Which statements from the speech help to develop this point? select the two correct answers.

The preschool period marks a time of transition for children. During this period, children begin to spend more time outside the home and in play-based settings with peers. By 3 years of age, many preschoolers can sit and attend for at least short intervals, and by the end of the preschool period, the typically developing child is expected to be capable of participating in group activities and attending to and following the instructions of an adult (Paul and Norbury, 2012). For the preschooler with developmental disorders, the preschool years also mark a time when clinical services are likely to move out of the home and into centers and clinics. However, parent-based programs are common during these years. The following subsections summarize the treatment modalities that make up the typical standards of care for the preschool child with speech and/or language disorders and the evidence for their efficacy.

Children with severe language disorders are likely to engage with others to accomplish a variety of communication acts, such as talking about things around them, asking questions, and expressing preferences (e.g., by saying “no”). Their language is likely to be characteristic of a younger child, with limited vocabulary and simple or immature sentences. Importantly, children with severe language disorders also are likely to understand things said to them at this lower level. If this gap in achievement persists into the early school years, these children are likely to enter school with language skills similar to those of children who are 3-4 years old. For these children, the goal of language treatment is to close this gap to the extent possible. To accomplish this goal, therapists need to promote growth in the child's implicit language knowledge base across a range of communication skills. The treatment programs for these preschool-age children (ages 3-5) are diverse and often tailored to the particular needs of the child, based on the factors described earlier in this chapter. The factors that influence language treatment programs for preschool children with language disorders fall into four general areas: (1) treatment goals, (2) mode of teaching, (3) learning context, and (4) parameters of service delivery. These factors are summarized in Box 3-3 and described in greater detail in the subsections that follow.

Selected Examples of Child-Focused Elements of Language Treatment Programs for Preschool-Age Children.

Treatment goals Several principles govern the selection of treatment goals. First, the goals are based on evidence of aspects of communication that are known to be vulnerable in children with language disorders. Second, the goals are selected to enhance the child's ability to participate in social interactions and develop precursor skills for school entry. Third, although treatment goals for children with severe language disorders may be itemized separately, they need to span comprehension, vocabulary, grammar, social communication/pragmatics, and preliteracy, and the treatment is likely to address several of these goals at once (Paul and Norbury, 2012). Finally, specific treatment goals will be based on the child's developmental readiness for learning. For instance, Fey and colleagues (2003) suggest targeting grammatical forms that are used at low frequencies and thus likely emerging in the child's system. Readiness also can be indicated by evidence that the child is able to use a language form or function when supported by adults (Schneider and Watkins, 1996).

Mode of teaching Two features are common to all of the teaching modes for preschool-age children with severe language disorders. First, an effort is made to increase the amount of language experience provided to the child. Learning theories in psychology often acknowledge that more trials in a learning task will result in better learning, and this principle also has been found to apply to language development (Hart and Risley, 1995; Huttenlocher et al., 1991; Matthews et al., 2005; Moerk, 1983). Second, an effort is made to enhance the saliency or prominence of the language target being taught to the child by increasing emphasis on or control over the placement of the target in the utterance (Dalal and Loeb, 2005; Weismer, 1997).

One instructional method, referred to as “modeling,” draws on the social learning theory that emphasizes observational learning (Bandura, 1971). With this method, the child is provided an elevated number of exemplars of a language form. In some cases, this is done in the context of high-density exposures during focused treatment sessions, while in others, it is embedded in natural conversational interactions. In both kinds of settings, modeling has been found to result in gains in the targeted language forms (Leonard et al., 2004; Nye et al., 1987; Vasilyeva et al., 2006; Weismer and Murray-Branch, 1989).

As was noted earlier, talk that encompasses semantic extensions, recasts, and expansions is also often used in preschool programs where clinicians are the agent of change. Several preschool language intervention programs emphasizing responsive language have shown evidence of effectiveness (Bunce, 1991; Dale et al., 1996; Fey et al., 1993; Justice et al., 2008).

Common to all of the above teaching modes is the fact that the child is not taught directly to express the target language. In contrast, some treatment programs place a strong emphasis on a direct form of teaching through elicited imitation. In this case, the child is instructed to imitate a word or sentence and given feedback when he or she makes an imitative attempt. A substantial literature has shown that teaching through imitation can result in improved use of the targeted language forms (Camarata et al., 1994; Connell, 1987; Connell and Stone, 1992; Nye et al., 1987). Yet while imitation is clearly effective in teaching specific targeted behaviors, generalization beyond these targets is often limited.

In summary, an array of basic patterns of language interactions with children can be used to promote language growth. For example, Law and colleagues (2004, 2008) have performed meta-analyses on the effectiveness of language interventions and concluded that treatment programs are effective for improving vocabulary with a standardized mean difference of 0.89 and mixed evidence for improvement in expressive grammar. A recent meta-analysis on the effect of recasting on improvement in grammar found a mean standardized difference of 0.96 for gains in the targeted grammatical form measures and 0.76 for generalization to untreated grammatical forms (Cleave et al., 2015). The evidence is strongest for those methods that include responsive interactions, although directive language engagement, particularly in limited amounts, can also be effective. Most language intervention programs combine several of these methods, along with a general emphasis on overall increments in the frequency of language use.

Learning context Most language intervention programs for preschool children use multiple modes of teaching. When these modes are combined, they can result in different types of learning contexts that may be clinician-centered, child-centered, or a mix of the two. The clinician-centered context is one in which the emphasis is on high rates of listening and speaking the targeted language forms within a highly structured drill-and-practice setting. The clinician controls what is said and what the child does. Paul and Norbury (2012) note that this approach has been advocated by several clinical investigators on the grounds that children with language disorders need the structure and intensity of this learning context. In contrast with clinician-centered approaches are those that are child-centered, in which the emphasis is on preserving the qualities of natural adult–child interactions, and in particular the pragmatics of conversation. The child is allowed to lead the interaction and thus the content, while the clinician follows. The hybrid approach represents a middle ground. One prominent example is incidental teaching (Hart and Risley, 1975), in which the clinician arranges the play setting to provide for talk about the targets and motivations for talking. Interjected into the play are short intervals of focused teaching that involves more directive language. Many of these services are provided in school-based settings through IDEA.

Parameters of service delivery The ways in which speech and language services are provided vary along several parameters. One such parameter is the treatment “dose,” including such variables as the duration of the treatment session, the number of sessions, and the spacing of treatment. Although one might expect that more treatment is likely to be more effective, the evidence in this regard is not clear (Schooling et al., 2010). Yoder and colleagues (2012) found that learner characteristics may interact with the influence of treatment dose and that dose effects are complex (Yoder et al., 2012).

Another important parameter of service delivery is the agent of change. For preschool children, the principal agent of change may be a speech-language clinician, a preschool teacher, or the child's parents. Comparisons of parents and clinicians as agents have shown that outcomes are largely comparable (Dale et al., 1996; Fey et al., 1993, 1997; Schooling et al., 2010). Outcomes also are comparable whether services are provided in groups or individually, and in centers and clinics or the children's homes (Schooling et al., 2010).

In summary, considerable evidence shows that clinical treatment for language disorders can improve preschool children's language abilities. However, the learning effects are greatest for those skills that are the target of intervention. The effects of treatment are less pronounced for those skills that reflect a widespread restructuring of the child's language system. As a result, the preschool child with a language disorder, particularly if the disorder is severe, is likely to continue to have the disorder by the time he or she enters school.

At the most extreme end of the continuum of severity of speech and language disorders are children who are nonspeaking. By 3 years of age, the absence of speech is indicative of some form of severe communication impairment (Whitman and Schwartz, 1985).

The speech of one-third to one-half of children with cerebral palsy is so limited that it is not functionally intelligible (Andersen et al., 2010; Himmelmann et al., 2013). Another group of children who fail to develop spoken communication are those with severe intellectual disability and/or autism. By 14 months of age, for example, most infants are able to draw the caregiver's attention to something by pointing and naming. This basic communication function is limited or absent in some children with severe intellectual disability or autism spectrum disorder. Provision of a basic functional communication system has been shown to reduce aggressive and self-injurious behavior in these children (Kurtz et al., 2003).

Such systems—termed alternative and augmentative communication systems—can be organized into two groups: those that depend on alternative body systems, such as gestures or facial expressions (unaided communication systems), and those that require some tool or equipment (aided systems) (Romski and Sevcik, 2005), ranging from a set of pictures or paper and pencil to computer-based speech-generating systems. For young children who are not literate, the most common options are those that do not require or use print. If such a child has good motor skills, an unaided system involving gesture or a picture-based system may be employed. A review of all of these systems is beyond the scope of this study, but given the focus of this report on young children with severe speech and language disorders, two systems used commonly with such children are described below.

One of the oldest alternative and augmentative communication systems entails the use of a set of pictures that are arranged on a board or placed on pages in a book (Beukelman and Mirenda, 2005). The pictures often represent basic messages that the child needs or wishes to express. For children with very limited motor abilities, the communication board can be placed on a tray attached to the child's wheelchair. As the child progresses in the use of the device, it is usually necessary to alter its content to include new messages. Furthermore, as the child's capabilities with language, print, and mobility change, other alternative and augmentative communication systems may be appropriate.

For some nonspeaking children, the absence of spoken communication is due to their lack of understanding of communication functions such as informing a listener about basic needs. Such children need to be introduced to rudimentary communication activities in the hope of not only improving their functional communication skills but also enabling their overall further progress. A common treatment program for this purpose is the picture exchange communication system (Bondy and Frost, 2001), in which the child is provided with pictures of desired objects and taught to use the pictures to request the objects from teachers or caregivers. Several studies have provided evidence that this treatment increases the number of communicative requests, although evidence that these skills generalize to other communication partners, to other communication functions, or to speech is limited at present (Flippin et al., 2010; Preston and Carter, 2009).

Preschool children who are nonspeaking because of poor language ability are likely to have lifelong needs for support, particularly if their deficits reflect severe receptive language disorders and/or other neurodevelopmental disorders. If such children develop any spoken communication skills, those skills may be quite limited. In contrast, if the basis of the communication problem is largely a limitation in speech production, and receptive language abilities are relatively unaffected, computer-based electronic communication systems are likely to be effective, and these children have a good chance of entering into regular education and mainstream society.

It is important to emphasize that for many children with severe deficits, the use of alternative and augmentative communication systems may not result in levels of communication found in typically developing children. However, if such a system can increase the child's ability to communicate five or six messages rather than one or two, the resulting gains for communicating with parents, teachers, and others may be substantial, and may prevent or resolve aggressive and self-injurious behaviors. Because of the heterogeneity in the etiology of those disorders that necessitate the use of such systems, as well as in the cognitive ability and speech and language level of affected children, much of the research on these interventions has a single-case (single-subject) design (Schlosser and Sigafoos, 2006). This literature indicates that children receiving these interventions improve in communication function, but with rare exceptions, they will not develop typical speaking ability and will continue to require alternative and augmentative systems as a primary means of communication.