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.

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.

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.

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.

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.

Enhanced milieu teaching for children with autism spectrum disorder in South Africa.

Purpose: Efficient and effective interventions are required to meet the communication needs of children with autism spectrum disorders (ASDs). However, most children with ASD living in South Africa do not receive individualised interventions.Method: This multiple baseline study examined the effects of therapist-implemented enhanced milieu teaching (EMT) on the diversity and frequency of spoken language of three children with ASD in South Africa.Result: A moderate functional relation was demonstrated between the introduction of EMT and increases in (1) the number of different words and (2) the number of spontaneous utterances used by each participant. Some evidence of generalisation to novel partners and contexts was observed.Conclusion: Results indicated that EMT may be effective for improving communication in South African children with ASD. Implications for clinical practice and cultural and linguistic adaptations are discussed.

The Longitudinal Effects of Early Language Intervention on Children's Problem Behaviors.

Researchers examined whether a parent-implemented language intervention improved problem behaviors 1 year after intervention. Ninety-seven children with language delays (mean age at 12-month follow-up = 48.22 months) were randomized to receive Enhanced Milieu Teaching (EMT) language intervention or business as usual treatment. Twelve months after the intervention ended, children in the EMT intervention condition displayed lower rates of parent-reported externalizing, internalizing, and total problem behaviors. A mediation analysis revealed that the relation between EMT and problem behaviors was partially mediated by child rate of communication for both internalizing and total problem behaviors. A developmental framework is proposed to explain the impact of EMT on problem behaviors, and future lines of research are discussed.

The Influences of Child Intelligibility and Rate on Caregiver Responses to Toddlers With and Without Cleft Palate.

OBJECTIVE: The purpose of this study was to investigate the influences of child speech intelligibility and rate on caregivers' linguistic responses. DESIGN: This study compared the language use of children with cleft palate with or without cleft lip (CP±L) and their caregivers' responses. Descriptive analyses of children's language and caregivers' responses and a multilevel analysis of caregiver responsivity were conducted to determine whether there were differences in children's productive language and caregivers' responses to different types of child utterances. SETTING: Play-based caregiver-child interactions were video recorded in a clinic setting. PARTICIPANTS: Thirty-eight children (19 toddlers with nonsyndromic repaired CP±L and 19 toddlers with typical language development) between 17 and 37 months old and their primary caregivers participated. MAIN OUTCOME MEASURES: Child and caregiver measures were obtained from transcribed and coded video recordings and included the rate, total number of words, and number of different words spoken by children and their caregivers, intelligibility of child utterances, and form of caregiver responses. RESULTS: Findings from this study suggest caregivers are highly responsive to toddlers' communication attempts, regardless of the intelligibility of those utterances. However, opportunities to respond were fewer for children with CP±L. Significant differences were observed in children's intelligibility and productive language and in caregivers' use of questions in response to unintelligible utterances of children with and without CP±L. CONCLUSIONS: This study provides information about differences in children with CP±L's language use and caregivers' responses to spoken language of toddlers with and without CP±L.

Teaching Low-Income Spanish-Speaking Caregivers to Implement EMT en Español With Their Young Children With Language Impairment: A Pilot Study.

Purpose: This study examined the effectiveness of teaching low-income Spanish-speaking caregivers of young children with language impairment a naturalistic language intervention, EMT en Español. Method: A single-case, multiple-baseline, across-behaviors design replicated across 3 caregiver-child dyads was used to examine the effects of teaching core EMT en Español strategies. The training program utilized the Teach-Model-Coach-Review instructional approach to teach strategies to support children's language development in Spanish. All sessions were at home and in Spanish. Results: Caregivers increased their use of matched turns, target talk, expansions, and a communication elicitation procedure following training on each specific skill. Additionally, caregivers generalized increased use of matched turns and target talk to an untrained activity during the intervention period and maintained their behavior 1 month after completing intervention. Two of 3 caregivers generalized their use of expansions, and 1 caregiver generalized her use of a communication elicitation procedure. Modest effects on the child's number of different words were observed for 2 of the 3 target children over the course of the intervention sessions. All 3 children demonstrated increases in total spontaneous words. Conclusion: Spanish-speaking caregivers were able to implement naturalistic language teaching strategies with their young children with language impairment in a relatively short-term intervention.

One-Year Language Outcomes in Toddlers With Language Delays: An RCT Follow-up.

OBJECTIVES: The current study is a 1-year follow-up analysis of data from a randomized controlled trial of Enhanced Milieu Teaching (EMT) for toddlers with language delays. Outcomes and predictors of child language and parent intervention implementation were examined 6 and 12 months after the end of the intervention. METHODS: Toddlers with language delays were recruited from the community, and 97 toddlers and parents were randomly assigned to receive usual community treatments or a 3-month EMT intervention with parent training. Multiple regression analyses were used to estimate the differences between groups at the 6- and 12-month follow-up periods. A subgroup of participants with receptive and expressive language delays was used in a post hoc moderator analysis of treatment outcomes. RESULTS: Children in the treatment arm did not differ from children in the control arm at 6- and 12-month follow-ups. However, post hoc analyses revealed that children with receptive-expressive language delays were persistently delayed relative to normative performance throughout the follow-up period. CONCLUSIONS: The immediate effects of the brief delivery of EMT were not sustained over the 1-year follow-up period. However, the short-term intervention may not have been sufficient for children with receptive-expressive delays to develop typical language abilities, suggesting they may need more intensive early intervention. Although this intervention may not be necessary for all children with primary language delays, future research should determine the extent to which children with receptive-expressive delays may benefit from more intensive intervention.