Facilitation

The first role intervention can play is that of facilitation. With facilitation, the rate of growth or learning is accelerated, but the final outcome is not changed. In other words, facilitative language intervention helps children to achieve language milestones sooner than they would have if left to their own devices, but it does not mean that they ultimately achieve higher levels of language function than they would have without intervention.

If all facilitation does is increase the rate of acquisition of a particular behavior without altering the child’s eventual language status, why bother to intervene? Gottlieb (1976) argued that facilitation could help a child increase his or her ability to differentiate among perceptions. In other words, facilitation can bring language to a higher level of awareness. This awareness can influence other aspects of development. For example, perhaps a child with a phonological disorder would outgrow his multiple articulation errors without intervention by age 8 or 9. But if intervention to overcome these errors is provided earlier, this intervention may not only improve articulation but also may focus the child’s attention on the sound structure of words. This increased awareness may contribute to the child’s phonological analysis skills, which, as we shall see later, are important for the development of literacy. Some writers (e.g., Whitehurst et al., 1991) suggest that if therapy is merely facilitative and the child would eventually outgrow the disorder anyway, there is no justification for intervening. But many clinicians (Olswang & Bain, 1991; Paul, 1991a; Robertson & Weismer, 1999) have argued that facilitative intervention is justified because of the other systems in development that accelerating language skills may affect. Take a child like Sammy.

This example illustrates how improving communication can affect a child’s social skills, behavioral repertoire, self-esteem, and family relations. These outcomes also are considerations in deciding whether to initiate intervention. Communication influences many aspects of a child’s life, and increasing its maturity, even if a problem would eventually be outgrown, can often result in changes that go beyond the language behavior itself.

Maintenance

A second way that intervention can change behavior is through maintenance. Olswang and Bain (1991) explained that intervention for the purpose of maintenance preserves a behavior that would otherwise decrease or disappear. Gottlieb (1976) argued that maintaining behaviors is important to “keep an immature system intact, going, and functional so that it is able to reach its full development at a later stage” (p. 28). A toddler with a cleft palate, for example, for whom surgery was delayed for medical reasons, might need intervention to maintain babbling and early vocal behaviors. These behaviors would then be functioning and available for building intelligible language once the palatal vault was closed by surgery.

Induction

Finally, intervention can serve the role of induction. Induction of a behavior means that the intervention completely determines whether some endpoint will be reached. Without the intervention, the outcome is not achieved. For example, a hearing-impaired 4-year-old who uses very little spoken language, who comes from a hearing family, and who has no access to the deaf community will not learn Sign language as a form of communication unless intervention takes place. The use of intervention to teach the child Sign language as a form of communication would be an example of induction.

Induction is the most dramatic form of intervention and the one for which we would most like to take credit. Unfortunately, in most real-life situations we do not know ahead of time whether our intervention is accomplishing facilitation or induction. Induction, of course, is the most cost-effective purpose of intervention, and when deciding whether to intervene, we feel more at ease if we can convince ourselves that the effect of the intervention will be induction rather than facilitation. In truth, though, we often do not have enough information to know. In these cases, we would argue that clinicians be familiar with the role of the facilitation in language learning and be prepared to assert the importance of facilitation as a valid outcome of intervention.

Evidence-based practice

Let’s imagine you are a clinician working with a preverbal 3-year-old named Brendan. One day, Brendan’s parents come to you with a newspaper article, which says that exposing children who don’t talk to a certain kind of auditory stimulation (through a special set of earphones) leads to speech. There’s a Web address in the article, and the parents have looked it up; the program is available for $2000; all they have to do is send for it and have the child wear the earphones for 20 minutes three times a day. They ask you whether you think they should purchase the program, and whether you would include 20 minutes of this treatment within each of Brendan’s sessions with you. How will you answer them? These kinds of questions lead us to the need for evidence-based practice (EBP).

Ochsner (2003) defined evidence-based practice as “the conscientious, explicit, and unbiased use of current best research results in making decisions about the care of individual clients” by integrating clinical expertise with the best available external clinical evidence from systematic research (Sackett et al., 2000). Dollaghan (2007) discussed these issues and reminded us that EBP does not only mean solving clinical problems by going to the external evidence, defined primarily as published literature, to find the best available scientific support for the use of specific intervention approaches, although it does mean that, too. Fey and Justice (2007) tell us that EBP includes evaluating internal evidence as well. Internal evidence comes from characteristics of the client and family, their willingness to participate in a treatment approach, and their preference; as well as our own clinician preferences, professional competencies, and values; and the values, policies, and culture of the institutions in which we work. Let’s talk about how we can evaluate external evidence first, then we’ll consider how internal evidence is included in this decision-making process.

Dollaghan (2004, 2007) suggested we approach external evidence using three principles:

Let’s see what these principles might mean to us in practice. First, they tell us that we can’t take “experts” at their word. If you go to a workshop and a famous clinician tells you about a new approach that can’t fail, you have to ask yourself, “How does she know?” If the answer is not based on data presented, but rather on her confidence and experience, we have to consider her endorsement with a few grains of salt. Why? Well, maybe the approach does work for her, but it works because she is an especially talented clinician and another person doing the same thing may not get the same results. Or maybe she works with certain kinds of clients, who are not like the clients in your practice. There could be lots of reasons. The point is, her saying it works is not enough. If you decide to try the approach, you should carefully monitor its effects on your clients, and perhaps compare it to other approaches you are using before deciding that it is really right for your practice and your clients.

Dollaghan’s second and third principles tell us that not only must we view experts with skepticism, we must read published research with the same critical attitude. When we say “critical” in this context, though, we don’t just mean finding fault. We have a very specific set of criteria in mind that we want to measure the studies we read against. Fey and Justice (2007) outlined a series of questions we can ask ourselves to help determine the type and quality of a study. These are summarized in Figure 3-2. The answers to these questions allow us to classify a report we read in the literature according to the levels of evidence it provides. These levels are summarized in Table 3-1. The higher the level of evidence we can find for a particular approach, the more confident we can be that the approach has strong scientific support. Finn, Bothe, and Bramlett (2005) provide additional guidance for evaluating claims about evidence.

But suppose we find strong scientific support for a particular practice. Is that the end of our decision-making process? Perhaps, but perhaps not. I’ll give you an example. As we’ll see in Chapter 4, some of the strongest support available for any approach to eliciting initial speech from young children with autism spectrum disorders (ASD) is for behavioral, or operant, methods. These methods have been carefully investigated for many years, and have the greatest number of studies as well as the highest quality of research evidence behind them. Does this strong scientific evidence mean to us that every preverbal child with ASD must be given operant training? You’ve probably already thought of some reasons why the answer is “not necessarily.” Perhaps the clinician is not well trained or experienced in this approach, or perhaps it conflicts with her values. Maybe the parents don’t like it, and think it would make their child too passive. All these are examples of the internal evidence that also needs to go into deciding about an approach to intervention.

What does EPB require of us, then? Do we have to read every published study in order to be EBP practitioners? Of course not—that would be impossible! Should we disregard scientific evidence if our own or a family’s values or experiences don’t match it? That would not be very responsible, either, since research does provide guidance in making clinical decisions. Fey and Justice (2007), Dollaghan (2007), and Sackett et al. (2000) outlined a reasonable approach to incorporating EBP that includes the following steps:

As you can see from this brief introduction to EBP, it offers a framework to help us make the crucial clinical decisions that go into the planning of an intervention program. Brackenbury, Burroughs, & Hewitt (2008) provide additional guidelines for using EBP in clinical practice. Let’s look at some of the other elements that go into this planning process.

Products of intervention: setting goals

McCauley and Fey (2006) and McLean (1989) suggested that there are three aspects of the intervention plan: the intended products, or objectives, of the intervention; the processes used to achieve these objectives; and the contexts, or environments, in which the intervention takes place. Let’s see what each of these aspects entails.

A major source of information for goal setting is the assessment data. The appraisal tells us about the child’s current level of functioning in the various language areas. McCauley and Fey (2006) describe intervention goals at three levels. These include the following:

Because many children with DLD have multiple linguistic deficits, it is helpful to have some criteria for setting priorities among the deficits identified in the baseline assessment. Nelson, Camarata, Welsh, Butkovsky, and Camarata (1996) found that both forms that did not appear in the child’s speech at all and forms that were used correctly some of the time were equally amenable to improvement with intervention. This research suggests that both these types of forms make suitable intervention targets. Fey (1986) and Fey, Long, and Finestack (2003) suggested, though, that forms that the child is already using a majority of the time correctly, even if some errors are still being made, should not be targeted for intervention. These forms are well on their way to mastery and will probably improve without direct teaching. Their suggestions are summarized in Box 3-1.

This strategy for goal setting can be thought of as targeting the child’s zone of proximal development (Levykh, 2008; Schneider & Watkins, 1996; Shepard, 2005; Vygotsky, 1978). The zone of proximal development (ZPD) is the distance between a child’s current level of independent functioning and potential level of performance. In other words, the ZPD defines what the child is ready to learn with some help from a competent adult. Figure 3-3 gives a schematic representation of the ZPD. Choosing a goal within the child’s current knowledge base is wasting the child’s time, teaching something that is already known. Unfortunately, this error is sometimes made in intervention out of a misguided desire to ensure that the child succeeds on an intervention task. If a goal, such as production of a plural morpheme, is identified, and a child is found to perform at 80% correct on the first activity involving this morpheme, this indicates that the child does not need to be taught it. To persist in providing intervention on such an objective is to work short of the child’s ZPD. The client is not being challenged to assimilate new knowledge and is simply demonstrating what he or she has already learned. This may make the clinician feel good, but it does not help the child acquire new forms and functions of language.

If the child is only 40% correct in the first sessions on a certain morpheme, however, the clinician can feel relatively confident that the form is within the child’s ZPD. If continued intervention eventually produces 80% correct responses, the clinician would be justified in continuing to provide opportunities for the child to use this form, to stabilize and generalize its use. After several sessions in which the form is used correctly almost all the time in both structured and conversational contexts, though, the notion of ZPD suggests that it is best to move on to another target, checking back on plural morphemes occasionally to be sure that they are maintained in the child’s repertoire. Focusing on targets for longer than necessary to get them stabilized into the child’s knowledge base and generalized into conversational use does not make the most of intervention resources.

Similarly, it is important to choose objectives that are not beyond the client’s ZPD. If a goal is too far above the current knowledge base, the child will be unable to acquire it efficiently and may not learn it at all. For a child in the two-word stage of language production, for example, using comparative “-er” forms, which are normally acquired at a developmental level of 5 to 7 years (Carrow-Woolfolk, 1999a), is in most circumstances too far from the child’s current level of functioning to be an appropriate goal. Again, the probable range of the ZPD is based on detailed assessment data, which pinpoints where the child is already functioning, and on knowledge of normal development, which allows us to determine the next few pieces of language development to fall into place. Lidz and Gindis (2003) and Schneider and Watkins (1996) point out that using dynamic assessment techniques to establish the ZPD also is helpful. This would mean identifying a particular form that is used infrequently or not at all in the client’s spontaneous speech. Diagnostic teaching could be used to determine whether adult scaffolding makes it possible for the child to produce the form more accurately or often. If so, the form is within the child’s ZPD and makes an appropriate therapy target.

We will need to take some other considerations—besides the child’s current level of functioning and the ZPD—into account when setting long- and short-term goals, though. Let’s examine what some of these considerations might be.

Processes of intervention

Once the specific objectives of the intervention have been determined, it is time to decide on a general approach or combination of approaches to use in the program and to choose or design particular intervention activities. Let’s look at the options available to speech-language pathologists (SLPs) in these areas.

Intervention approaches

Fey (1986) discussed a continuum of naturalness in intervention approaches. This continuum represents the extent to which the settings and activities in intervention resemble “real life” or the world outside the clinic room (Figure 3-4). We can vary intervention activities along this continuum of naturalness. Activities in language intervention can be a lot like the activities a child engages in during the rest of his or her life, or they can be very different. We can go from very naturalistic settings and activities such as play in the child’s home to very contrived activities, such as drill in a setting such as a clinic room, or we can choose settings and activities somewhere midway along this continuum. Three basic approaches to intervention identified by Fey (1986) will be outlined here. We don’t mean to suggest that a clinician has to choose just one of them. Our aim should be to make the best match among a particular client, a particular objective, and an intervention approach. Some clients may do better with one approach than another. Other clients may do well with one approach for one objective and a different approach for another. One objective may be well suited to a highly structured approach; another may be better served by a more open-ended approach. Often, several activities are designed to address a particular objective—some highly structured, some with a low level of structure, and others a compromise between the two. The important thing is to be aware of the range of approaches available for planning intervention activities and to be able to take advantage of this range of approaches in setting up a comprehensive, economical, efficient intervention program that meets each client’s individual needs. We should also, as we will see later in the chapter, evaluate the available evidence in the research literature for the effectiveness of particular approaches with particular goals for particular kinds of clients.

The clinician-directed approach

In these approaches, the clinician specifies materials to be used, how the client will use them, the type and frequency of reinforcement, the form of the responses to be accepted as correct, and the order of activities—in short, all aspects of the intervention. Clinician-directed (CD) approaches, also referred to as drill (Shriberg & Kwiatkowski, 1982a) or discrete trial intervention (DTI), attempt to make the relevant linguistic stimuli highly salient, to reduce or eliminate irrelevant stimuli, to provide clear reinforcement to increase the frequency of desired language behaviors, and to control the clinical environment so that intervention is optimally efficient in changing language behavior. CD approaches tend to be less naturalistic than other approaches we will discuss, since they involve so much control on the part of the clinician and since they purposely eliminate many of the natural contexts and contingencies of the use of language for communication. Peterson (2004) defined these approaches as ones in which the clinician selects the stimulus items, divides the target language skill into a series of steps, presents each step in a series of massed trials until the client meets a criterion level of performance, and then provides an arbitrary reinforcement. Roth and Worthington (2010) provide an excellent introduction to this approach. Their summary of this basic training protocol appears in Box 3-2.

BOX 3-2   Training Protocol for Clinician-Directed Intervention

• Clinician gives instructions in declarative form (“Say the name for the picture after me.”).

• Clinician presents stimulus or antecedent event (“Big ball.”).

• Clinician waits for client to respond, allowing sufficient time for client to formulate response.

• Clinician presents consequent event or reinforcement (primary such as food, or secondary, such as social praise [“Good talking”], tokens to accumulate for a prize, or feedback regarding the acceptability of the response).

• Feedback might include biofeedback instrumentation or information on performance (“You said four of the five correctly.”)

Adapted from Roth, F.& Worthington, C. (2010). Treatment resource manual for speech-language pathology (4th ed.) Clifton Park, NY : Delmar.

An advantage of CD approaches is that they allow the clinician to maximize the opportunities for a child to produce a new form, producing a higher number of target responses per unit time than other approaches allow. This provides excellent opportunities for the child to get extended practice using a new form or function.

Proponents of this approach (e.g., Connell, 1987; Fey & Proctor-Williams, 2000; Smith, Eikeseth, Sallows, & Graupner, 2009) also point out that its unnaturalness is itself an advantage. They argue that if clients were going to learn language the “natural” way, by listening and interacting with others, they would not need intervention. The fact that the child has, for whatever reason, failed to learn language through natural interactions suggests that something else is needed. The something else, in this view, is the highly structured, clinician-controlled, tangibly reinforced context of the behaviorist’s intervention.

There is something to be said for this position. CD approaches have been shown in a large literature of research studies to be consistently effective in eliciting a wide variety of new language forms from children with language disabilities of many types (see Abbeduto & Boudreau, 2004; Fey, 1986; Goldstein, 2002; Paul & Sutherland, 2005; Peterson, 2004; Reichow & Wolery, 2009; Rogers, 2006, for reviews). The proponents of the CD approach appear to be justified in arguing that children who have not learned language the “old-fashioned way,” by interacting naturally with their parents, benefit from formal behavior modification procedures. Furthermore, some research (Friedman & Friedman, 1980) suggests that, while children with higher IQs learn better in a more interactive intervention program, those with lower IQs or more severe disabilities perform better when a CD approach is used. Connell (1987) showed, using an invented morpheme, that children with normal language acquisition learned more efficiently when the form was merely modeled for them, whereas children with DLD learned the form better when they were required to imitate the instructor’s production of it. These studies tend to support the behaviorist position that CD approaches to language intervention work better than more naturalistic ones for children with DLD. Studies of children with ASD have also shown that CD approaches appear superior to more eclectic approaches for improving language and cognitive skills (e.g., Cohen, Amerine-Dickens, & Smith, 2006; Eikeseth, Smith, Jahr, & Eldevik, 2002; Eikeseth, Smith, Jahr, & Eldevik, 2007).

But, of course, that’s not the whole story. Cole and Dale (1986), for example, were not able to replicate the Friedman and Friedman results and found no differences between interactive and CD approaches. Nelson et al. (1996) showed more rapid acquisition of grammatical targets and increased generalization with a conversational intervention treatment than an imitative one. Camarata, Nelson, and Camarata (1994) reported that children with language impairments learned syntactic targets more quickly under naturalistic conditions than with a CD approach. A meta-analysis by Delprato (2001) suggested that naturalistic interventions showed a consistent advantage over CD methods. Howlin, Magiati, Charman, and MacLean (2009) found CD approaches worked well for some children but not others. More fundamentally, perhaps, numerous studies (e.g., Hughes & Carpenter, 1983; Mulac & Tomlinson, 1977; Zwitman & Sonderman, 1979; see Peterson, 2004, for review) show difficulties in generalization to natural contexts of forms taught with a CD approach, even when use reaches high levels of accuracy within the CD framework. Cirrin and Gillam (2008) report, in a review of literature, that imitation (CD), modeling (child-centered, CC), or modeling plus evoked production (hybrid) all are equally but modestly effective in teaching new syntactic and morphological forms. Gillum et al. (2003), while generally favoring more naturalistic approaches, argue that clinicians and researchers need to determine which developmental profiles in clients are best matched to particular intervention methods.

It seems, then, that while CD approaches can be highly efficient in getting children to produce new language forms, they are not so effective in getting them to incorporate these forms into real communication outside the structured clinic setting, and that more naturalistic methods can also provide an efficient means of addressing language targets. What shall we make of these findings? Some writers, including Hubbell (1981), Norris and Hoffman (1993), and Owens (2009), have argued that the lack of generalization seen in CD approaches renders them useless and that the only approaches that are right for language intervention are more natural and interactive. This view, in our opinion, involves “throwing the baby out with the bath water.” Since CD approaches have proven efficacy in eliciting new language forms, why not take advantage of this efficacy? CD approaches can be used in initial phases of treatment to elicit forms that the child is not using very much spontaneously or at all. Fey, Long, and Finestack (2003) argue that drill formats that emphasize contrasts between two forms (such as past/present or singular/plural) are the most effective use of CD formats. Either simultaneously, or later, once the form or function has been stabilized with a CD approach, some of the more naturalistic approaches we will discuss can be used to help bring the form into the child’s conversational repertoire (Smith, 2001). Let’s look at three major varieties of CD activities: drill, drill play, and modeling.

Drill

Shriberg and Kwiatkowski (1982a) defined several types of clinical activities in terms of their degree of structure. The most highly structured in their framework is drill, which makes use of the classic DTI format. In a drill activity, the clinician instructs the client concerning what response is expected and provides a training stimulus, such as a word or phrase to be repeated. These training stimuli are carefully planned and controlled by the clinician. Often they contain prompts or instructional stimuli that tell the child how to respond correctly, for example by imitating the clinician. If prompts are used, they are gradually eliminated or faded on a schedule predetermined by the clinician. When prompts are used, the client provides a response to the clinician’s stimulus. If this response is the one the clinician intended, the child is reinforced with verbal praise or some tangible reinforcer, such as food or a token. A motivating event also may be provided. For example, if the child is to label clothing items, he or she may be asked to place a sticker of the item in a sticker album after it has been named appropriately and the response has been reinforced. If the client’s response is not the intended target, the clinician attempts to shape the response by reinforcing the production of parts of the complete target and gradually increasing the number of components that must appear correctly to obtain the reinforcement. Drill is the most efficient intervention approach in that it provides the highest rate of stimulus presentations and client responses per unit time.

One problem with drill in Shriberg and Kwiatkowski’s study was that neither the clients nor the clinicians liked it very much. The clients did not find it very motivating, and the clinicians were uncomfortable with its high degree of structure and low level of motivation. It is interesting to note that the clinicians in the study did not like drill even though it was obvious that it got the job done and provided an efficient and effective form of intervention.

Drill play

Drill play is another CD approach, which differs from drill only in that it attempts to provide some motivation into the drill structure. It does this by adding an antecedent motivating event, that is, one that occurs not only after the target response is reinforced but also before it is even elicited. Thus there are two motivating events in drill play, one that goes along with the original training stimulus the (antecedent motivating event) and one that follows the reinforcement (the subsequent motivating event). For example, take the activity mentioned before—using stickers to motivate naming clothing items. As an antecedent motivating event, the client may be allowed to choose any sticker from a sheet of clothing stickers that he or she would like to put in the album. The training stimulus would elicit the name of clothing item represented by the sticker. After reinforcement for correct labeling, the client would be allowed to put the sticker in the album, as a subsequent motivating event.

Shriberg and Kwiatkowski (1982a) found drill and drill play to be equally efficient and effective in eliciting responses in phonological intervention. Furthermore, clinicians in the study liked drill play a lot better than they did drill and believed that their clients did, too. Do these findings about phonological intervention transfer to language? We don’t really know, since this question has not been addressed in language intervention research in as clear a manner as Shriberg and Kwiatkowski have addressed it. But it seems reasonable to expect the two modes of intervention to produce similar outcomes with semantic, syntactic, pragmatic, and phonological goals. These findings suggest that many of the advantages of highly structured CD approaches can be retained while client motivation and clinician comfort are increased, by small but well-thought-out modifications of the basic DTI approach.

Does this mean that we should never drill, if drill play is just as effective and more fun? Not necessarily. Some children, in fact, may enjoy the predictability and simplicity of drill. Many computer language-teaching programs are, in fact, drill formats that use their own graphic displays as subsequent motivating events, and many children find these to be quite a treat. The bottom line, in our opinion, is that if drill works for a certain client, we should by all means use it initially to elicit new forms and functions. If it doesn’t work, we should use whatever works better. The important thing is to have a range of techniques and approaches on our clinical palate from which to draw, mix, and match to suit the needs of clients.

Modeling

Fey (1986) presented a second CD alternative to straight drill procedures. This arises from social learning theory and involves the use of a third-person model—thus the name, modeling approach. Like drill, modeling uses a highly structured format, extrinsic reinforcement, and a formal interactive context. But here, instead of imitating, the child’s job is to listen. The client listens as the model provides numerous examples of the structure being taught. Through listening, the child is expected to induce and later produce the target structure. The child never has to imitate a structure immediately after the model. Instead this procedure implicitly requires the child to find a pattern in the model’s talk that is similar across all the stimuli presented. In Leonard’s (1975a) modeling procedure, a “confederate,” such as a parent, is used by the clinician as a model. The clinician, after pretesting the client on the target structure, gives the model a set of pictures not used in the pretest and asks, “What’s happening here?” The confederate provides, for example, a be + (verb)+-ing utterance that describes each picture presented by the clinician (e.g., “the boy is drinking,” “the girl is eating,” “the cat is walking”). After 10 or 20 of these descriptions, the client is asked to “talk like” the model and to describe a similar but not identical set of pictures. In this phase the model and client alternate their productions until the child produces three consecutive correct versions. Then, the child is asked to continue until a criterion (say, 8 out of 10 consecutive correct responses) is reached. At this point, the client would be tested on the pretest stimuli without models. This method can easily be adapted when a confederate is not available by using a doll or puppet (with the clinician’s voice) as a model.

All three variations we’ve discussed—drill, drill play, and modeling—share the tightly structured, formal, clinician-controlled features that characterize operant approaches to intervention. They share the advantages these approaches provide: specification of linguistic stimuli, clear instructions and criteria for appropriate responses, reinforcement designed to increase the frequency of correct responding, high levels of efficiency in evoking maximal numbers of responses per unit time, and proven effectiveness in eliciting new language behaviors. They all share certain disadvantages, too. They are relatively “unnatural” and are dissimilar to the pragmatic contexts in which language is used in everyday conversation. Perhaps as a result, their targets are not spontaneously incorporated into everyday language use, even when they reach criterion levels in the structured intervention situation. These facts imply that CD approaches ought to be considered in initial phases of intervention to evoke use of forms the child is not using very often in spontaneous conversation, because of their great efficiency for this purpose. Because of their drawbacks, though, CD aproaches should be combined with other modalities to effect the transition from use in formal intervention contexts to use in everyday interactions. Let’s see what some of these alternative approaches might be.

Child-centered approaches

You can lead a horse to water, but you can’t make it drink. That’s the problem with CD approaches. Some children simply refuse to engage in CD activities, no matter how good it is for them. Some clinicians might call these children “behavior problems” and would spend long stretches of intervention time trying to train them to participate in CD formats. These “hard-to-treat” children rebuff any attempt to get them to say what the clinician tells them to say, no matter how tempting the reinforcement.

For these children, an alternative intervention approach seems warranted. That is, even if we believe that CD approaches are the most efficient means of language change, we may need to have another weapon at our command for children who refuse to engage in them, at least until we can establish a better relationship with the client and get him or her to want to cooperate with us. Sometimes we need to win a child’s trust.

For another kind of client, too, the CD approach may not be the best first step. This is the child that Fey (1986) called “unassertive.” An unassertive child responds to speech, but rarely initiates communication. These children are passive communicators who let others control interactions. In a sense, a CD approach panders to these clients’ propensity to sit back and let others do the interactive work. Having these clients respond when and how they are told to is essentially reinforcing them to continue the old, passive communication pattern.

For both these children—the obstinate child and the unassertive communicator—CD approaches may not be the most appropriate first step in an intervention program. That is not to say that CD approaches never work for these clients, only that we may need to do something else first before we ask them to work with us. For the obstinate and unassertive child particularly, the child-centered (CC) approach (Fey, 1986; Girolametto & Weitzman, 2006; Sheldon & Rush, 2001) may be a good introduction to intervention. CC approaches can be appropriate adjuncts to the program for many children with language disorders. CC approaches go by several names, including indirect language stimulation (ILS; Fey, 1986), facilitative play (Hubbell, 1981), pragmaticism (Arwood, 1983), and developmental or developmental/pragmatic approaches (Prizant & Wetherby, 2005a). In using a CC approach, a clinician arranges an activity so that opportunities for the client to provide target responses occur as a natural part of play and interaction. From the child’s point of view, the activity is “just” play or conversation. A clinician may use a variety of linguistic models as instructional language when they seem appropriate in the context of the child’s activity. There are no tangible reinforcers, no requirements that the child provide a response to the clinician’s language, and no prompts or shaping of incorrect responses when they do occur, although the clinician does consequate, or follow up, any child remarks in specific ways, as we’ll see.

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

Assessment and intervention in the prelinguistic period Child language disorders in a pluralistic society Special consideration for special populations Assessing advanced language Assessment of developing language Assessing students’ language for learning

Stay updated, free articles. Join our Telegram channel

Join