Enhancing Syntactic Knowledge in School-Age Children With Developmental Language Disorder: The Promise of Syntactic Priming.

PURPOSE: We propose that implicit learning, including syntactic priming, has therapeutic promise to enhance the syntactic knowledge of children with developmental language disorder (DLD). METHOD: We review the chunk-based learning framework of syntactic learning, the developmental evidence in support of it, and the developmental literature on syntactic priming as an instance of chunk-based statistical learning. We use this framework to help understand the nature of the syntactic learning difficulties of children with DLD. We then briefly review the available explicit treatments for syntactic deficits and end by proposing an implicit training activity that integrates syntactic priming with the principles of statistical learning. RESULTS: Statistically induced chunk-based learning is a powerful driver of syntactic learning, and syntactic priming is a form of this learning. Repeated priming episodes during everyday language interactions lead children to create abstract and global syntactic representations in long-term memory. We offer some thoughts on an implicit language intervention approach with syntactic priming at its center. CONCLUSIONS: Children's learning of syntactic structures is influenced by repeated syntactic priming experiences. Including a syntactic priming activity in our language intervention toolbox has the promise to enhance children's syntactic knowledge and sentence comprehension and production abilities.

Less Versus More: The Effect of Recast Length in Treatment of Grammatical Errors.

PURPOSE: Although conversational recast treatment is generally efficacious, there are many ways in which the individual components of the treatment can be delivered. Some of these are known to enhance treatment, others appear to interfere with learning, and still others appear to have no impact at all. This study tests the potential effect of clinicians' recast length on child learning during a recast treatment. METHOD: Twenty-six preschool children were treated for grammatical errors using Enhanced Conversational Recast Treatment. Half heard recasts of four or fewer words (Short Recast condition), and half heard recasts of five or more words (Extended Recast condition). Outcome measures included generalization of the treated grammatical form, spontaneous use of these forms, change in mean length of utterances in words, and the number of children in each condition who showed a clinically meaningful response. RESULTS: There was strong evidence of improvements in the use of grammatical forms targeted by the treatment compared with forms that were tracked but not treated. Twenty children (11 in the Short Recast condition and nine in the Extended Recast condition) showed a clinically meaningful response. There was minimal support for the hypothesis that the length of clinician utterance influenced either progress on a grammatical form targeted by the treatment or on the child's mean length of utterance in words. CONCLUSIONS: The study adds to the evidence for the efficacy of Enhanced Conversational Recast Treatment. However, there is little evidence that clinicians need to regulate the length of the recast they provide to children. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.24653613.

Determining the Diagnostic Accuracy of the Test of Integrated Language and Literacy Skills for College Students.

PURPOSE: This study sought to determine whether the Test of Integrated Language and Literacy Skills (TILLS; Nelson et al., 2016) can accurately identify language disorders in college-aged adults. METHOD: Fifty-nine college students between the ages of 18 and 23 years were administered the test battery validated by Fidler et al. (2011) for the diagnosis of language disorders as well as the Identification Core (ID Core) subtests of the TILLS validated for ages 12-18 years. Sensitivity and specificity information was calculated for the TILLS at various cut-scores to determine the diagnostic accuracy of the ID Core for this population. Discriminant function analysis was also performed to determine if sensitivity and specificity could be improved using empirically derived discriminant scores. RESULTS: The recommended cut-score of 42 for ages 12-18 years underidentified individuals with language disorders in this sample. An adjusted cut-score of 51 maximized sensitivity and specificity to acceptable levels. Discriminant function analysis also yielded acceptable sensitivity and specificity (> 80%). CONCLUSION: Using either an adjusted cut-score for the ID Core or weighted discriminant scores, the TILLS can be used to accurately differentiate between college-aged adults with and without language disorders.

The Dimensionality of Language and Literacy in the School-Age Years.

PURPOSE: This was an investigation of the dimensionality of oral and written language to test the hypothesis that a two-factor model with sound/word and sentence/discourse language levels would best fit language and literacy data for a population-based sample in the school-age years. METHOD: A stratified secondary data set of 1,500 participants was drawn randomly from a larger nationally representative U.S. data set (N = 1,853) gathered during standardization of the Test of Integrated Language and Literacy Skills. A sample of 254 students with prior diagnoses of language and literacy disorders (LLD) was drawn from the full data set. Confirmatory factor analysis was used to compare the hypothesized two-factor model with other theoretically possible models. RESULTS: The hypothesized two-factor language-levels model had an acceptable-to-good fit to the full data set, as did the three-factor model, with verbal memory added. High interfactor correlation between verbal memory and sentence/discourse constructs, as well as a preference for parsimony, led to the acceptance of the two-factor model as best. This language-levels model had a good fit to the data at ages 8-11 years, and an excellent fit at ages 12-18 years, but only a poor fit for ages 6-7 years (yet still better than other two-factor or unitary models). It had a reasonable fit for students with LLD, although the three-factor model fit their data slightly better. CONCLUSIONS: Oral and written language abilities during the school-age years are best explained by a two-factor model with sound/word and sentence/discourse language levels and memory as a contributing factor. Implications for identifying and treating language and literacy disorders as multidimensional rather than categorical are discussed.

Evaluating the Equivalence of Telepractice and Traditional Administration of the Test of Integrated Language and Literacy Skills.

PURPOSE: This study evaluated the equivalence of the Test of Integrated Language and Literacy Skills (TILLS) when administrated via telepractice (Tele-TILLS) and face-to-face methods. METHOD: Participants were 51 children and adolescents in three age bands, ages 6-7 years (n = 9), 8-11 years (n = 21), and 12-18 years (n = 21). Data were gathered by 25 volunteer examiners who assessed the same participants twice within a 2- to 4-week period, using Tele-TILLS and traditional methods in randomly selected, counterbalanced order. RESULTS: Evaluation of identification equivalence showed 96% agreement between methods (49 of 51 decisions), with 39 agreements of no disorder, 10 agreements of yes disorder, and two disagreements (yes disorder for Tele-TILLS and no disorder for traditional). Partial correlations, controlled for test order, showed moderate to high agreement between all composite and subtest scores, except Nonword Repetition. Scoring by examiners and the first author showed high interrater agreement. No differences between Nonword Repetition scores were found for students who wore headsets (n = 12), whereas differences were found for those who did not (n = 34). CONCLUSIONS: This study provided preliminary evidence that Tele-TILLS results can be equivalent to traditional TILLS, supporting its validity for identifying language/literacy disorder and interpreting profiles. The small, highly homogeneous sample with well-educated parents limits generalizability to the broader population. Caution is warranted when testing 6- to 7-year-old students for whom Nonword Repetition is part of the Identification Core score. Suggestions are provided for optimizing technological setup, preparing facilitators, and making minor modifications in subtest administration.

Translating Enhanced Conversational Recast to a Telepractice Setting.

PURPOSE: This investigation adapted a well-studied language treatment method, Enhanced Conversational Recast, paired with auditory bombardment to a teletherapy format. METHOD: The study used a single case series approach (n = 7) to determine the feasibility of teletherapy with children ages 5 and 6 years of age. Treatment targeted grammatical errors in the context of dialogic reading and craft activities. Clinicians administered 24 doses in the form of focused conversational recasting, followed by 12 doses consisting of simple sentences containing the grammatical forms targeted for remediation. Children were treated for up to 26 sessions, with four children treated on consecutive weekdays and three treated twice a week. Treatment progress was operationalized as generalization of target grammatical forms to untreated linguistic contexts, as well as spontaneous use of the treated form. To control for nontreatment effects, generalization of an untreated form was also tracked throughout the treatment period. RESULTS: Six of the seven children showed clinically meaningful gains in the use of the grammatical forms targeted for treatment within the treatment period. This was true for children enrolled in both treatment schedules. Learning for treated forms was retained after treatment was discontinued. In comparison, no change was seen for untreated forms for six of the seven children. CONCLUSIONS: The results suggest that this treatment method is feasible in a telepractice format, even with young children. The range of individual results is generally comparable to previous face-to-face versions of this treatment.

Dynamic Norming for Systematic Analysis of Language Transcripts.

PURPOSE: This exploratory study sought to establish the psychometric stability of a dynamic norming system using the Systematic Analysis of Language Transcripts (SALT) databases. Dynamic norming is the process by which clinicians select a subset of the normative database sample matched to their individual client's demographic characteristics. METHOD: The English Conversation and Student-Selected Story (SSS) Narrative databases from SALT were used to conduct the analyses in two phases. Phase 1 was an exploratory examination of the standard error of measure (SEM) of six clinically relevant transcript metrics at predetermined sampling intervals to determine (a) whether the dynamic norming process resulted in samples with adequate stability and (b) the minimum sample size required for stable results. Phase 2 was confirmatory, as random samples were taken from the SALT databases to simulate clinical comparison samples. These samples were examined (a) for stability of SEM estimations and (b) to confirm the sample size findings from Phase 1. RESULTS: Results of Phase 1 indicated that the SEMs for the six transcript metrics across both databases were low relative to each metric's scale. Samples as small as 40-50 children in the Conversation database and 20-30 children in the SSS Narrative database resulted in stable SEM estimations. Phase 2 confirmed these findings, indicating that age bands as small as ±4 months from a given center-point resulted in stable estimations provided there were approximately 35 children or more in the comparison sample. CONCLUSION: Psychometrically stable comparison samples can be achieved using SALT's dynamic norming system that are much smaller than the standard sample size recommended in most tests of children's language.

The Role of Spontaneous Repetitions During Treatment of Morphosyntactic Forms for Children With Developmental Language Disorder.

Purpose Children with developmental language disorder sometimes spontaneously repeat clinician models of morphemes targeted for treatment. We examine how spontaneous repeating of clinician models in the form of recasts associates with improved child production of those emerging morphemes. Method Forty-seven preschool children with developmental language disorder participated in Enhanced Conversational Recast therapy and were monitored for spontaneous repetitions of morphemes modeled by the clinician through conversational recasting. We calculated proportion of correct and incorrect productions elicited during treatment and for generalization probes as well as treatment effect sizes. We then used odds ratios to determine the probability that a spontaneous repetition may precede treatment gains and calculated correlations of correct repetitions with correct in-treatment productions of targets and treatment effect sizes. Results Spontaneous repetitions were highly likely to happen just prior to meaningful treatment progress. Children with higher frequencies of correct spontaneous repetitions of morpheme targets also showed higher frequencies of correct productions of these forms during the course of treatment. Furthermore, children with an earlier onset of repetitions and higher frequencies of correct repetitions showed overall larger effect sizes at the end of treatment. Conclusions Children's use of correct forms in their repetitions may serve as a self-scaffold for mastering productions of the correct form via structural priming mechanisms. Tracking spontaneously repeated targets may be a useful milestone for identifying response to treatment.

Not All Procedural Learning Tasks Are Difficult for Adults With Developmental Language Disorder.

Purpose The experiment reported here compared two hypotheses for the poor statistical and artificial grammar learning often seen in children and adults with developmental language disorder (DLD; also known as specific language impairment). The procedural learning deficit hypothesis states that implicit learning of rule-based input is impaired, whereas the sequential pattern learning deficit hypothesis states that poor performance is only seen when learners must implicitly compute sequential dependencies. The current experiment tested learning of an artificial grammar that could be learned via feature activation, as observed in an associatively organized lexicon, without computing sequential dependencies and should therefore be learnable on the sequential pattern learning deficit hypothesis, but not on the procedural learning deficit hypothesis. Method Adults with DLD and adults with typical language development (TD) listened to consonant-vowel-consonant-vowel familiarization words from one of two artificial phonological grammars: Family Resemblance (two out of three features) and a control (exclusive OR, in which both consonants are voiced OR both consonants are voiceless) grammar in which no learning was predicted for either group. At test, all participants rated 32 test words as to whether or not they conformed to the pattern in the familiarization words. Results Adults with DLD and adults with TD showed equal and robust learning of the Family Resemblance grammar, accepting significantly more conforming than nonconforming test items. Both groups who were familiarized with the Family Resemblance grammar also outperformed those who were familiarized with the OR grammar, which, as predicted, was learned by neither group. Conclusion Although adults and children with DLD often underperform, compared to their peers with TD, on statistical and artificial grammar learning tasks, poor performance appears to be tied to the implicit computation of sequential dependencies, as predicted by the sequential pattern learning deficit hypothesis.

Predictors of Treatment Response for Preschool Children With Developmental Language Disorder.

Purpose Enhanced Conversational Recast treatment is an effective intervention for remediating expressive grammatical deficits in preschool-age children with developmental language disorder, but not all children respond equally well. In this study, we sought to identify which child-level variables predict response to treatment of morphological deficits. Method Predictor variables of interest, including pre-intervention test scores and target morpheme production, age, and mother's level of education (proxy for socio-economic status) were included in analyses. The sample included 105 children (M = 5;1 [years;months]) with developmental language disorder who participated in 5 weeks of daily Enhanced Conversational Recast treatment. Classification and regression tree analysis was used to identify covariates that predicted children's generalization of their trained grammatical morpheme, as measured by treatment effect size d. Results Our analysis indicates that the Structured Photographic Expressive Language Test-Preschool 2 (SPELT-P 2) scores and the Peabody Picture Vocabulary Test-Fourth Edition scores significantly predicted the degree of benefit a child derived from Enhanced Conversational Recast treatment. Specifically, a SPELT-P 2 score above 75 (but still in the impaired range, < 87) combined with a high Peabody Picture Vocabulary Test-Fourth Edition score (> 100) yielded the largest treatment effect size, whereas a SPELT-P 2 score below 75 predicted the smallest treatment effect size. Other variables included in the model did not significantly predict treatment outcomes. Conclusions Understanding individual differences in response to treatment will allow service providers to make evidence-based decisions regarding how likely a child is to benefit from Enhanced Conversational Recast treatment and the expected magnitude of the response based on the child's background characteristics.

Data-Informed Guideposts for Decision Making in Enhanced Conversational Recast Treatment.

Background To maximize treatment efficiency, it would be useful to determine how long to continue a treatment approach before concluding that it is not effective for a particular client, whether and when generalization of treatment is likely to occur, and at what point to end treatment once a child is approaching mastery. Method We analyzed aggregate data from 117 preschoolers with developmental language disorder from a decade of treatment studies on Enhanced Conversational Recast therapy to determine whether the timing of treatment response impacts its overall effectiveness and whether certain levels of accuracy during treatment enable 100% accurate generalization after treatment ends. Results We found that children who take longer than 10 days to answer one item correctly during treatment are unlikely to ever respond to the treatment approach. Generalization accuracy closely followed treatment accuracy, suggesting the two are tightly linked for this treatment method. We did not find evidence that attaining a certain level of accuracy below 100% during treatment enabled children to generalize with 100% accuracy after treatment ended. Conclusions Clinicians using Enhanced Conversational Recast treatment can use these markers to help make evidence-based decisions in their practice regarding how long to continue treatment. Importantly, these data suggest that stopping treatment before a child has attained 100% accuracy (for at least three sessions) does not ensure that a child will ever reach 100% accuracy on their own.

Diagnosis of Developmental Language Disorder in Research Studies.

Purpose The aim of this study was to investigate the extent to which researchers in the field of developmental language disorder are utilizing validated methods to diagnose their research participants. Method We examined 90 research articles published from 2015 to 2019 that included English-speaking participants from the United States who were identified as having a developmental language disorder or specific language impairment. From these articles, we identified the tests and measures used to identify participants and classify them as healthy or impaired. We then consulted the test manuals and the literature to find information on sensitivity and specificity of the test and the evidence-based cut score that maximized identification accuracy. Results Of the 90 articles examined, 38 (42%) were found to reflect validated diagnostic methods, and 51 (58%) did not. Conclusion Our results illustrate that validated methods are used less than half of the time even by those who should have a high level of expertise and despite calls for increasing scientific rigor in research practices.

Maximizing Treatment Efficiency in Developmental Language Disorder: Positive Effects in Half the Time.

Purpose When a behavioral treatment is generally efficacious, the central research questions shift to optimized dose delivery. In this study, we determine whether a validated treatment method can be made more effective or efficient by increasing the dose density employed. Method Twenty children were treated with Enhanced Conversational Recast methods to treat morphological errors. Half received 24 doses per session within a half hour (approximately 1 dose/1.25 min), and the other received the same number of doses within 15 min (approximately 1 dose/38 s). Generalization of morpheme use was probed throughout treatment and at a 6-week follow-up. Spontaneous use of treated morphemes was also tracked. Results Although the treatment was effective overall, there were no significant differences between treatment conditions on any of the outcome measures. Follow-up performance correlated significantly with performance at the end of the treatment period. Conclusion Minimal between-groups differences suggest that performance does not suffer when dose rates are compressed into half the time during treatment, making the high-density dose delivery method a more efficient delivery method. This could make time available within a treatment session to address other goals or allow for more classroom instructional time for the child. Supplemental Material https://doi.org/10.23641/asha.8968559.

Individual Versus Small Group Treatment of Morphological Errors for Children With Developmental Language Disorder.

Purpose This study examines the effects of enhanced conversational recast for treating morphological errors in preschoolers with developmental language disorder. The study assesses the effectiveness of this treatment in an individual or group ( n = 2) setting and the possible benefits of exposing a child to his or her partner's treatment target in addition to his or her own. Method Twenty children were assigned to either an individual ( n = 10) or group ( n = 10, 2 per group) condition. Each child received treatment for 1 morpheme (the target morpheme) for approximately 5 weeks. Children in the group condition had a different target from their treatment partner. Pretreatment and end treatment probes were used to compare correct usage of the target morpheme and a control morpheme. For children in the group condition, the correct usage of their treatment partner's target morpheme was also examined. Results Significant treatment effects occurred for both treatment conditions only for morphemes treated directly (target morpheme). There was no statistically significant difference between the treatment conditions at the end of treatment or at follow-up. Children receiving group treatment did not demonstrate significant gains in producing their partner's target despite hearing the target modeled during treatment. Conclusions This study provides the evidence base for enhanced conversational recast treatment in a small group setting, a treatment used frequently in school settings. Results indicate the importance of either attention to the recast or expressive practice (or both) to produce gains with this treatment. Supplemental Material https://doi.org/10.23641/asha.7859975.

Data-driven item selection for the Shirts and Shoes Test.

PURPOSE: The first stage of test development is the generation of a pool of potential items to be used in the assessment. Ideally, these items are then tested in the field on members of the population for which the assessment is intended. This initial analysis assures that tests build in validity at the level of the individual items. METHOD: Seventy-four potential test items developed for the Shirts and Shoes Test (Plante & Vance, 2012) were tested on 513 children between the ages of 3 and 6 years. An Item Response Theory (IRT) approach was used to identify potential items in the item pool which are unsuitable due to one or more types of deviation from the IRT model. Furthermore, an IRT approach provides data that permits the ordering of items by difficulty. RESULTS: A total of 19 items were discarded due to noteworthy deviations in one or more of the measures related to item response characteristics. The remaining 55 items reflected a range of skill difficulty and were deemed suitable for an age range of 3- to 6-years. CONCLUSIONS: Item Response Theory can be used productively to identify items that fail to add to the reliability and validity of a test during the earliest stages of test development. The number of items culled for this test demonstrates that the content of the items alone does not assure that the items perform in ways that promote accurate skill measurement.

Learning Without Trying: The Clinical Relevance of Statistical Learning.

Purpose: Statistical learning research seeks to identify the means by which learners, with little perceived effort, acquire the complexities of language. In the past 50 years, numerous studies have uncovered powerful learning mechanisms that allow for learning within minutes of exposure to novel language input. Method: We consider the value of information from statistical learning studies that show potential for making treatment of language disorders faster and more effective. Results: Available studies include experimental research that demonstrates the conditions under which rapid learning is possible, research showing that these findings apply to individuals with disorders, and translational work that has applied learning principles in treatment and educational contexts. In addition, recent research on memory formation has implications for treatment of language deficits. Conclusion: The statistical learning literature offers principles for learning that can improve clinical outcomes for children with language impairment. There is potential for further applications of this basic research that is yet unexplored.

Effective Use of Auditory Bombardment as a Therapy Adjunct for Children With Developmental Language Disorders.

Purpose: Modeling of grammatical forms has been used in conjunction with conversational recast treatment in various forms. This study tests the relative effect of providing bombardment prior to or after recast treatment. Method: Twenty-eight children with developmental language disorder participated in daily conversational recast treatment for morpheme errors. This treatment was either preceded or followed by a brief period of intensive auditory bombardment. Generalization to untreated lexical contexts was measured throughout the treatment period to assess the degree of learning and how quickly the onset of measurable learning occurred. Results: There were no significant differences in elicited use of morphemes for the groups of children who received auditory bombardment before or after enhanced conversational recast treatment. However, there was a difference in the number of children who could be considered treatment responders versus nonresponders, favoring those who received auditory bombardment after recast treatment. Conclusion: A brief period of auditory bombardment is a relatively low cost addition to recast treatment methods, given how little time it takes. There is a small but measurable advantage to following recast treatment with a period of auditory bombardment. Supplemental Material: https://doi.org/10.23641/asha.5960005.

Exemplar Variability Facilitates Retention of Word Learning by Children With Specific Language Impairment.

Purpose: Variability in the input plays an important role in language learning. The current study examined the role of object variability for new word learning by preschoolers with specific language impairment (SLI). Method: Eighteen 4- and 5-year-old children with SLI were taught 8 new words in 3 short activities over the course of 3 sessions. Half of the children saw 3 identical objects corresponding to each new word during training (No Variability group); the other half of the children saw 3 different objects corresponding to each new word during training (High Variability group). Children completed vocabulary learning tests for objects seen during training and for new within-category objects that were never seen during training as a test of category generalization. Learning was assessed the day after each training activity, and retention was assessed 3 weeks after the last training session. Results: There were no group differences on trained or generalization items immediately following training sessions. However, children in the High Variability group demonstrated significantly better retention 3 weeks after experimental training. Conclusion: These findings demonstrate that object variability facilitates retention of new word learning by children with SLI. Supplemental Material: https://doi.org/10.23641/asha.5583979.

Neural Correlates of Morphology Acquisition through a Statistical Learning Paradigm.

The neural basis of statistical learning as it occurs over time was explored with stimuli drawn from a natural language (Russian nouns). The input reflected the "rules" for marking categories of gendered nouns, without making participants explicitly aware of the nature of what they were to learn. Participants were scanned while listening to a series of gender-marked nouns during four sequential scans, and were tested for their learning immediately after each scan. Although participants were not told the nature of the learning task, they exhibited learning after their initial exposure to the stimuli. Independent component analysis of the brain data revealed five task-related sub-networks. Unlike prior statistical learning studies of word segmentation, this morphological learning task robustly activated the inferior frontal gyrus during the learning period. This region was represented in multiple independent components, suggesting it functions as a network hub for this type of learning. Moreover, the results suggest that subnetworks activated by statistical learning are driven by the nature of the input, rather than reflecting a general statistical learning system.