week 1 last class
Topics in Early Childhood Special Education 2014, Vol. 33(4) 212 –224 © Hammill Institute on Disabilities 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0271121413497520 tecse.sagepub.com
Topical Article
Language development is a primary task of the first few years of life. Delays in language often are primary indica- tions of developmental delays and are likely to impact development across all domains. While there is variation in the rate and timing of language development, the sequence of language milestones is generally predictable among chil- dren within cultures. Most typically developing toddlers acquire a core vocabulary of functional words by their 2nd year of life (Crais, 1990). However, some toddlers exhibit delayed vocabulary acquisition associated with identified disorders (e.g., Down syndrome) or diagnosed develop- mental delays (American Speech-Language-Hearing Association, 2005). In addition to children with known dis- orders and delays, 15% of toddlers develop language at a slower pace without any concomitant delays in other devel- opmental domains (Desmarais, Sylvestre, Meyer, Bairati, & Rouleau, 2008). While a subset of these toddlers will catch up to typically developing children by the preschool years, some will have persistent delays (Paul, 2000; Rescorla, 2002). Recent federal data indicated that the number of infants and toddlers with delays served under Part C Early Intervention (EI) increased from just under 190,000 (1.6% of all infants and toddlers) in 1998 to over 320,000 (2.2%) in 2007 (U.S. Department of Education, 2012) and sug- gested that 8% to 12% of preschool children have language delays (U.S. Preventive Services Task Force, 2006).
Children with language delays are more likely to experi- ence literacy delays (van der Schuit, Peeters, Segers, van Balkom, & Verhoeven, 2009) and social, emotional, or behavioral problems (van Daal, Verhoeven, & van Balkom, 2007). The effects of language impairments are cumulative and might impact later school success if not addressed early.
Family-Centered Approach
A family-centered approach is central to the general phi- losophy and framework of EI (McWilliam, 2010, 2012; Powell & Dunlap, 2010). Research consistently supports EI approaches that focus on enhancing parent and caregiver capacity to meet the needs of infants and toddlers (Bruder & Dunst, 2000). For example, research indicated that increased parent responsivity is associated with enhanced child lan- guage skills (Dunst & Trivette, 2009a) and improved devel- opmental outcomes (Baggett et al., 2010). Several recent
497520TECXXX10.1177/0271121413497520Topics in Early Childhood Special EducationMoore et al. research-article2013
1University of Oregon, Eugene, USA 2University of Colorado Denver, USA
Corresponding Author: Heather W. Moore, Communication Disorders and Sciences Program, 5284 University of Oregon, Eugene, OR 97403-5284, USA. E-mail: hbmoore@uoregon.edu
A Program for Improving Toddler Communication Through Parent Coaching
Heather W. Moore, PhD, CCC-SLP1, Erin E. Barton, PhD, BCBA-D2, and Maria Chironis, MS1
Abstract The purpose of this manuscript was to describe a community-based program, Language and Play Everyday (LAPE), aimed at evaluating effective practices for enhancing parents’ capacity to increase their toddlers’ communication skills. LAPE was a parent education program focused on coaching parents to embed naturalistic language-enhancing strategies within daily routines. Participants included eight families of toddlers with expressive communication delays ranging in age from 22 to 36 months. LAPE was delivered using group and individual sessions. After participating in the program, parents increased their responsivity and use of other language-enhancing behaviors. Social validity measures indicated that parents were satisfied with procedures, goals, and outcomes of the project. Moreover, children improved their expressive language skills. Implications for future research and application are discussed.
Keywords infants and toddlers, speech and language delays, parent coaching
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reviews and meta-analyses support EI approaches that focus on enhancing parents’ responsivity and capacity to support their children’s development. Dunst and his colleagues identified specific essential characteristics of parent respon- sivity related to improved child developmental outcomes. Effective parents responded contingently, based on the child’s focus or intent, and in mutually reinforcing ways (Dunst & Trivette, 2009a; Trivette, Dunst, & Hamby, 2010). Moreover, approaches that promoted full participa- tion of families in assessment and intervention were related to improved child outcomes (Dunst, Trivette, & Hamby, 2006, 2007, 2008a).
For infants and toddlers, responsive interactions with parents during daily routines and activities provide essential opportunities for learning and promoting development. In fact, the influence of parents on child development is criti- cal; parents are the most significant facilitators of learning for infants and toddlers (Powell & Dunlap, 2010). Thus, EI should focus on family coaching (i.e., supporting their abil- ity to enhance their child’s development) rather than pro- viding direct service to the child. This focus on the family ensures the child has multiple learning opportunities during meaningful routines and activities (Jung, 2003; McWilliam,
2010). A family-centered approach means practitioners focus on increasing the quality of parent−child interactions within daily routines and activities, which is likely to enhance family quality of life (McWilliam, 2010). Several family coaching practices have been identified based on family-centered practices and adult learning principles (Powell & Dunlap, 2010; Rush & Shelden, 2011; Sandall, Hemmeter, Smith, & McLean, 2005). These coaching prac- tices (see Table 1) emphasize the families’ strengths and values, identify natural learning opportunities within daily routines and activities, and use evidence-based adult learn- ing strategies to build parents’ capacity to enhance their children’s development (Campbell & Sawyer, 2007).
Parent Implemented Naturalistic Language Interventions
Early language development is largely impacted by every- day conversations between parents and their children (Hart & Risley, 1995; Kaiser & Roberts, 2011; Roberts & Kaiser, 2011). Language development is likely directly related to the quality and quantity of the language input received, which occurs within the context of social interactions and is
Table 1. LAPE Evidence-Based Family Coaching Practices.
Evidence-based Practices LAPE example
1. Individualized approach to family coaching The individual home sessions were structured according to the family’s needs. Parents chose the strategies they wanted to practice.
2. Focus on daily routines with the family’s materials in natural settings
The individual home sessions were scheduled during routines the family identified. The coaches supported the parents in using the strategies during daily routines.
3. Focus on supporting family participation and building family capacity and competence
Initial group sessions focused on early language and play development and how parent interactions can influence development. Group sessions also allowed parents to support each other’s efforts at home. Improvements in caregiver confidence were measured over time.
4. Identify functional child outcomes a discussion about the family’s priorities
At the beginning of the training we asked parents to identify a functional goal for their child. To meet this goal, parents identified strategies they wanted to work on and specific words they wanted to help their children say each week.
5. Works directly with the caregiver and uses effective coaching strategies
During individual sessions, targeted strategies were reviewed and parents practiced the strategies with their children while their coach observed. If needed, coaches modeled strategies. After each practice activity, parents reflected on their use of the strategies and ways they could incorporate them into daily routines. Then coaches provided specific feedback, support, and suggestions.
6. Focus on caregiver responsivity and caregiver–child interactions
Parents were taught to identify times when their children were initiating communication. Then they were taught take conversational turns with their children during play and daily interactions.
7. Use of videos for demonstration and reflection
Parent–child interactions were recorded prior to intervention. After the responsive strategies were introduced, parents watched the videos and rated their use of each strategy. Then the coaches reviewed and discussed the videos again with the parents.
8. Identify opportunities to practice across the day and in between visits
At the end of each group and individual training, parents identified strategies they will use and target words they will teach in the coming week.
9. Systematic progress monitoring Parents completed a daily log to rate their use of each strategy and a weekly log to note their child’s progress on targeted vocabulary.
Note. LAPE = Language and Play Everyday. Source. Evidence-based Practices are adapted from Dunst and Kassow (2007), McWilliam (2010), Powell and Dunlap (2010), Rush and Shelden (2011).
214 Topics in Early Childhood Special Education 33(4)
individually determined. Parent education programs that focus on supporting child language development can be highly effective (Kaiser & Roberts, 2011). Naturalistic lan- guage interventions focus on teaching parents to embed language-enhancing strategies into daily routines and play. Common characteristics of naturalistic teaching strategies include: using direct and natural reinforcement, focusing on functional skills, using a variety of materials, and following the child’s interests and lead (McGee, Morrier, & Daly, 1999). The use of these strategies allow for authentic learn- ing experiences and greater generalization of language skills (Kashinath, Woods, & Goldstein, 2006). Research indicates that naturalistic teaching strategies are feasible— meaning parents can implement them with high fidelity, and effective—meaning they are functionally related to improvements in child language development (Roberts & Kaiser, 2011).
Evidence-based naturalistic teaching approaches include enhanced milieu teaching (EMT; Hancock & Kaiser, 2006) and responsive education-prelinguistic milieu teaching (RE-PMT; Warren et al., 2006). EMT is a hybrid approach that incorporates environmental arrangement, responsive interaction, and milieu strategies to increase expressive and pragmatic language in children with emerging language skills. Several studies suggest that parent-implemented EMT is an effective and efficient intervention for late- talking toddlers (Kaiser, Hancock, & Nietfeld, 2000; Kashinath et al., 2006; Roberts & Kaiser, 2011). In addi- tion, parents consistently learned the strategies and reported feeling confident in their ability to use EMT following training (Peterson, Carta, & Greenwood, 2005). RE-PMT uses the same intervention strategies as EMT but focuses on teaching prelinguistic language skills (i.e., intentional, non- verbal communication). The research on RE-PMT indicates it also is an effective, parent-implemented intervention for children (Fey et al., 2006; Yoder & Warren, 2002).
Research also supports implementing these approaches with parents during individual and group trainings. Group training, with individualized supports, allows information to be shared in a quick and concise format, provides space and time for shared parent support, and might be less costly (Carter et al., 2011; Kaiser, Hemmeter, Ostrosky, Alpert, & Hancock, 1995). However, the most popular group training programs (e.g., Hanen Centre, 2011) are costly for interven- tionists, not well suited for current Part C systems, and might not be effective for all families because they are not easily individualized (Carter et al., 2011). Furthermore, although there are empirically supported intervention approaches for enhancing parents’ capacity to promote their child’s language development, there is a significant research to practice gap. Recent research indicates evidence-based practices are not being implemented in EI, and the amounts of services families receive are fewer than recommended (Dunst & Trivette, 2009b; Hebbeler, Spiker, & Kahn, 2012;
Stahmer & Mandell, 2007). Additional research is needed to examine strategies for improving parent education curri- cula that can be cost-effective and efficiently implemented by practitioners within a variety of community settings.
The purpose of this manuscript is to describe the devel- opment of a parent-education program, Language and Play Everyday (LAPE). The first and second authors developed LAPE to address a community need for an efficient and cost-effective, community-based parent-education pro- gram, focused on increasing parents’ use of naturalistic language-enhancing strategies and improving communica- tion skills in their toddlers’ with expressive communication delays. The community need paralleled national research on Part C EI services. That is, research has shown that the ser- vices families receive through Part C were fewer than rec- ommended, and not all eligible children and families were being served (Dunst & Trivette, 2009b; Hebbeler et al., 2012; Hume, Bellini, & Pratt, 2005). For example, the National Early Intervention Longitudinal Study (NEILS; Hebbeler et al., 2007) found families received an average of 1.5 hours of Part C services per week, families missed about one fourth of their scheduled visits, and the amount of fund- ing per child has decreased by an estimated 50% over the last decade (Hebbeler et al., 2012). This report concluded that overall, families received relatively few face-to-face services. Moreover, for 44% of the families, the services focused only on the child, rather than the family, which is unlikely to have a larger impact on the child’s development. LAPE was developed to address this community need by using a cost-effective, group format to teach parents to: (a) identify and respond to their children’s communication attempts, (b) provide opportunities for their toddlers to communicate, and (c) use developmentally appropriate lan- guage. Specific strategies and supports were identified based on the individual needs of each child and family. The components of the program, evaluation procedures, pro- gram outcomes, and implications for future research and practice are described.
Description of Program
Participants
Thirteen parents and their toddlers with expressive com- munication delays participated in LAPE across three ses- sions. However, only eight parent−child dyads attended all sessions and complete all assessment; thus, only these eight were included in these analyses. Five additional parent−child dyads participated in LAPE sessions, but did not complete all assessments or missed sessions. Parents were recruited from a local EI agency and local early child- hood programs (seven mothers and one father participated). LAPE was a voluntary program. Six of the eight children were receiving additional EI services (see Table 2). Parents
Moore et al. 215
varied in age (i.e., ages ranged from 29 to 41 years), educa- tion (i.e., two reported “some college,” one reported “com- munity college degree,” four reported “Bachelor’s degree,” and one reported “master’s degree”), and income level (i.e., four reported an income level between “US$20,000-US$50,000” and four reported an income level between “US$50,000-US$80,000”). Inclusion crite- ria for children were (a) chronological age between 24 and 36 months, (b) verbal vocabulary between 10 and 50 words as measured by the MacArthur-Bates Communicative Development Inventory (Words and Sentences Form; CDI-II; Fenson et al., 2007), and (c) had parents who attended all sessions and completed all assessments.
Training Structure and Settings
The LAPE program consisted of group and individual ses- sions across three cohorts of parents and toddlers. The cohorts were conducted sequentially over 1 year. Two or three parent−child dyads were included in these analyses from each cohort (Cohort 1 included three of four parent−child dyads, Cohort 2 included two of five parent−child dyads, and Cohort 3 included three of four parent−child dyads). The group sessions occurred in a classroom at a community school and the individual ses- sions occurred in the families’ homes. Individual sessions were 1 hr and group sessions ranged from 90 min to 2 hr based on group preferences (i.e., Cohorts 1 and 3 requested 2-hr sessions and Cohort 2 requested 90-min sessions). For the first two cohorts, the group and individual sessions were staggered across 7 weeks (i.e., two group sessions, one indi- vidual session, two group sessions, one individual session, and a final group session). Because the parents in Cohorts 1 and 2 did not maintain use of LAPE strategies at follow-up, the authors decided to stagger Cohort 3’s sessions and
embed a 6-week break after the first individual session. Moreover, they replaced the final group session with an individual session. Thus, for cohort 3, the total session length was 15 weeks. This was intended to promote mainte- nance of parent use of LAPE strategies and individualize the final session to the needs of the dyad. Although there were variations in the format, the curriculum was identical across cohorts.
Interventionists
The first author, a speech-language pathologist, led all group sessions and graduate students in Early Intervention/ Early Childhood Special Education (EI/ECSE) and Communication Disorders Sciences (CDS) were the pri- mary interventionists. They received practicum course credit for participating. Across the three cohorts, a total of 12 graduate students participated in LAPE. Each parent was paired with a student who served as his or her “coach” for the duration of LAPE. The students also administered the initial assessment tests, participated in the group sessions, and led individual sessions. The first and second author, an early childhood special educator, taught the students the treatment protocol, oversaw their individual session plans, and closely supervised them during all assessment and coaching activities.
Parent Strategies
LAPE followed a family coaching approach to teach par- ents to use naturalistic language teaching strategies (see Tables 1 and 3). LAPE strategies were chosen because they were empirically supported, easily embedded into daily routines, and appropriate given the needs of toddlers. Moreover, several studies have demonstrated parents can
Table 2. Child Demographic Characteristics.
PLS-IVb VABS-IIc
Dyad Disability statusa Chronological age (months) Race of child Other community services AC EC DLS SS Motor
1 DD 31 White/Caucasian EI toddler group 85 74 83 87 114 2 DD 31 Multiracial EI toddler group 77 69 98 89 72 3 SELD 25 White/Caucasian No other services 128 83 117 89 90 4 DD 25 White/Caucasian EI toddler group 81 79 105 95 111 5 SD 32 White/Caucasian SLP services 81 77 95 93 93 6d SD 24 White/Caucasian SLP services 81 (67) 96 (79) 77 82 90 7e SELD 28 White/Caucasian No other services 78 73 87 78 88 8 DD 32 White/Caucasian EI toddler group 50 50 73 78 79
aDD = developmental disability; SELD = specific expressive language delay; SD = structural disability (e.g., cleft lip/palate). bPLS-IV = Preschool Language Scale (4th ed.); AC = Auditory Comprehension subtest; EC = Expressive Communication subtest. cVABS-II = Vineland Adaptive Behavior Scales (2nd ed.); DLS = Daily Living Skills domain; SS = Socialization domain; Motor = Motor Skills domain. dThis child was 7 days away from turning 24 months at the time of testing. The PLS-IV scores in parentheses are after rounding up his age to 24 months. eOnly father–child dyad.
216 Topics in Early Childhood Special Education 33(4)
implement these strategies with training and support (see Roberts & Kaiser, 2011, for a meta-analysis of this research).
Parent Training Components
LAPE consisted of three major components: group parent support sessions, individual sessions in homes, and practice in-between sessions. This was intentionally designed to give parents opportunities to interact with other parents of toddlers with communication delays; deliver content and model strategies in a supportive, cost-effective manner; dis- cuss opportunities to practice the strategies during daily routines in-between sessions; and provide individualized, routine-based coaching. The following sections describe the LAPE program components.
Group support sessions. Table 4 outlines the content of the parent support sessions. The goals of the first session were to: (a) allow the parents to meet and learn more about each other, (b) introduce basic communication and play concepts (e.g., early language and play milestones), and (c) help par- ents identify their toddler’s current communication skills. Parents also worked individual with their coaches to iden- tify goals for their toddlers and themselves. For example,
toddler goals included: “[Child] will use 25 new words by the end of LAPE.” Examples of parent goals were “I will learn the best strategies to use,” and “I will get tips to help my child talk.”
Subsequent group sessions started with a group discus- sion about progress. Each parent reported on her toddler’s progress and how she was utilizing previously taught strate- gies at home (not included in the second session). The first author encouraged parents to reflect on, comment, and sup- port each other’s progress and offer suggestions as needed. Then parents were separated and met individually with their coaches to more specifically discuss and document progress at home. After the individual coaching activity, the first author provided an overview of new strategies (see Table 4). Parents also met individually with coaches at the end of every session to plan their use of the strategies at home (new and previously taught).
Individual sessions. Each family also received individual ses- sions in their home 2 to 3 times during their participation in LAPE (see Table 4). The coaches used the family coaching strategies described in Table 1. During the first home ses- sion, parents and coaches watched the parent−toddler video sample collected prior to intervention and rated the parent’s use of each of the LAPE strategies already introduced in the
Table 3. LAPE Strategies and Dependent Variables.
LAPE strategy/description Corresponding dependent variable
Wait and respond. Wait for your child to communicate and then respond accordingly.
Responsivity (RE) = Number of times the adult responded to child’s words or actions / Number of spoken adult turns
Talk in short, simple sentences. When talking directly to your child, use sentences your child would be likely to say.
Target Level Talk (TLT) = Number of utterances spoken by the adult within 1–3 words of child’s identified MLU / Number of spoken adult utterances
Answer instead of asking. Avoid asking yes/no and “test” questions (e.g., What color is this? How many do you have?).
Questions (Q) = Number of adult yes/no questions + test questions / Number of spoken adult utterances
Repeat and add. When your child says a word or sentence, repeat what s/he said and add a word.
Expansions (EXP) = Number of times the adult expanded child’s utterance by adding a new and related word, phoneme, or grammatical marker.
Do what your child does and talk about it. Imitate your child’s actions, and say what s/he would say.
Verbal Mapping (VM) = Number of times the adult imitated child’s nonverbal action and added a word or sentence.
Say what your child would say. Respond to your child’s spontaneous requests/comments by saying the word/words your child might say in a way that encourages/prompts her/him to imitate you.
Incidental Teaching (IT) = Number of times the adult responded to the child’s communication attempt by saying a word the child might say and Model (M) = Number of times the adult modeled the name of an object or action with the intention that the child would imitate it.
Give your child a choice. Say the words for the items as you provide choices, such as “do you want milk or juice?”
Forced Choice (FC) = number of times the adult verbally gave a choice between 2 or more objects.
Environmental Arrangement. Give your child more opportunities to communicate by setting up situations where your child wants/needs to (e.g., Ask for more of something, Seek your assistance, Comment on something new or silly).
These were not coded, but were designed to create opportunities for communicative interactions and promote the child’s initiations.
Note. Due to low frequency of occurrence, the following related variables were combined into one variable, titled other language-enhancing behaviors (O-LEBs) = EXP + VM + IT + FC + M / Number of total spoken adult utterances. LAPE = Language and Play Everyday.
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group sessions. Based on this discussion, the parent chose two strategies to focus on during the remainder of the visit (e.g., say what your child would say, target level talk). The coach and parent discussed the strategies and the coach modeled use of the strategies. Then, the parent initiated a routine (e.g., mealtime, diapering) or a play activity (e.g., book reading, playing with toys) with their toddler and practiced the strategies for 5 to 10 min. Following the activ- ity, the coach encouraged the parent to self-reflect on her or his use of the targeted strategies. For example, the coach might have asked the parent to talk about what went well during the routine and what was difficult. Then, the coach provided specific, performance-based feedback (e.g., “When you used just two words to say “hat on” he imitated you!” or “Wow. You were really responsive when he walked into the playroom. You followed and resumed your play there.” Or “When you waited for her to initiate pulling on her pants, she said ‘help’!”). At the beginning of each subsequent visit, the coach and parent had a general discus- sion about the child’s language progress and his or her use of the LAPE strategies at home. The parent then identified
two strategies (previously learned in group sessions) to focus on during the visit, practiced the strategies, reflected, and received feedback (as described above). Before the end of the visit, the coach and parent set up a plan for practicing all LAPE strategies during the family’s daily routines at home.
In-between session practice. As previously mentioned, at the end of each group and individual session, the parents identi- fied when and how they planned to practice the LAPE strat- egies at home and wrote their ideas on a weekly LAPE strategy log. After the first home coaching session, parents were asked to practice the strategies 15 min per day during routine and play activities with their children and rate their progress on their weekly logs.
Evaluation Procedures
Toddler standardized measures. To fully describe the partici- pants before intervention, two assessments were adminis- tered with each toddler (see Table 2). The Preschool
Table 4. LAPE Parent Group Session Content.
Sessiona New content Method Review from previous session Method
1 Introductions Group Overview / Schedule
Group activity
Review CDI-II and sound repertoire results
Individual review with coach
Language and play milestones
Group discussion
Identify how your child communicates
Individual activity with group discussion
Identify parent and child goals
Individual discussion with coach
2 Defining and identifying home routines (play, social, and daily)
Group discussion then individual discussion with coach)
Discuss home play observations Group discussion
Responsive strategies Group discussion, video examples, role-play
Confirm parent and child goals Individual discussion with coach
3 Teaching new vocabulary through responsive strategies
Group discussion, individual planning with coach
Discuss child progress, homework, and use of responsive strategies at home
Group discussion and then individual discussion with coach
4 Environmental arrangement strategies
Group discussion, modeling with classroom examples, individual discussion and planning with coach
Discuss child progress, homework, and use of responsive strategies at home
Group discussion and then individual discussion with coach
5 Modeling Group discussion, modeling, role- play, individual discussion with coaches
Discuss child progress, homework, and use of responsive strategies, environmental arrangement strategies at home
Group discussion and then individual discussion with coach
6 Individual conferences to review child and parent progress and make recommendationsb
Note. LAPE = Language and Play Everyday. aFidelity was measured using group session checklists for each session. bCovered in final individual session for Cohort 3.
218 Topics in Early Childhood Special Education 33(4)
Language Scale 4th edition (PLS-4; Zimmerman, Steiner, & Pond, 2002) was administered to measure the child’s receptive and expressive language. The Vineland Adaptive Behavior Scales (VABS-II; Sparrow, Cicchetti, & Balla, 2005) was completed through parent interview and was used to measure the child’s daily living, social, and motor skills. In addition, the parent-completed CDI-2 measured the child’s verbal vocabulary and was used as part of the inclusion criteria and as an outcome measure.
Play and routine observations. Toddler and parent progress was measured using summative and formative measures. Prior to the start of LAPE each parent−child dyad partici- pated in two videotaped samples in their homes (collected on the same day). During a 10-min play sample, parents played with their toddlers using a standard set of toys pro- vided by the authors. The toys included dolls, cups, plates, books, blocks, and games (e.g., Mr. Potato HeadTM). In a 10-min routine sample, parents interacted with their chil- dren during a parent-identified routine. Parents selected mealtime, diapering, dressing, or getting ready for bed. During pre-LAPE observations, parents were instructed to interact with their children using any strategies they nor- mally use to encourage their children to communicate. The same play and routine activities were videotaped again immediately after LAPE (i.e., post) and at a 3-month follow-up. During these sessions, parents were instructed to use LAPE strategies. Five graduate students transcribed and coded all videos after establishing 90% interobserver agree- ment (IOA) on nonstudy videos. Four parent variables were coded: (a) responsivity (RE), (b) target level talk (TLT), (c) questions (Q), and (d) other language-enhancing behaviors (O-LEBs). These are described in Table 3. Two child vari- ables were calculated: (a) mean length of utterance (MLU; mean number of words per child utterance) and (b) initia- tions (see Table 6).
Progress monitoring. Parents monitored their use of the LAPE strategies and progress toward self-selected goals. As described previously, the parents completed a respon- sivity log every week. If a parent did not bring a completed log with them to a group or individual session, the coach asked the parent to complete it before the group session began. During group and individual sessions, the parents reviewed their progress as reflected on their log, and dis- cussed with their coaches the progress toward their self- selected goals. Following intervention, parents also completed the LAPE Goal Questionnaire, which asked them to indicate whether LAPE helped them meet their goals for themselves and their children.
Interobserver agreement. Twenty-eight (58%) randomly selected play and routine session videos (i.e., including at least 20% of videos across dyads, sessions, time) were
independently coded by a second coder to calculate interob- server agreement (IOA). IOA was calculated using the point-by-point method (Kennedy, 2005). IOA averaged 90.7% (82.0%–96.6%) across dyads, sessions, behaviors, and time.
Fidelity. The authors measured implementation fidelity and intervention fidelity. Implementation fidelity refers to the procedures used to support the parents’ use of LAPE strate- gies; intervention fidelity refers to the parents’ use of indi- vidual strategies with their toddlers (Dunst et al., 2008b). Implementation fidelity was collected in three ways. First, a checklist was created for the group sessions outlining the planned components of the sessions (e.g., “discuss parent and child progress at home,” “review the strategy Repeat and Add”). Students (who were not presenting or coaching) used the checklist designed for LAPE group sessions to measure implementation fidelity of every group session. This ensured the group training components were similar across cohorts. The number of planned components for group sessions ranged from 5 to 12. The group session implementation fidelity averaged 93.6% (range = 78%– 100%) across sessions and cohorts. Second, the first or sec- ond author completed fidelity checklists at all individual sessions. These outlined the planned components of indi- vidual sessions to ensure the coaches conducted these ses- sions as planned and that they were similar across dyads. The number of planned components for individual sessions ranged from 9 to 12. The individual sessions implementa- tion fidelity averaged 90.42% (range = 77%–100%) across sessions, dyads, and cohorts. Occasionally a parent would want to spend extra time working on a specific strategy or a routine was cut short, and the coach would decide to skip or spend less time on a component. Thus, the implementation fidelity indicated coaches completed most of the planned components, but were flexible and responsive to parent and toddler needs (McWilliam, 2012). Third, attendance was recorded at all group sessions. Two parents missed one group session each, and missed content was reviewed dur- ing a make-up session. Intervention fidelity was measured using a weekly review of the parent-completed responsivity log. All eight parents reported consistently using the LAPE strategies at home.
Social validity. Social validity was measured in two ways. First, parent satisfaction with the group trainings was mea- sured after each group session with an anonymous ques- tionnaire. These ratings were consistently high. Second, at the end of LAPE parents rated their satisfaction with the goals, procedures, and outcomes with an anonymous social validity questionnaire. The overall mean for the nine items on the questionnaire was 5.32 (i.e., the scale ranged from 1 = strongly disagree to 6 = strongly agree), which signi- fied strong social validity. Parents indicated LAPE was
Moore et al. 219
effective for increasing their children’s communication skills across daily routines (M = 5.14) and during play inter- actions (M = 5.21). Moreover, they reported using LAPE strategies outside of the home (M = 4.64) and stated that they would recommend the LAPE program to other parents with toddlers with communication delays (M = 5.86).
Program Outcomes
Multiple measures were used to evaluate parent and child outcomes from LAPE. Initially, outcome analyses were
conducted by cohort. However, there were no differences identified across cohorts. Thus, given the small number of dyads, outcomes were analyzed individually and are pre- sented as such in the subsequent sections (see Tables 5 and 6).
Parent Outcomes
Responsivity (RE). Parents demonstrated variability in RE during pre-LAPE observations, and seven parents increased their RE following intervention. In general, parents were
Table 5. Parent Outcomes by Variable.
Pre Post Follow-up
Dyad Behavior Play Routine Play Routine Play Routine
1 RE 49.4 29.4 69.0 64.5 62.2 55.4 TLT 64.4 72.6 93.9 91.9 94.0 89.0 Q 35.6 22.1 13.7 12.6 17.9 23.3 O-LEBs 4.0 2.1 24.4 24.3 16.3 7.5 2 RE 39.4 39.2 67.0 56.0 53.8 57.0 TLT 63.6 65.1 72.0 73.0 93.3 89.9 Q 15.5 16.8 7.0 10.7 8.9 13.5 O-LEBs 8.6 8.7 15.9 8.7 24.4 10.1 3 RE 53.2 43.3 70.8 53.4 63.2 50.9 TLT 55.3 33.8 95.4 78.1 84.6 66.7 Q 39.4 36.6 5.8 8.2 3.9 17.5 O-LEBs 10.1 7.0 27.6 30.1 5.1 14.0 4 RE 50.3 55.8 77.7 43.0 57.4 48.5 TLT 62.0 60.0 95.4 80.5 89.8 77.2 Q 27.7 26.2 8.3 17.0 20.5 15.0 O-LEBs 22.9 6.9 52.8 13.6 6.3 9.5 5 RE 58.9 53.4 63.8 58.8 62.7 65.4 TLT 66.9 70.5 95.7 79.9 78.4 64.4 Q 43.0 31.6 10.6 6.9 16.8 28.2 O-LEBs 5.0 6.0 16.5 12.6 13.5 12.2 6 RE 42.6 62.0 69.5 77.7 77.3 63.4 TLT 71.3 61.8 86.8 77.7 93.5 78.0 Q 22.1 32.0 3.5 22.3 4.7 13.4 O-LEBs 6.6 13.4 21.1 8.5 8.4 3.7 7 RE 51.9 31.5 82.0 39.1 76.9 42.2 TLT 38.4 35.2 86.4 44.5 88.7 54.4 Q 45.0 16.7 15.3 4.7 13.0 17.7 O-LEBs 17.2 1.8 24.6 11.4 28.7 10.9 8 RE 28.8 29.7 44.0 36.0 57.0 35.5 TLT 95.0 96.2 98.4 97.5 97.6 91.5 Q 35.7 18.4 20.8 12.2 26.2 17.0 O-LEBs 4.0 5.0 29.6 16.3 6.2 10.3 Group M (SD) 46.9 (9.4) 42.8 (12.8) 68.0 (11.3) 53.6 (14.0) 63.8 (8.8) 52.2 (10.2) 64.6 (15.8) 61.9 (20.3) 90.5 (8.6) 77.9 (15.7) 90.0 (6.1) 76.4 (13.6) 33.0 (10.4) 25.1 (7.7) 10.6 (5.7) 11.8 (5.7) 14.9 (7.8) 18.2 (5.1) 9.8 (6.9) 6.4 (3.7) 26.6 (11.7) 15.7 (7.7) 13.6 (9.0) 9.8 (3.1)
Note. RE = Responsivity: Percentage of spoken adult turns; TLT = target level talk: Percentage of total adult utterances; Q = question asking: Percent- age of total adult utterances; O-LEBs = other language-enhancing behaviors: Percentage of total adult utterances.
220 Topics in Early Childhood Special Education 33(4)
more RE during play than in routines. However, at 3-month follow-up only two parents continued to improve RE; five did not maintain postintervention levels.
Target Level Talk (TLT). Parents demonstrated variability during pre-LAPE observations in their TLT (i.e., the per- centage of utterances within their child’s MLU). All eight parents improved their use of TLT in play and routine activ- ities following LAPE, and parents consistently used more TLT during play. Overall, parents maintained their use of TLT at 3-month follow-up.
Questions (Q). Parents demonstrated a high percentage of Q pre-LAPE. All eight parents decreased their use of Q fol- lowing intervention and used fewer Q during play than in routines. However, at follow-up, none of the eight parents maintained these decreases during routines. Four of the eight parents maintained the decreases during play.
Other Language-Enhancing Behaviors (O-LEB). Parents dem- onstrated variability during pre-LAPE observations in their use of O-LEB. All participants increased their use of O-LEB following intervention; the greatest increase occurred dur- ing play. However, none of the eight parents maintained these increases during routines. Three parents maintained their increased use of O-LEB during play.
Parent Self-Progress Monitoring
As mentioned previously, all parents reported consistently using the LAPE strategies at home on a weekly log.
Results of the LAPE Goals Questionnaire indicated that out of 27 LAPE goals written by the parents, 25 were met, and 2 were not addressed because they were speech production goals.
Child Outcomes
All children increased their vocabulary following LAPE and at follow-up, as reported by parents on the CDI-II. As expected, progress varied by disability group. Children with Specific Expressive Language Delays (n = 2) gained the greatest number of words (M = 502 words, range = 501–502); children with Developmental Delays (n = 4) gained the fewest number of words (M = 130 words, range = 33–194). Likewise, all children increased their mean number of words per utter- ance (MLU) postintervention and at follow-up. Overall, chil- dren started at a mean of 0.9 during play and 1.0 during routines and by follow-up were at 1.7 for play and 1.5 for routines. The average MLU for typically developing toddlers (age 18–36 months) is 1.8 to 3.1 (Paul & Norbury, 2011). The children varied in their use of communicative initiations prior to the start of LAPE with a larger range of initiation in the routine samples than the play samples. All children increased their use of initiations post-LAPE. However, at follow-up, children increased their use of initiations during play but not routines.
Discussion
This project was designed to evaluate the effectiveness of a community-based parent education program: LAPE. The
Table 6. Child Outcomes by Variable.
MLUd in play Percent child initiationse
CDIb-II—Number of
words Pre Post F Pre Post F
Dyad Disability statusa Pre Post Fc Play Rout Play Rout Play Rout Play Rout Play Rout Play Rout
1 DD 47 101 205 1.0 1.0 1.3 1.4 1.4 1.3 21.8 48.4 46.1 56.6 38.5 32.7 2 DD 12 35 56 1.0 1.0 1.2 1.0 1.1 1.1 1.3 3.3 5.2 3.5 22.7 10.2 3 SELD 39 139 541 1.0 1.0 1.3 1.4 3.6 1.9 20.9 14.3 41.9 38.2 73.9 31.8 4 DD 16 79 208 1.0 1.1 1.1 1.1 1.2 1.2 1.9 4.7 10.1 6.6 16.7 1158 5 SD 40 127 208 1.1 1.0 1.3 1.4 1.4 1.2 8.6 6.2 19.6 37.6 20.7 17.5 6 SD 11 205 501 1.0 1.0 1.1 1.1 1.9 2.4 13.0 11.3 20.4 18.3 48.4 0.0 7 SELD 14 306 515 0.0 1.0 1.3 1.2 1.2 1.7 0.0 5.0 33.3 13.0 31.5 10.6 8 DD 19 42 52 1.3 1.2 1.0 1.1 1.8 1.5 12.5 1.8 39.1 41.5 55.1 46.3 M 24.8 129.3 285 0.9 1.0 1.2 1.2 1.7 1.5 10.0 11.9 27.0 26.9 38.4 20.1 SD 14.7 90.2 203.6 0.4 0.1 0.2 0.2 0.8 0.5 8.6 15.3 15.3 19.1 19.7 15.4
aDisability status: DD = developmental disability, SELD = specific expressive language delay, SD = structural disability. bCDI = MacArthur−Bates Com- municative Development Inventory–2nd Edition (words and sentences form). cF = follow-up. dMLU = mean length of utterance (Number of words in intelligible utterances divided by total intelligible utterances). ePercent Child Initiations = percentage of child turns that are initiated by the child (i.e., intelligible and unintelligible utterances and nonverbal communicative acts initiated by the child divided by total number of child turns).
Moore et al. 221
intervention was designed based on recommended family coaching practices and incorporated empirically supported language-enhancing strategies (e.g., environmental arrange- ment, responsive interaction strategies). The effectiveness of LAPE was evaluated with multiple quantitative mea- sures. Three notable findings were identified. First, the results from LAPE are promising. The parents increased their use of language-enhancing strategies (i.e., RE, TLT, modeling) and decreased their use of question asking (which might limit child language growth) after participat- ing in LAPE. Moreover, parents were satisfied with LAPE and indicated that LAPE met most of the goals they wrote for themselves and their children. Although child progress varied substantially according to disability group, all chil- dren increased their vocabulary, MLU, and initiations. While causal relations cannot be determined based on the small sample size, lack of controls, and the developmental nature of child language, the outcomes are notable due to the relatively small dosage of intervention (i.e., 4–5 group sessions, 2–3 individual sessions; totaling 9.5 to 12 hr over 7 or 15 weeks) as compared with other similar parent- training interventions, such as Hanen—It Takes Two to Talk (i.e., 8 group sessions, 3 individual video feedback sessions, totaling 30 hr; Girolametto & Weitzman, 2006) and EMT (approximately 30 individual sessions contingent on parents meeting criterion, totaling 10 hr; Hancock & Kaiser, 2006). The current evaluation supports existing research documenting that a hybrid approach (group train- ing with individual support) might be effective for teaching parents language-enhancing strategies in a short period of time (Carter et al., 2011; Kaiser et al., 1995).
Second, with the exception of TLT, six parents did not maintain their use of LAPE strategies at the 3-month follow-up. Although RE, Q, and O-LEBs did not return to pre-LAPE levels, there was a clear decrease in use over time. Two out of three parents maintained their high levels of RE at 3-month follow-up in the third cohort, which had a longer treatment duration (same dosage), but Q and O-LEB did not maintain. Previous studies also have documented that use of language-enhancing strategies does not maintain over time without extensive follow-up coaching and sup- port (Peterson et al., 2005).
Third, parents consistently used more LAPE strategies during play than routines. Play and routines were discussed at length during the group and individual sessions and prac- ticed during individual sessions. After analyzing data from the first two cohorts, the authors decided to change the for- mat of the daily responsivity log to encourage more practice during routines and incorporated more routine examples during group and individual sessions. However, there were still no substantial differences between the cohorts. These differences might indicate that it is more difficult to embed language-enhancing strategies into routines, perhaps because the primary focus of the routine for the parent is
completing the routine (e.g., getting the child dressed), rather than the child’s communication skills, whereas dur- ing play parents can focus directly on teaching new com- munication skills. Parents might need more support and guidance on how to embed communication strategies into routines while still attending to the task at hand.
Limitations and Future Research
Although multiple outcome measures were utilized, causal relations between intervention and child outcomes could not be deduced. As discussed previously, LAPE was devel- oped to address a community need, so no control partici- pants were identified. Future research should experimentally examine the efficiency and effectiveness of the LAPE model as it compares with “business as usual” EI across disability groups (e.g., using a randomized wait-list control design). Moreover, there is a dearth of information on pater- nal use of language-enhancing strategies. Although only one father participated in this study, the authors anecdotally noted differences between the mothers’ and the father’s interactions with their children. As fathers take a more active parenting role and participate more in therapeutic interventions with their children, research should examine their unique interaction and communication styles.
Parents in LAPE did not maintain their use of language- enhancing strategies at 3-month follow-up. Future studies should examine practices that promote maintenance, includ- ing monthly parent support sessions, web-based supports, or individual follow-up and coaching. In fact, previous research indicates parent education group trainings are only effective when supplemented with intensive, individual supports (Carter et al., 2011; Kaiser et al., 1995). However, few cost-effective, early language intervention approaches exist that are feasible and useful for interventionists work- ing within Part C systems, and the few that do are not effec- tive for all families (Carter et al., 2011) or are not flexible enough to be implemented by a variety of EIs in authentic settings. For example, future research might examine the use of phone or web-based support as a supplement to follow-up coaching to promote parents’ maintenance of skills learned. Future studies should continue to examine feasible, effective curricula that can be implemented within the confines and limitations of the Part C service delivery systems.
Implications for Practice
LAPE is an example of a parent education program devel- oped through recommended practice guidelines and current research. LAPE was designed as a supplemental “first level of response” to provide brief, intensive help to parents of toddlers exhibiting communication delays. The following five recommendations are based on LAPE outcomes.
222 Topics in Early Childhood Special Education 33(4)
First, group training might be effective for giving par- ents information in a short period of time. Group-based pro- grams can be cost-effective and offer the support and guidance of peer-parents, which might increase engage- ment and participation. This has been shown to be true for parent education programs focused on reducing children’s challenging behaviors (McIntyre & Phaneuf, 2008). Groups should be kept small (5–6 families) and allow ample time for parents to support each other, share progress, and dis- cuss implementation of the strategies. In LAPE, the authors anecdotally noted that parents frequently supported each other during group sessions.
Second, despite the advantages of group-based parent education programs, groups alone are not effective (Kaiser et al., 1995); individual support is necessary to support fam- ilies. In LAPE, the purpose of the individual sessions was to help the parents identify which specific strategies they used well, which new strategies they wanted to start implement- ing, and how to implement them in their homes. Moreover, parent−child observations were important for making data- based decisions. Thus, individual sessions should be based on each family’s unique needs.
Third, effective family coaching practices exist and should be implemented (Powell & Dunlap, 2010). During home visits, early interventionists should build relation- ships with families, model strategies, provide multiple opportunities for practice, and give performance-based feedback that builds on the parent’s self-reflection. Video recordings should be used for demonstration, self-reflection, and performance-based feedback.
Fourth, parents should be taught to embed language- enhancing strategies during daily play and routine activities. During group and individual sessions, early interventionists should talk with parents about how they typically engage with their children and then individualize examples accord- ingly. Not all parents have the time or desire to play in tradi- tional ways (e.g., sitting on the floor with toys) with their children everyday. Instead early interventionists should dis- cuss what they are already doing (e.g., playing and talking in the car, at bath time) and which daily activities might be most conducive to teaching new communication skills, acknowledging that some home activities are more hectic and task-directed than others. Once activities are identified, early interventionists should help parents identify specific opportunities during those activities to embed the strategies and provide modeling and time for parents to practice during coaching sessions (McWilliam, 2010).
Fifth, coaching should be responsive to the family’s changing needs and the child’s language development. Early interventionists should teach milieu strategies (e.g., model) if responsive and environmental arrangement strate- gies are not producing significant outcomes for the child. For some parents, milieu strategies might promote more directive and fewer responsive behaviors. Thus, early
interventionists should teach responsive and environmental arrangement strategies first (Hancock & Kaiser, 2006).
Conclusion
The purpose of this project was to develop a parent educa- tion model focused on enhancing parent responsivity and improving the language skills of toddlers with expressive communication delays. LAPE incorporated family coach- ing and language-enhancing strategies using group and individual sessions in a relatively brief period of time (i.e., 7–15 weeks). After participating in LAPE, all parents increased their use of language-enhancing strategies and decreased their use of question asking. However, only two parents maintained these increases after 3 months. Social validity measures indicated parents were satisfied with pro- cedures, goals, and outcomes of the project. This suggests LAPE is a promising parent education program, though fur- ther refinements are needed.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was funded in part by a grant from the University of Oregon College of Education Hope Baney Fund.
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