of online databases and reference lists to identify experimental and quasi-experimental group design studies. All studies tested the effects of early communication interventions at least 3 months post-intervention. Participants were children 0-5 years old with language impairments. Coders identified study features and rated methodological quality indicators for all studies. Effect sizes at long-term timepoints and associations with potential moderators were estimated using multilevel meta-analysis with robust variance estimation. RESULTS: Twenty studies with 129 long-term outcome effect sizes met inclusion criteria. Studies included children with developmental language disorders or language impairment associated with autism. The overall average effect size was small and significant (g = .22, p = .002). Effect size estimates were larger for prelinguistic outcomes (g = .36, p < .001) than for linguistic outcomes (g = .14, p = .101). Significant factors were the posttest effect sizes, the risk of bias for randomized trials, and etiology of language impairment for linguistic outcomes. Time post-intervention did not significantly predict long-term effect sizes. CONCLUSIONS: Outcomes of early language and communication interventions appear to persist for at least several months post-intervention. More research is needed with collection and evaluation of long-term outcomes, a focus on measurement, and consistency of primary study reporting. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.23589648.

Teaching Caregivers to Implement the Caregivers Optimizing Achievement of Children With Hearing Loss (COACH) Intervention.

PURPOSE: This study examined the effectiveness of Caregivers Optimizing Achievement of Children With Hearing Loss (COACH), an intervention in which parents were taught naturalistic interaction strategies that addressed the unique linguistic input needs of their young children with hearing loss. METHOD: A single-subject multiple-baseline across-behaviors design was used with four caregiver-child dyads to determine the effects of COACH training on caregivers' use of the COACH language facilitation strategies and on their children's language abilities. RESULTS: A functional relation was demonstrated between teaching of strategies and caregivers' use of the strategies across three dyads with slower, consistent changes observed in a fourth dyad. Improvements in children's use of target-level language were observed for children in three dyads. CONCLUSIONS: Caregivers were able to implement COACH language facilitation strategies, although the pace of caregivers' learning differed across dyads. Caregivers reported high satisfaction with participating in the intervention. Future research using a randomized design and a longer intervention condition is needed for a more complete assessment of the effects of the intervention on children's language abilities. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.22290082.

Comparing Interventions With Speech-Generating Devices and Other Augmentative and Alternative Communication Modes: A Meta-Analysis.

PURPOSE: Optimal augmentative and alternative communication (AAC) systems for children with complex communication needs depend in part on child characteristics, child preferences, and features of the systems themselves. The purpose of this meta-analysis was to describe and synthesize single case design studies comparing young children's acquisition of communication skills with speech-generating devices (SGDs) and other AAC modes. METHOD: A systematic search of published and gray literature was conducted. Data related to study details, rigor, participant characteristics, design information, and outcomes were coded for each study. A random effects multilevel meta-analysis was performed using log response ratios as effect sizes. RESULTS: Nineteen single case experimental design studies with 66 participants (M age = 4.9 years) met inclusion criteria. All but one study featured requesting as the primary dependent variable. Visual analysis and meta-analysis indicated no differences between use of SGDs and picture exchange for children learning to request. Children demonstrated preferences for and learned to request more successfully with SGDs than with manual sign. Children who preferred picture exchange also learned to request more easily with picture exchange than with SGDs. CONCLUSIONS: Young children with disabilities may be able to request equally well with SGDs and picture exchange systems in structured contexts. More research is needed comparing AAC modes with diverse participants, communication functions, linguistic complexity, and learning contexts. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.22111181.

The effect of responsiveness to speech-generating device input on spoken language in children with autism spectrum disorder who are minimally verbal†.

The use of speech-generating devices (SGD) in early interventions for children with autism spectrum disorder (ASD) can improve communication and spoken language outcomes. The purpose of this study was to describe children's responsiveness to SGD input modeled by a social partner during adult-child play interactions over a 24-week intervention trial and explore the effect of that responsiveness on spoken language growth. This secondary analysis consisted of 31 children with less than 20 functional words at study entry who received a blended behavioral intervention (JASPER + EMT) as part of a randomized controlled trial. Significant improvements were seen in rate of responsiveness to both adult SGD models and adult natural speech models; only rate of responsiveness to SGD models at entry was a significant predictor of frequency of commenting and was a more robust predictor of number of different words post-intervention. Lastly, at entry, children with more joint attention and language responded to SGD models at significantly higher rates. Attention and responsiveness to SGD output may be important mechanisms of language growth and children who have more joint attention skills may particularly benefit from use of an SGD.

Teaching Caregivers to Support Social Communication: Results From a Randomized Clinical Trial of Autistic Toddlers.

BACKGROUND: Studies of early caregiver-mediated interventions targeting social communication of young autistic children have yielded variable child outcomes. This study examined the effects of combining two caregiver-mediated interventions on caregiver strategy use and child social communication and language outcomes. METHOD: This was a multisite parallel randomized controlled trial. Participants included 120 caregivers and their autistic children between 24 and 36 months of age. Dyads were randomly assigned to receive a hybrid intervention that combined Enhanced Milieu Teaching (EMT) and Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER) or to a behavior management control condition, each delivered over 6 months. Caregivers in the JASP-EMT group received twice-weekly, in-home, and hour-long sessions. Outcomes were measured at baseline, the end of intervention (T1), and 6 months later (T2) and included a naturalistic language sample procedure, standardized measures, and caregiver report measures. This trial was registered at clinicaltrials.gov (NCT02595697). RESULTS: Child outcomes did not differ between conditions at T1 or T2 for child primary (social communication) or secondary (language, play, and autism symptoms) outcomes. Relative to control group caregivers, intervention group caregivers demonstrated significantly higher use of JASP-EMT strategies at T1 and T2, with the exception of two strategies (Responsiveness and Matched Responsiveness), which were used significantly more by control group caregivers. Neither autism severity nor baseline caregiver responsiveness moderated outcomes. Post hoc analyses revealed significant correlations between specific strategies and all child outcomes. CONCLUSIONS: Twice-weekly caregiver-mediated intervention that taught caregivers of autistic children to use social communication support strategies did not yield significant child outcomes. Future studies should examine possible sources for the lack of main effects including unexpected differences in linguistic features of caregiver input, changes in control group caregiver behavior, and insufficient intervention dosage. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.21714278.

Teaching Spanish-Speaking Caregivers to Implement EMT en Español: A Small Randomized Trial.

PURPOSE: The primary purpose of this study was to examine the effects of using the Teach-Model-Coach-Review approach to teach Spanish-speaking caregivers from low-income households to implement EMT en Español with their young children with language delays. A secondary purpose was to explore the effects of the caregiver-implemented intervention on children's vocabulary. A final and more exploratory goal was to gain insight into caregivers' perceptions of the intervention. METHOD: 21 caregiver-child dyads participated in the intent-to-treat randomized control trial. Their children were 30-43 months old with language delays. Dyads were randomly assigned to receive 24 caregiver training sessions delivered at home in Spanish or a wait list control group. Pre, post and 3-month follow assessments included observational measures of caregiver-child interactions and child standardized vocabulary assessments. Caregivers completed surveys rating their perception of the intervention. RESULTS: Caregivers in the intervention group had significantly higher percentages of matched turns, expansions, and targets at post-assessment and of expansions and targets at follow-up compared to the control group. Overall, children in the intervention condition had significantly higher receptive vocabulary scores and performed better than children in the control condition on observational measure of their lexical diversity, with moderate effect sizes for most outcomes. Caregivers perceived the intervention as effective and culturally appropriate. CONCLUSIONS: Teach-Model-Coach-Review is effective in increasing Spanish-speaking caregivers' use of EMT en Español strategies with their young children with language delays. The intervention also appears to be effective for child vocabulary outcomes and acceptable to caregivers.

Hybrid Telepractice Delivery of Enhanced Milieu Teaching: Effects on Caregiver Implementation and Child Communication.

Purpose This study investigated the effects of enhanced milieu teaching (EMT) on caregiver implementation of language support strategies and child communication skills using a hybrid telepractice service delivery model. Method Four caregivers and children with language delays aged 18-27 months participated in a multiple baseline across behaviors single-case research design. The therapist provided EMT to each caregiver-child dyad using a hybrid telepractice service delivery model with approximately 40% in-person and 60% telepractice sessions. Caregivers were taught to use five EMT language support strategies: matched turns, target talk, expansions, time delays, and milieu teaching episodes. Caregiver instruction followed the Teach-Model-Coach-Review approach. Caregiver outcomes were two measures of EMT implementation fidelity, accuracy, and frequency of EMT strategy use. Accuracy was measured by the percentage of spoken turns in which caregivers used each strategy correctly. Frequency was measured by the number of spoken turns in which caregivers used each strategy correctly. Child outcomes were number of communication acts, weighted count of communication acts, and number of different words. Results There was a functional relation between the intervention and the accuracy of EMT strategy use for all four dyads, and the frequency of strategy use for three dyads. Caregiver use of EMT strategies maintained for 6 weeks post-intervention. After caregivers learned EMT strategies, gradual increases in the number of communication acts, weighted count of communication acts, and number of different words occurred for three children. Conclusion Results demonstrate the preliminary efficacy of using a hybrid telepractice service delivery model to teach caregivers EMT language support strategies. Supplemental Material https://doi.org/10.23641/asha.14977605.

Short-term trajectories of restricted and repetitive behaviors in minimally verbal children with autism spectrum disorder.

Very little is known about the 30% of children with Autism Spectrum Disorder (ASD) who remain minimally verbal when they enter school. Restricted and repetitive behaviors (RRBs) are well-characterized in younger, preschool, and toddler samples. However, the prevalence and impact of RRBs has not been characterized in older, minimally verbal children. The goal of this study was to characterize this core diagnostic feature in minimally verbal children with ASD ages 5-8 years over a 9-month period to better understand how these behaviors manifest in this crucially understudied population. RRBs were coded from caregiver-child interactions (CCX) at four timepoints. Upon entry into the study, children demonstrated an average of 17 RRBs during a 10-min CCX. The most common category was Verbal. RRBs remained constant over 6 months; however, a slight reduction was observed at the final timepoint. Compared to prior literature on younger samples, minimally verbal children with ASD demonstrated higher rates of RRBs and higher rates of verbal RRBs. Further work is required to understand the function and impact of RRBs in minimally verbal children. LAY ABSTRACT: Approximately one-third of children with autism spectrum disorder (ASD) remain minimally verbal at the time of school entry. In this study, we sought to characterize the presence of restricted and repetitive behaviors (RRBs) in school-aged children (5-8) who were minimally verbal. Compared to prior studies, minimally verbal children with ASD had higher frequencies of RRBs and demonstrated a different profile of behaviors, including more verbal RRBs.

Generalized Effects of Naturalistic Social Communication Intervention for Minimally Verbal Children with Autism.

JASP-EMT, the combined Enhanced Milieu Teaching (EMT) and Joint Attention, Structured Play, and Emotion Regulation (JASPER) interventions, has been found to be effective for promoting social communication in young children with autism (Kasari et al. in J Am Acad Child Adolesc Psychiatry 53(6):635-646, https://doi.org/10.1016/j.jaac.2014.01.019 , 2014). The current study examined the effects of this naturalistic intervention on social language use in three children with autism who were in the early stages of language acquisition. Generalization to communication partners who did not utilize the intervention strategies was systematically examined using a multiple-baseline design. The results from this study indicate that this blended intervention is effective in increasing target social language for young children with autism, however, generalization to communication partners does not readily occur. Implications for practice and future research are discussed.

Multi-component communication intervention for children with autism: A randomized controlled trial.

LAY ABSTRACT: This study reports the results of a randomized trial for preverbal preschoolers with autism that demonstrates the effects of multiple intervention strategies including caregiver training. About 50% of children with autism are not talking by age 3 and up to 30% of children with autism will remain minimally verbal past age 5. Interventions delivered by clinicians and caregivers have the greatest effects on spoken language and may reduce the rate of those who remain minimally verbal. Sixty-eight children ages 3-5 with autism and their caregivers participated in this randomized trial comparing the communication intervention to a comparison group. A brief, multi-component, communication intervention (including a speech-generating device) for children with autism that addresses core deficits may be effective in improving joint attention skills immediately following intervention and social communication skills 4 months following intervention. Future research is needed to understand for whom and under what conditions this intervention is most effective.

Effects of a naturalistic intervention on the speech outcomes of young children with cleft palate.

Purpose: The purpose of this study was to investigate the extent to which a naturalistic communication intervention, Enhanced Milieu Teaching with Phonological Emphasis (EMT + PE) improved the speech outcomes of toddlers with cleft palate with or without cleft lip (CP ± L)Method: This study was a stratified randomised controlled trial.Setting: Treatment was delivered in a university clinic by a trained speech-language pathologist.Thirty children aged between 15 and 36 months (M = 25) with nonsyndromic CP ± CL and typical cognitive development were randomly assigned to a treatment (EMT + PE) or business as usual comparison condition.Participants in the EMT + PE treatment group received 48, 30-min sessions, over a 6-month period. Fidelity of treatment was high across participants.The primary outcome measures were percent consonants correct (PCC), consonant inventory, compensatory articulation errors, and nasal emission.Result: Regression analyses controlling for pre-intervention child characteristics were conducted for PCC and consonant inventory. Intervention was not a significant predictor of post-intervention outcome. Words per minute differentiated the children who benefitted from the intervention from those who did not. Reduction in compensatory errors and nasal emission occurred in both groups but to a greater degree in the EMT + PE group.Conclusion: EMT + PE is a promising early speech intervention for young children with CP ± L, especially for children with higher rates of word use.

The Effects of Early Intervention on Social Communication Outcomes for Children with Autism Spectrum Disorder: A Meta-analysis.

This meta-analysis examined the effects of early interventions on social communication outcomes for young children with autism spectrum disorder. A systematic review of the literature included 1442 children (mean age 3.55 years) across 29 studies. The overall effect size of intervention on social communication outcomes was significant (g = 0.36). The age of the participants was related to the treatment effect size on social communication outcomes, with maximum benefits occurring at age 3.81 years. Results did not differ significantly depending on the person implementing the intervention. However, significantly larger effect sizes were observed in studies with context-bound outcome measures. The findings of this meta-analysis highlight the need for further research examining specific components of interventions associated with greater and more generalized gains.

Effects of an Intervention Designed to Increase Toddlers' Hearing Aid Use.

The purpose of this study was to examine the effectiveness of Ears On, an intervention designed to increase toddlers' use of hearing devices. A single-case, multiple-baseline design across participants was used with three parent-child dyads who demonstrated low hearing aid use despite enrollment in traditional early intervention services. Data logging technology was used to objectively measure hearing aid use. A functional relationship was identified between participation in the intervention and the number of hours children utilized their hearing aids. Two dyads met the criterion set for completing the intervention: an average of 8 hr of daily hearing aid use. One dyad did not reach this criterion but did meet the parent's goal of full-time use in the child's educational setting. For all dyads, increases in use were maintained 1 month after completion of the intervention. Findings support use of this short-term, intensive, individualized intervention to improve hearing aid use for toddlers with hearing loss.

Rates of Prelinguistic Communication and Early Symbol Use in Young Children With Down Syndrome: Using a Progress-Monitoring Tool to Model Growth.

Purpose This study aims to provide descriptive data on rates of expressive communication skill use in young children with Down syndrome (DS) across early childhood. Children with DS are known to have delays in expressive communication, but there are little current data on rates of communication in early skills, such as gestures, vocalizations, words, and word combinations. In addition, few studies use measures that offer a composite or "across-skills" view of early development across time. Method This article used a longitudinal descriptive design to generate growth curves for expected rates of communication in young children with DS in 4 major skill elements as measured by the Individual Growth and Development Indicator-Early Communication Index. Using data from 19 children aged 11-42 months with DS, we used hierarchical linear modeling to generate growth curves for children with DS while comparing them to the benchmarked data available for children who are typically developing. Results Results indicate relative strengths in gesture use, a longer period of vocalizations, and lower rates of growth in single and multiple word combinations across time. Children differed significantly from one another on all parameters. Conclusion These data indicate a need to develop and research interventions to support the transition from gestures to words and that support early word combinations in young children with DS.

Teaching Preschoolers With Down Syndrome Using Augmentative and Alternative Communication Modeling During Small Group Dialogic Reading.

Purpose This study evaluated the effect of aided augmentative and alternative communication modeling (AAC-MOD) on the communication skills of children with Down syndrome (DS) during small group dialogic reading. Method Four children with DS between 3;1 and 5;3 (years;months; M = 4;5) and 5 typically developing peers between 3;5 and 5;9 (M = 4;3) participated. Effects were examined using a multiple probe across behaviors design with 4 children with DS. To simulate typical dialogic reading routines in inclusive classrooms, a strategy called Read, Ask, Answer, Prompt (Binger, Kent-Walsh, Ewing, & Taylor, 2010) was applied during the baseline and intervention sessions. Results A functional relation was demonstrated between (a) AAC-MOD and percentage of correctly identified symbols for 3 participants, (b) AAC-MOD and rate of symbolic communication for 2 participants, and (c) AAC-MOD and number of different words for 2 participants. Increases in number of multiple word combinations occurred for 2 participants. All 4 children maintained their percentage of correctly identified symbols. Increases in rate of symbolic communication did not generalize to thematic play contexts, a distal measure of response generalization. Conclusion AAC-MOD is an effective strategy for teaching target vocabulary and increasing rate of symbolic communication in young children with DS. Supplemental Material https://doi.org/10.23641/asha.10093538.

Early Speech and Language Development in Children With Nonsyndromic Cleft Lip and/or Palate: A Meta-Analysis.

Objective The aim of the study was to conduct a meta-analysis of research examining the early speech and language functioning of young children, birth to age 8;11 (years;months), with nonsyndromic cleft lip and/or palate (NSCL/P) compared to their peers without NSCL/P. Method We conducted a random-effects metaregression using 241 effect sizes from 31 studies comparing 955 young children with NSCL/P to 938 typically developing peers on measures of speech and language functioning. Moderators were sample characteristics (i.e., age, cleft type, publication year, and study location) and measurement characteristics (i.e., speech sample material, language modality and domain, and assessment type). Results Young children with NSCL/P scored significantly lower on measures of speech and language compared to children without NSCL/P. Children with NSCL/P had smaller consonant inventories (standardized mean difference effect size [ESg] = -1.24), less accurate articulation (ESg = -1.13), and more speech errors (ESg = 0.93) than their peers. Additionally, children with NSCL/P had poorer expressive (ESg = -0.57) and receptive (ESg = -0.59) language skills than their peers. Age and assessment type moderated effect sizes for expressive language. As children with NSCL/P aged, their expressive language performance became more similar to their peers. Expressive language effect sizes from parent reports and observational language measures (estimated effect size = -0.74) were significantly lower than those from standardized norm-referenced tests (estimated effect size = -0.45). Conclusions These findings suggest that young children with NSCL/P experience delays relative to their peers across multiple speech and language constructs. Differences between children with NSCL/P and their typically developing peers appear to decrease with age. Supplemental Material https://doi.org/10.23641/asha.11356904.