• TABLE OF CONTENTS
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 Front Cover
 Preface
 Table of Contents
 Abstract
 Introduction
 Methodology
 Results
 Discussion
 Conclusion
 Acknowledgement
 Reference
 Appendix
 Tables






Title: Review of evidence-based practices for language intervention of school-age children : implications for treatment, research, and personnel preparation in sppech-language pathology
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Table of Contents
    Front Cover
        Page 1
    Preface
        Page 2
    Table of Contents
        Page 3
    Abstract
        Page 4
    Introduction
        Page 5
    Methodology
        Page 6
        Page 7
    Results
        Page 8
        Page 9
        Page 10
        Page 11
        Page 12
        Page 13
        Page 14
        Page 15
    Discussion
        Page 16
        Page 17
        Page 18
        Page 19
        Page 20
    Conclusion
        Page 21
    Acknowledgement
        Page 22
    Reference
        Page 23
        Page 24
        Page 25
        Page 26
    Appendix
        Page 27
        Page 28
        Page 29
        Page 30
        Page 31
    Tables
        Page 32
        Page 33
        Page 34
        Page 35
        Page 36
        Page 37
        Page 38
        Page 39
        Page 40
        Page 41
        Page 42
        Page 43
        Page 44
        Page 45
        Page 46
        Page 47
Full Text




Review of Evidence-Based Practices for Language Intervention of
School-Age Children: Implications for Treatment, Research, and
Personnel Preparation in Speech-Language Pathology
Prepared for the Center on Personnel Studies in Special Education






by
Frank M. Cirrin
Minneapolis Public Schools

Ron Gillam
Utah State University




October 2006
COPSSE Document No.OP-2

IDEAs
thatWork


Center on Personnel Studies in Special Education


UNIVERSITY OF FLORIDA


http://www.copsse. org


CO 'E









CENTER ON PERSONNEL STUDIES IN SPECIAL EDUCATION


UNIVERSITY OF FLORIDA

JOHNS HOPKINS UNIVERSITY

VANDERBILT UNIVERSITY

UNIVERSITY OF COLORADO -BOULDER

INSTRUCTIONAL RESEARCH GROUP, LONG BEACH, CA

COPSSE research is focused on the preparation of special education professionals and its
impact on beginning teacher quality and student outcomes. Our research is intended to inform
scholars and policymakers about advantages and disadvantages of preparation alternatives and
the effective use of public funds in addressing personnel shortages.

In addition to our authors and reviewers, many individuals and organizations have contributed
substantially to our efforts, including Drs. Erling Boe of the University of Pennsylvania and
Elaine Carlson of WESTAT. We also have benefited greatly from collaboration with the National
Clearinghouse for the Professions in Special Education, the Policymakers Partnership, and their
parent organizations, the Council for Exceptional Children and the National Association of State
Directors of Special Education.


The Center on Personnel Studies in Special Education, H325Q000002, is a cooperative
agreement between the University of Florida and the Office of Special Education Programs of
the U. S. Department of Education. The contents of this document do not necessarily reflect the
views or policies of the Department of Education, nor does mention of other organizations imply
endorsement by them.
Recommended citation:
Cirrin, F.M., & Gillam, R. (2006). Review of evidence-based practices for language intervention of
school-age children: Implications for treatment, research, and personnel preparation in
speech-language pathology. (COPSSE Document Number OP-2). Gainesville, FL:
University of Florida, Center on Personnel Studies in Special Education.
Additional Copies may be obtained from:
COPSSE Project
P.O. Box 117050
University of Florida
Gainesville, FL 32611
IDEAS 352-392-0701
thatWork 352-392-2655 (Fax)
U. S. Office of Special
Education Programs There are no copyright restrictions on this document; however,
please credit the source and support of the federal funds when
copying all or part of this document.









CONTENTS


A bstract..................................................... .................................. ............4

Introd uctio n................................................................................................ .. .5

M ethods..................... .... ............... ............... ................................................ 6

R esu lts.......................................................................................................... . ............. 8

Discussion...............................................................................................16

Conclusions.............................................................................................21

REFERENCES..........................................................................................23

Appendix A. Databases Searched and Search Terms Used................................27

Appendix B. Key Features to Consider for Evaluating the Quality of Evidence
from Individual Studies of Treatment (ASHA, 2004a)................................ ..29

Appendix C. Overview of Distinguishing Features of Evidence Levels in Proposed
Adaptation of the Oxford System for Evaluating Individual Studies of Treatment
Efficacy (Oxford Centre for Evidence-Based Medicine, 2001)..........................30

Table 1. Databases Searched and Search Terms Used......................................32

Table 2. SemanticsNocabulary/Concepts/Word-Finding.....................................34

Table 3. Phonological Awareness/Metalinguistics ............................................40

Table 4. Computer-based Language Intervention.........................................43

Table 5. Pragmatics/Conversation/Discourse/Narratives.....................................46









ABSTRACT

This systematic review focused on peer-reviewed articles published in the past 20 years that
assessed the outcomes of language therapy for school-age students with language disorders. The
purposes are: (a) to identify effective language intervention practices used by Speech-Language
Pathologists [SLPs] that lead to positive outcomes for school-age children with language
disorders; (b) to identify gaps in the evidence base and areas in need of further research; and (c)
to discuss implications for personnel preparation based on what is known about effective
practices for language intervention in schools.

A computer search of electronic databases and hand searches of other sources revealed 19 studies
that used experimental designs of the type that are generally considered to be reliable and valid:
randomized clinical trials, systematic reviews, non-randomized comparison studies, and single-
subject design studies. The studies that meet our criteria for inclusion were grouped into the
general areas of Syntax/Morphology, Semantics/Vocabulary/Concepts, Phonological Awareness/
Metalinguistics, Computer-based Language Intervention, and Pragmatics/Conversation/
Discourse/Narratives.

This review revealed relatively few studies of the effectiveness of language intervention
practices with school-age children over the past 20 years. In addition, 11 of the 19 studies we
found limited participants to children in kindergarten and first grade, and no studies were located
that looked at students with language disorders in middle grades or in high school.

We conclude that the effectiveness of many language intervention practices that are currently
being used with school-age children with language disorders has not been directly tested. We
outline specific areas where there are significant gaps in the evidence and discuss the
implications of evidence-based practices for personnel preparation in Speech-Language
Pathology [SLP].









INTRODUCTION

As part of the current climate of accountability in our nation's schools, Speech-Language
Pathologists [SLPs] face increasing mandates to use instructional methods that have
demonstrated effectiveness and efficiency and to apply evidence-based practice [EBP] when
making assessment and intervention decisions (Individuals with Disabilities Education Act
[IDEA], 2004). New graduates from personnel preparation programs who serve school-age
children must be well prepared to apply EBP to clinical decision making when they are
employed in schools. This requires that they begin their careers with knowledge of evaluation
and intervention techniques that are supported by scientific evidence. EBP has been defined as
"the conscientious, explicit, and judicious use of current best evidence in making decisions about
the care of individual patients... [by] integrating individual expertise with the best available
external clinical evidence from systematic research" (Sackett, Rosenberg, Gray, Haynes, &
Richardson, 1996, p. 71). The American Speech-Language-Hearing Association [ASHA] has
conceptualized the goal of EBP as the integration of (a) clinical expertise, (b) best current
evidence, and (c) client values to provide high-quality services that reflect the values, needs, and
choices of students and families served by SLPs (ASHA, 2004a). Readers are referred to
ASHA's position paper and technical report on EBP (ASHA, 2005a, 2005b) for further
information on EBP in the discipline of Speech-Language Pathology [SLP].

SLPs working in the schools provide services to students from every disability category in the
Individuals with Disabilities Education Act (2004) presenting with a wide range of speech and
language disorders (ASHA, 2004b). A review of the research examining intervention for all
these disability groups and speech and language disorders would far exceed the scope of this
project. Therefore, this review focuses on experimental research on the effectiveness of language
therapy provided in school settings to students with language disorders. These students make up
the largest subgroup of students with communication disorders who receive intervention services
from SLPs in schools (ASHA, 2004b). Children with language disorders, often referred to as
having a specific language impairment or a language-learning disability (Paul, 2001), are a
heterogeneous group who have difficulty acquiring, comprehending, and/or expressing
themselves with spoken and/or written language. These children may have difficulties in one or
more aspects of language, including phonology, semantics, grammatical morphology, complex
syntax, and/or pragmatics. Many of these children present problems in information processing
skills related to attention, speech perception, working memory, and phonological awareness.
Their difficulties with learning and using language place them at significant risk for social and
academic problems throughout the school-age years and into young adulthood.

To provide effective services to school-age children with language disorders, practicing
clinicians and students in university training programs need a strong background in language
intervention strategies that have been demonstrated to be effective. The purposes of this paper
are: (a) to identify effective language intervention practices used by SLPs that lead to positive
outcomes for school-age children with language disorders, (b) to identify gaps in the evidence
base and areas in need of further research, and (c) to discuss implications for personnel
preparation based on what is known about effective practices for language intervention in
schools.









METHODS

1. This systematic review focuses on peer-reviewed articles published in the past 20 years
that assessed the outcomes of language therapy for school-age students with language
disorders. A systematic review, which is a formal assessment of a body of scientific
evidence related to a clinical question, describes the extent to which various diagnostic or
treatment approaches are supported by the evidence but stops short of making specific
recommendations for clinical practice (ASHA, 2004a). Computer searches of electronic
databases were conducted to locate appropriate studies. These databases and search terms
used are presented in Appendix A. In addition, the Bamford-Lahey Children's
Foundation (2004) database on EBP in child language disorders and the following
journals were searched to locate relevant literature: Language, Speech, and Hearing
Services in Schools; Journal of Speech, Language, and Hearing Research; and American
Journal of Speech-Language Pathology. We also examined the reference lists in the
studies that were identified in our search for articles that we may have missed. Searches
of other sources of the literature (e.g., Dissertation Abstracts International and textbooks)
and searches for unpublished studies and presentations were not conducted; thus, the
conclusions based on this review should be considered tentative. We reviewed all studies
that met the following selection criteria:

2. Studies had to focus on experimental measures of the effectiveness of language
intervention practices for students with language disorders. Descriptions of language
intervention programs without objective measures of treatment effectiveness were not
included.

3. Studies had to include school-age students with language disorders as a primary
disability. To be considered school-age, students had to be in kindergarten through 12th
grade and/or over the typical age for kindergarten entry (over 5 years). Studies on
language intervention with preschool children (under the age of 5) with specific language
impairments were not included in this review because of our focus on school-age students
and constraints on time and resources. Further discussion of the implications of this
decision appears below. Neither were studies of language intervention (e.g., vocabulary,
linguistic concepts) with "at risk" students (without identified language disabilities) in
general education settings included. Studies of students with language disorders related to
autism spectrum disorders (ASD) and to cognitive disabilities or general developmental
delays were not included in this review because comprehensive reviews of this literature
have already been published. Readers are referred to Goldstein (2002) for a systematic
review of language intervention studies for students with ASD and to Sigafoos and
Drasgow (2003) for a review of studies of language intervention for students with
cognitive disabilities.

4. Studies had to be one of the following design types: Level 1 (which includes randomized
clinical trials [RCTs] and systematic reviews of RCTs); or Level 2 (which includes
nonrandomized comparison studies and single-subject design studies). In a study that
uses a Level 1 design, the investigator actively compares two different treatment
conditions that he or she has created by randomly assigning participants to conditions.

^^^^ ^^^ ^^^^ ^^^ ^^^ ^^^^ ^^^ ^^^ ^^^^ ^^^ ^^- ^^^^ ^^^ ^^^^ ^^^ ^^^ ^^^^ ^^^ ^^^ ^^^^ ^ 1 --









Level 2 studies include comparisons of treatment groups when investigators did not use
random assignment. Most researchers in SLP also include multiple-baseline, single-
subject design studies in Level 2. We limited our review to Type 1 and Type 2 studies
because these yield data generally considered to be reliable and valid. Further
descriptions of research design characteristics and an overview of levels of an evidence
system for evaluating individual studies of treatment efficacy are presented in
Appendices B and C.

5. Studies had to be published between 1985 and 2005 in peer-reviewed journals.

6. Studies that had reading/writing skills as intervention targets as the main focus were not
included. Studies on the production or comprehension of written/read vocabulary were
not included.

Effect size is a method of quantifying the effectiveness of a particular intervention relative to
some comparison intervention (i.e., quantifies the size of the difference between two groups)[see
Schuele & Justice (2006) for a tutorial on the interpretation of effect size]. We calculated and
reported effect sizes when sufficient data (i.e., pretest and posttest means and standard
deviations) were provided for group and single-subject designs. Group effects were calculated
using Cohen's d, in which effect size=M (posttest score of the experimental group) M (posttest
score of the control group)/pooled standard deviation. Effect sizes were computed using the
following on-line effect size calculators: www.cemcentre.org/ebeuk/research/effectsize/
Calculator.htm and web.uccs.edu/lbecker/Psy590/escalc3.htm. With this method, an effect size
of 0.2 is considered small, 0.5 is medium, and 0.8 or greater is large (Cohen, 1988). Effect sizes
for single-subject designs (in which a single child's performance is compared over one or more
baseline periods with treatment periods) were calculated by computing the percentage of non-
overlapping data (the percentage of data points during the treatment phase that are higher than
the most positive data point for the baseline period). With this method, higher percentages of
non-overlapping data indicate stronger effects: 90%=very high; 70%-90%=moderate; 50%-
70%=mildly effective or questionable; <50% = ineffective.









RESULTS

A total of 19 studies that met the five criteria were located and reviewed.

Tables 1-5 provide a summary of the language intervention studies reviewed in this paper
according to the specific aspects of language that were the target of the intervention or, in the
case of computer-based intervention, the general intervention approach used:

Table 1 Syntax/Morphology (2 studies)
Table 2 Semantics/Vocabulary/Concepts/Word Finding (6 studies)
Table 3 Phonological Awareness/Metalinguistics (4 studies)
Table 4 Computer-Based Language Intervention (5 studies)
Table 5 -Pragmatics/Conversation/Discourse/Narratives (2 studies).

These five language categories are somewhat broad, so we grouped studies (i.e., treatment
targets) into these general domains to aid interpretation of our results. We have attempted to
offset the heterogeneity of the treatment targets in each category by describing the actual
language targets taught in these intervention programs in the tables and in the text.

Each table includes authors, publication title, and date of the study [col. 1]; study participants,
sample sizes, ages, primary disability, location or class placement of the study, and service
provider [col. 2]; research design, treatment targets, therapy methods [col. 3]; major findings,
including any effect sizes [col. 4].

Syntax and Morphology

Our search yielded two studies of interventions designed to treat aspects of syntax and
morphology in school-age children. See Table 1. One study was a nonrandomized comparison of
experimental and control groups (Connell & Stone, 1992); and one study was a multiple-
baseline, single-subject design (Weismer & Murray-Branch, 1989). A total of 36 students with
specific language impairments participated; all participants were under age 6 yrs 11 mo and
presumed to be enrolled in kindergarten or first grade. Three of four participants in the single-
subject study had expressive disorders, and the fourth had both receptive and expressive
language disorders. The type of language disorder was not described for the 32 participants in the
group comparison study.

Treatment targets in the Weismer and Murray-Branch study varied as each participant had
different grammatical targets as per a language evaluation. Thus, participant A's targets were
present progressive -ing, 3rd person singular -s, auxiliary "be" forms, and copula "be" forms;
participant B's were regular & irregular past tense, nominative case pronouns, and auxiliary
inversion for questions; participant C's were articles, present progressive -ing, 3rd person
singular -s, auxiliary "be" forms, and copula "be" forms; participant D's targets were articles,
present progressive -ing, auxiliary "be" forms, copula "be" forms, and prepositions (in, to, at).
Treatment targets in the Connell and Stone study were investigator-designed invented
morphemes: one of four suffixes attached to concrete nouns capable of being represented by


S0









pictures, to indicate one of the following meanings (large/small, whole/part, whole/broken) (e.g.,
"TVum" to indicate a broken TV).

The single-subject study (Weismer & Murray-Branch, 1989) assessed participants' production of
individualized grammatical targets after intervention consisting of adult models of targets and
intervention that included models plus training stimuli structured to evoke child productions of
target forms. The group comparison study (Connell & Stone, 1992) assessed students'
production and comprehension of novel morphemes after treatment that presented adult models
and treatment that included models plus a direction for the participant to imitate the target
morpheme. The results of both studies indicated improved performance on language measures
following all therapy methods (modeling, modeling plus evoked production, imitation); and all
therapy methods appeared to be equally effective for the majority of participants.

The effect sizes of the comparisons between baseline and treatment phases in the Weismer and
Murray-Branch study varied between "ineffective" (for the participant with mixed expressive
and receptive disorder) and "large" (for participants with expressive disorder only). Effect sizes
were not reported for the nonrandomized treatment comparison study (Connell & Stone, 1992)
and could not be calculated because pretest and posttest scores were not reported.

The main limitations of research on intervention for syntax or morphological problems are the
lack of a sufficient number of studies with school-age children and a lack of any Level 1
evidence to guide SLPs' clinical decisions about treating this common language problem. We
found no studies on intervention for grammar in participants over 7 years of age and no studies
that taught what clinicians regard as "complex syntax" (e.g., complex sentences, elaborated noun
phrases, etc.) necessary to function in school settings. The intervention procedures that have been
reported in the literature are limited to modeling, evoked production, and imitation. We were not
able to find any studies on the effect of different service delivery models on the grammatical
skills of students with language disorders or studies that examined generalization of skills
learned in therapy to classroom curriculum performance.

Semantics, Vocabulary, Concepts, and Word Finding

Our search yielded six studies of interventions designed to treat aspects of semantics,
vocabulary, concepts, and word finding in school-age children. See Table 2. All six studies
were nonrandomized comparison studies. One study directly assessed the effects of different
service delivery models on classroom vocabulary acquisition (Throneburg, Calvert, Sturm,
Paramboukas, & Paul, 2000); one study examined the effects of stimulus presentation rate and
other cues on the acquisition of novel vocabulary words (Weismer & Hesketh, 1993); one study
assessed expressive and receptive standardized vocabulary test outcomes as a result of two
reading feedback strategies (Crowe, 2003); one study examined the effects of direct instruction
on a verbal analogies test (Masterson & Perrey, 1999); and two studies assessed the effects of
treatment on students' word-finding skills (naming and recall) (McGregor & Leonard, 1989;
Wing, 1990). A total of 65 students classified as having specific language impairment
participated; 28 of these students were between ages 8 and 14 and the rest were under 7 years
old. Grade levels of the participants were not specified in most studies.









Treatment targets in McGregor and Leonard's study were investigator-designed elaboration
strategies (to provide the child with a richer knowledge of target words) and retrieval strategies
(to teach the child to use information already known about target words) thought to aid word
retrieval. These were taught via a set of 120 concrete nouns capable of being represented by
pictures.. Treatment targets in Wing's study were investigator-designed semantic or phonological
strategies thought to aid word retrieval and taught via a set of vocabulary items similar to but not
duplicating items on the Test of Word Finding. Treatment targets in Masterson and Perrey's
study, which were investigator-designed mediated learning and bridging strategies thought to aid
in analogical reasoning (verbal analogy performance), were taught via a set of verbal analogies
from five categories (synonyms, antonyms, function, linear order, and category membership).
Treatment targets in Crowe's study were investigator-designed traditional reading decoding
strategies or meaning-based Communicative Reading Strategies thought to aid oral language
performance (e.g., receptive and expressive vocabulary performance). Throneburg et al.'s
treatment targets were the meanings of a set of 60 vocabulary words from each classroom's
general education curriculum. Finally, the treatment targets used by Weismer and Hesketh were
the meanings of a set of nine investigator-designed novel words (one-syllable,
consonant/vowel/consonant forms with early developing sounds) representing either object
labels or locatives.

Language outcomes were measured by normed tests such as the Test of Word Finding (TWF)
and the Comprehensive Receptive and Expressive Vocabulary Test (CREVT), or unpublished
vocabulary, verbal analogy, naming, or recall tasks. The results of all six studies indicated
improved performance on language measures following treatment, even though the results of
several studies were somewhat equivocal. The Throneburg et al. (2000) study yielded similar
improvements on the language measures for children who received vocabulary intervention
through collaborative, classroom-based, and traditional pullout service delivery models, even
though treatment effects were largest for collaborative and classroom-based models. Crowe's
(2000) study indicated that participants' expressive CREVT scores improved more than those in
the control and traditional decoding feedback groups, but the posttest performance of all groups
on receptive and general vocabulary measures was worse than pretest performance. Direct
instruction had positive effects on students' performance on a verbal analogies test over a control
group (Masterson & Perrey, 1999). Intervention for word-finding problems improved the naming
and recall performance of participants over controls, but data did not indicate which of two
treatment strategies was more effective (McGregor & Leonard, 1989); scores of participants on
the TWF increased significantly after a phonologically based treatment strategy but not after a
semantic-based treatment (Wing, 1990).

The effect sizes of the comparisons between protests and posttests for four studies ranged
between moderate (Crowe, 2003; Wing, 1990) and large (Masterson & Perrey, 1999; Throneburg
et al., 2000). Effect sizes were not reported for one study on word finding (McGregor &
Leonard, 1989) could not be calculated for a study on the effects of prosodic and gestural cues on
novel word acquisition (Weismer & Hesketh, 1993) because means and standard deviations were
not provided.

There are relatively few studies on semantic, vocabulary, concept, and word-finding
interventions and no Level 1 evidence. The studies report good outcomes and relatively large

1 in









treatment effects for children with language impairments who receive intervention that targets
vocabulary and analogical reasoning. Only one study examined the effects of different service
delivery models on students' ability to learn vocabulary from the curriculum. Until the research
base expands and confirms the effectiveness of intervention programs for older students with
semantic and vocabulary problems, clinicians working in school settings will need to select
intervention procedures carefully and monitor students' progress on a regular and frequent basis.

Phonological Awareness and Metalinguistics

Our search yielded four studies of the effects of phonological awareness instruction with school-
age children with language impairments. See Table 3. All four studies were Level 2
nonrandomized comparisons of experimental and control groups or cohort studies. The
experimental groups received training in various combinations of rhyming, phoneme
identification, phonological segmentation, phoneme blending, and sound-symbol
correspondence. The treatment was provided within classrooms in one study (van Kleeck,
Gillam, & McFadden, 1998). The other three studies provided treatment in pullout sessions.
Phonological gains were measured by researcher-created tests. In the two articles by Gillon
(2000, 2002), reading gains were measured by performance on standardized tests. The number of
participants in the studies varied between 3 (Blischak, Shah, Lombardino, & Chiarella, 2004)
and 91 (Gillon, 2000). All participants had speech and language disorders and ranged in age
between 5 and 10 years. We excluded a number of other studies of phonological awareness
intervention that were conducted on children with reading disorders or dyslexia rather than
children with language impairments or did not employ Level 1 or Level 2 research designs.

Treatment targets in the van Kleeck et al. (1998) study focused on rhyming and phoneme
awareness. The rhyming targets included rhyme recognition, rhyme identification, rhyme
judgment, and rhyme generation. The phoneme awareness targets included matching initial
sounds, identifying initial sounds, generating words that begin with target sounds, sound
blending, and sound analysis. Gillon (2000, 2002) studied phonological awareness outcomes in
three intervention conditions. The phonological awareness intervention targeted phonological
identification, phoneme manipulation, phoneme segmentation, grapheme-phoneme
correspondence, and phoneme production. The traditional intervention targeted phoneme
production in isolation, syllables, words, and phrases. The minimal intervention focused on
phoneme production through monthly consultation between SLPs, teachers, and parents. Finally,
the intervention in the Blischak et al. (2004) study focused on phoneme-grapheme
correspondence, phoneme segmentation, phoneme manipulation, and pseudo word spelling.

The four studies demonstrated improved performance on phonological awareness measures
following treatment. For example, Gillon compared the outcomes of impaired and nonimpaired
children immediately after treatment (2000) and one year after treatment (2002). Her results
suggest that children with speech and language impairments normalized on the phonological
awareness and word recognition measures.

Three studies yielded large effect sizes. Van Kleeck et al. (1998) compared children in preschool
and prekindergarten classes with a cohort of children who had attended those classes the
previous year. The children who received treatment performed more than 1.5 standard deviations

1 11









better on their phoneme awareness measures than older children who had attended the same
classes a year earlier. Effect sizes could not be computed for the phonological awareness
measures for the Gillon (2000, 2002) studies but were computed for word recognition measures.
In those investigations, children with language impairments performed 0.64 standard deviations
better than normally achieving, age-matched controls one year after intervention. Finally,
Blischak et al. (2004) found that 3 children in a multiple-baseline design study improved on
phoneme manipulation and encoding probes. Across the 3 children who participated in their
study, 85% of the phoneme manipulation probes in the instruction phase were above baseline
levels, and 98% of the encoding probes were above baseline levels. Similar effects were found
across individual, small group, and classroom collaboration treatments.

The main limitations of the research on phonological awareness instruction are that there are too
few studies on phonological awareness intervention and no Level 1 evidence to support clinical
decisions in which SLPs could have a high degree of confidence. The studies reported good
outcomes for children with speech and language impairments who received intervention that
targeted phonological awareness. There is consistent evidence supporting the use of phonological
awareness intervention in school settings. However, until the research base in phonological
awareness intervention programs expands, clinicians working in school settings will need to
select intervention targets and procedures with caution and should monitor children's gains
carefully.

Computer-Based Language Intervention

Our search yielded five studies of the effects of computer-based language intervention on
children with language impairments. See Table 4. One study was an RCT (W. Cohen et al.,
2005); three studies were Level 2 nonrandomized comparisons of experimental and control
groups (Merzenich et al., 1996; Seger & Voerhoeven, 2005; Tallal et al., 1996); and one study
was a Level 2 multiple-baseline, single-subject design (Gillam, Crofford, Gale, & Hoffman,
2001). Four studies assessed language or auditory processing outcomes after children played
computer games associated with Fast ForWord-Language (FFW-L) or other computer games.
Language gains were measured by global tests such as the Clinical Evaluation of Language
Fundamentals, Third Edition; language sample analyses; or unpublished memory or auditory
processing tasks. One study (Seger & Voerhoeven, 2005) assessed phonological awareness
outcomes after children received treatment with phonological awareness games that either did or
did not have a modified speech component. The number of participants in the studies varied
between 4 (Gillam et al., 2001) and 60 (W. Cohen et al., 2005). All participants presented
language disorders and ranged in age between 5 and 10 years. Three of the four studies included
only children with mixed (receptive and expressive) language disorders. We excluded a number
of other studies of Fast ForWord because these were conducted on children with reading
disorders or dyslexia rather than children with language impairments, focused on reading instead
of expressive or receptive language outcomes, and/or did not employ research designs that met
the Level 1 or Level 2 criteria.

The treatment targets in the Merzenich et al. (1996) study included perceptual identification of
tone sequences and phoneme recognition. The treatment targets in the Tallal et al. (1996) study
included speech discrimination and on-line language comprehension. Both studies compared the

^^^^ ^^^ ^^^^ ^^^ ^^^^ ^^^ ^^^^ ^^^ ^^^^ ^^^ ^-^ ^^^^ ^^^ ^^^^ ^^^ ^^^^ ^^^ ^^^^ ^^^ ^^^1 1 1 1









speech perception and language outcomes of children who received stimuli with or without
acoustic modifications.

Cohen et al. (2005) compared language and literacy gains in children who received regular
school services only, children who received regular school services plus Fast ForWord-Language
(FFW-L), and children who received regular school services plus computer software without a
modified speech component. The treatment targets for the individual speech and language
services were not reported. The treatment targets for Fast ForWord-Language included
discrimination of tones and minimal pair words, detection of phoneme changes, phoneme and
syllable matching, recalling commands, and comprehending grammatical morphemes and
complex sentence structures. The computer software arm targeted listening, spelling,
phonological awareness, reading, writing, vocabulary, problem solving, narration, syntax, and
morphology. Gillam et al. (2001) compared the language outcomes of children who received
Fast ForWord-Language software and children who received Laureate Learning software. The
language targets for the Fast Forword-Language condition were the same as those in the Cohen
et al. (2005) study. The Laureate Learning software targeted comprehension and memory of
words, grammatical morphemes, sentences, and stories. Finally, the treatment targets in the
Seger and Voerhoven (2005) study were rhyming and phoneme synthesis in modified speech or
unmodified speech conditions.

The results of all five studies indicated improved performance on language or phonological
awareness measures following treatment with computer software. Comparisons of treatment
(FFW-L) and control groups were somewhat equivocal. The Cohen et al. (2005) RCT and the
Gillam et al. (2001) multiple-baseline design study yielded similar improvements on the
language measures for children who received FFW-L and children who received another type of
computer intervention for the same amount of time. Cohen and colleagues also included a
control group who did not receive computer treatment. The outcomes for the FFW-L group and
the control group did not differ. One of the three nonrandomized comparisons of experimental
and control groups did not yield group differences between participants who received computer-
based interventions with or without modified speech input. However, two other studies
conducted by the team of researchers who developed the FFW-L program (Merzenich et al.,
1996; Tallal et al., 1996) yielded outcomes that favored the children who received early
prepublicationn) versions of the FFW-L games with modified speech stimuli over children who
received similar games without modified speech.

The effect sizes of the comparisons between the three FFW-L groups in the W. Cohen et al.
(2005) study varied between small and trivial. Effect sizes could only be computed for the
language sample measures in the Gillam et al. (2001) multiple-baseline study. Three of the 4
students in that study (1 who received FFW-L and 2 who received Laureate Learning games)
presented improvements on mean length of utterance that were associated with relatively large
effects (d values greater than .8). Effect sizes, which were not reported for the two
nonrandomized treatment comparison studies (Merzenich et al., 1996; Tallal et al., 1996), could
not be calculated because the authors did not provide means and standard deviations.

There are a number of limitations with the current research in computer-based language
instruction. The main limitation with the research on computer-based language instruction is that

S1")









there are too few studies to support decisions in which clinicians could have a high degree of
confidence. Only one RCT focused on children with language impairments. The Cohen et al.
(2005) clinical trial needs to be replicated. One program, FFW-L, has been studied extensively.
Needed are studies that examine the efficacy and effectiveness of the many other computer-
based language intervention programs being used in schools. There is consistent evidence
supporting the use of computer-based language intervention in school settings. However, until
the research base in computer-based language intervention programs expands, clinicians working
in school settings will need to select the programs they use with caution and will need to monitor
children's gains carefully.

Pragmatics, Conversation, Discourse, and Narratives

Our search yielded two studies of interventions designed to treat aspects of pragmatics,
conversation, discourse, and narratives in school-age children. See Table 5. Both studies
employed multiple-baseline, single-subject designs (Bedrosian & Willis, 1987; Beilinson &
Olswang, 2003). Four students with specific language impairments participated as subjects,
ranging in age from 5 to 6 years. The participants were all kindergartners. One participant was
classified as specific language impaired, and 3 were identified as having social communication
deficits.

One single-subject study (Beilinson & Olswang, 2003) assessed participants' use of high-risk
peer group entry behaviors after children received direct instruction in the steps in a group entry
sequence. Treatment targets in Beilinson and Olswang's study were investigator-designed, peer-
group entry behaviors (general and specific statements to peers and use of desirable toys as entry
props), and investigator-designed steps in a peer-group entry sequence taught via a set of Meyer-
Johnson picture symbols. The other single-subject study (Bedrosian & Willis, 1987) assessed the
frequency of a student's topic initiations after direct instruction, modeling, and feedback within a
communicative intervention context. Treatment targets in Bedrosian and Willis's study were an
increase in the frequency of topic initiations in child/clinician conversation related to memory
(past events) and topic initiations related to future events.

The results of both single-subject studies indicated improved performance on peer group entry
and language measures. The effect sizes of the comparisons between baseline and treatment
phases in the Beilinson and Olswang (2003) and the Bedrosian and Willis (1987) studies varied
between moderate and quite large.

The main limitations with the research on pragmatics, conversational discourse, and narratives
are that there are so few studies with school-age children with language disorders, no studies
with children over 6 years old, and no studies with Level 1 evidence to support SLPs' clinical
decisions. Given the theoretical and practical importance of students' narrative skills to literacy
(ASHA, 2001), it is surprising that we found no Level 1 or Level 2 studies that investigated the
effects of narrative-based intervention with school-age students. We excluded one pretest and
posttest comparison study (Swanson, Fey, Mills, & Hood, 2005) that assessed the feasibility of
an intervention designed to increase the quality and quantity of students' narratives because it did
not employ a research design that met the Level 1 or 2 criteria (Note: It was not these authors'
intent to evaluate the efficacy of the intervention approach). Until additional experimental

1 A









treatment research is available, SLPs must choose intervention procedures for the critical
academic language skills of conversation and narrative and expository text production and
comprehension with caution and monitor their students' progress carefully.









DISCUSSION

Caveats

There are a number of caveats concerning the present review of language intervention
procedures in schools. First, this systematic review should not be viewed as practice guidelines
or recommendations for clinical practice. As outlined in the ASHA technical report on EBP
(ASHA, 2005b), it is recognized that evidence-based practice guidelines require a great deal of
time, resources, and training. According to the Scottish Intercollegiate Guideline Network
(SIGN, 2002; www.sign.ac.uk), 24 months is an estimate of the minimum time required to go
from identifying a clinical question to review, to forming an expert review panel (including
consumers), to reviewing and grading the available evidence, and finally to writing and
disseminating practice guidelines. SIGN also describes the costs of such efforts. Given the
timelines, resources, and scope of the present review, it was not possible to grade the evidence in
studies as per SIGN guidelines or to adhere to all the procedures recommended by SIGN to
construct impartial practice guidelines.

In addition, Johnston (2005) recently raised a number of issues about the value of existing
systematic literature reviews in the area of SLP that also may pertain to the present review. For
example, limiting reviews to studies utilizing RCTs or other experimental designs may exclude
large sectors of the practice of speech-language intervention. Further, it has not been
demonstrated that the evidence standards developed for healthcare clinical questions (e.g.,
regarding the safety of new drugs or medical procedures) may be the most appropriate to use for
nonmedical or behavioral therapy methods. For example, there is a possibility that RCT studies
may not prove to be the design of choice for studies on effective speech-language intervention
methods. The design requirements of these studies (group comparisons, random assignment,
blind assessment) make it nearly impossible for researchers to individualize instruction. In
clinical practice, an individual's strengths and weaknesses are evaluated; and then treatment
plans are tailored to the student's specific needs. That is not at all how clinical trials work. In
these studies, a large cohort of children is assessed by a group of individuals who never speak to
the clinicians providing the intervention services. Each child who is randomly assigned to a
treatment arm receives the same intervention that focuses on the same treatment targets, whether
those targets are related to the child's specific needs or not. For this reason, systematic reviews
that are limited to clinical trials studies (Level 1 evidence) may not provide clinicians with the
best evidence on which to base treatment decisions.

Another concern is that most systematic reviews to date have excluded children with language
disorders as a secondary disability, including children with autism or developmental delay.
Students with these disabilities make up a substantial proportion of children seen by SLPs in
schools (ASHA, 2004b). Also, concerns can be raised when systematic reviews limit studies to
children within a specific age range; for example, the present review excludes a large number of
treatment outcome studies with preschool children. Finally, there are concerns that recent
systematic reviews on the efficacy of speech-language intervention have not distinguished
among different types or the subcomponents of complex treatment packages. In addition, the
relationship between progress in therapy and number of treatment sessions has not been
explored. On this last point, Law, Garrett, and Nye (2005) have argued that the current research

^^^^ ^^^ ^^^^ ^^^ ^^^^ ^^^ ^^^^ ^^^ ^^^^ ^^^ ^-^^ ^^^ ^^^^ ^^^ ^^^^ ^^^ ^^^^ ^^^ ^^^^ ^^1 1 1 <









on effective treatments for speech and language disorders is best examined in terms of language
goals and outcomes rather than type of intervention. This is because intervention descriptions are
usually incomplete and underspecified and too heterogeneous to group in a meta-analysis.

Gaps in the Literature

This systematic review revealed relatively few studies of the effectiveness of language
intervention practices with school-age children over the past 20 years. However, a wide variety
of language intervention practices are being used in public school settings with a large number of
students with language-learning disorders. As a result, clinicians have relatively little research
evidence on which to base their practices.

In conducting the literature search for this paper, it was apparent that the majority of studies on
effectiveness of language intervention for children with language disorders have been carried out
with preschool children under the age of 5 years. This includes studies on intervention for targets
in the general areas of syntax/morphology (e.g., Cole & Dale, 1986; Fey, Cleave, & Long, 1997;
Fey, Cleave, Long, & Hughes, 1993; Fey & Loeb, 2002; Kaiser & Hester, 1994; Schwartz,
Chapman, Terrell, Prelock, & Rowen, 1985; Tyler, Lewis, Haskill, & Tolbert, 2002, 2003);
semantics/vocabulary/concepts (e.g., Girolametto, Pearce, & Weitzman, 1996; Robertson &
Weismer, 1997; Wilcox, Kouri, & Caswell, 1991); phonological awareness/metalinguistics (e.g.,
Justice, Chow, Capellini, Flanigan, & Colton, 2003; Justice & Ezell, 2000); and
pragmatics/discourse/conversation/narratives (e.g., Bradshaw, Hoffman, & Norris, 1998;
Hayward & Schneider, 2000). In addition, the major meta-analyses of the effectiveness of speech
and language intervention for children have been carried out exclusively on studies with
preschool children (Law, Garrett, & Nye, 2003, 2004). It is reasonable to expect that older
children might respond differently to various language intervention methods than young children
would. The effectiveness of many language intervention practices that are currently used with
school-age children (and apparently adapted from preschool language intervention studies) has
not been directly tested. This research now needs to be carried out directly with school-age
children with language disorders.


There is a strong need for studies that address basic questions about intervention effectiveness in
school settings. The following are specific areas where there are significant gaps in the evidence
on the effectiveness of language intervention with school-age children:

* The studies we reviewed had very few children beyond 5th grade as participants. Eleven of
the 19 studies we found limited participants to children in kindergarten and first grade. No
studies were located that looked at students with language disorders in middle grades or in
high school. This is a major gap in the language intervention evidence base and is especially
problematic for SLPs in school settings.

* SLPs who work in schools would benefit from efficacy studies that examine the language
outcomes of specific intervention procedures. For example, a great deal of evidence exists
supporting the use of contingent language facilitation procedures (e.g., modeling, imitation,
recasts, focused stimulation) on the grammatical development of preschoolers (Fey, 1986;

S1"7









Leonard, 1998; McCauley & Fey, 2006). However, there is no Level 1 or Level 2 research
that examines the use of these facilitative strategies with school-age children.

* The few studies we found on syntax were limited to intervention programs designed to
increase children's use of grammatical morphemes. A major gap in the research is the lack of
research on interventions for "complex syntax" (e.g., complex sentences, elaborated noun
phrases, elaborated verb phrases, interrogatives) necessary to function in school settings.

* We found no research examining the effectiveness of various language goal attack strategies
(i.e., Fey, 1986; Tyler et al., 2003). A goal attack strategy, which refers to the way in which
multiple goals are approached or scheduled, may include (a) a vertical strategy in which one
goal at a time is focused on until some predetermined level of accuracy is achieved, (b) a
horizontal strategy in which several goals are repeatedly targeted within every session, and
(c) a cycle strategy in which several goals are targeted, each for a specified time period
independent of accuracy, and the sequence is repeated.

* Only one of the 19 studies we reviewed (Cohen et al., 2005) examined treatment effect
maintenance. That study found little or no effect of a computer-based language intervention
program on student performance after six months. The lack of research on whether various
language interventions produce lasting positive effects in school-age children is a major gap
in the evidence.

* The effectiveness of specific intervention procedures on students' language outcomes needs
to be systematically examined in the area of semantics and vocabulary/concepts. Specifically,
research on treatment strategies is needed for curriculum vocabulary use and understanding
(in conjunction with reading), the use of storybooks as a tool for fostering vocabulary
development (i.e., Justice, Meier, & Walpole, 2005), and facilitating higher level language in
school-age students with language disabilities (e.g., figurative language, multiple meaning
words, idioms, metaphor).

* We found only three studies, all in the domain of Semantics/Vocabulary/Concepts/Word
Finding (Crowe, 2003; Throneburg et al., 2000; Weismer & Hesketh, 1993), that included
receptive language outcome measures, and one of those found a negative effect of
intervention on receptive vocabulary (Crowe, 2003). Law et al.'s meta-analyses (2003,
2004) showed inconclusive effects for intervention on improving preschool students'
receptive language skills. Research that examines the effectiveness of language intervention
on the receptive language abilities of school-age students with language disorders is needed,
especially given the large numbers of SLPs in schools who report serving students in this
area (ASHA, 2004b).

* One major gap in language intervention outcome research for school-age children is in the
area of narrative treatment strategies. There are many more articles and reports available
regarding how it is done or should be done (e.g., Hoggan & Strong, 1994). SLPs who work in
schools would benefit from efficacy studies on narrative outcomes for (a) prestory
intervention methods (e.g., preparatory sets, summarizing, semantic word mapping, think-
aloud, directed reading/thinking activities); (b) during-story intervention methods (e.g.,

10









extensions, questioning, episode/story mapping); (c) post-story intervention methods (e.g.,
question-answer relationships, internal states, word substitutions, discussion web, flow
charting, story retelling, story grammar cueing, journal, dramatic play, story generation); and
(d) interventions for narrative and expository text comprehension questions. For example,
studies like Swanson et al. (2005) need to be carried out using Level 1 or 2 research designs.
Swanson et al. assessed the quality and quantity of students' narratives after treatment that
included story imitations and retells, story generation tasks, and repeated retellings of stories
at home. Results indicated an increase in the narrative quality index for most participants (a
rating of the characters, physical setting, plot, ending, and language sophistication of a
child's narrative production), but not for the narrative quantity index (number of different
words used).

* Research is needed on the effects of various service delivery models on language treatment
outcomes for school-age children, including the effectiveness of different service delivery
models on outcomes for different language targets (e.g., grammar, vocabulary,
conversational discourse, narrative). A service delivery model, which is an organized
configuration of resources aimed at achieving a particular educational goal, includes
personnel, materials, specific instructional or intervention procedures, the schedule for
provision of services, settings in which intervention services will be delivered, and the direct
and indirect roles that service providers assume as they deliver language intervention to
students with language impairments (Cirrin & Penner, 1995). Gaps in the evidence for
service delivery models include research on the effectiveness of classroom-based and
collaborative language interventions (e.g., Farber & Klein, 1999), collaborative consultation
(e.g., Ellis, Schlaudecker, & Regimbal, 1995), classroom versus individual treatment for
language disorders (e.g., Wilcox et al., 1991), group therapy versus individual therapy, and
integrated indirect services for increasing the language abilities of students with severe
disabilities (e.g., Giangreco, 2000).

* The lack of evidence on the use of curriculum-relevant materials and standards in language
intervention (i.e., ecologically relevant therapy) and on the effects that language therapy has
on students' progress in the general education curriculum (reading, writing, math) is
especially problematic for SLPs who work in schools and must relate intervention to student
progress in the general education curriculum as per IDEA requirements.

* Another major gap in the evidence is that no studies were found that examined the amount
and frequency of intervention required to make significant progress on language targets for
children in schools. A study by Jacoby, Lee, Kummer, Levin, and Creaghead (2002)
determined the average number of treatment units needed to achieve improvements in
functional communication for preschool children receiving services in a hospital setting. This
study also provided some preliminary data on which children showed differential gains and
needed more treatment units. For example, Jacoby et al. found that younger children received
the greatest benefit per units of therapy provided and that children with lower initial
functional communication abilities required more units of therapy to demonstrate
improvement than children with higher initial ability levels. This type of research needs to be
replicated in school settings with older children in grades K-12.


1Cr\









Implications for Personnel Preparation: Evidence-Based Practices
Skill Set

SLPs and graduate students in training who intend to work with school-age children need a solid
foundation in EBP process and content in order to provide effective services to students in
schools with communication disabilities. A priority for ASHA is to help establish the skill set for
EBP throughout the SLP workforce as well as to provide resources to make EBP as practical as
possible in the workplace (i.e., schools; ASHA, 2004a). Specifically, SLPs working with school-
age children with language disorders must be able to independently implement the principles of
EBP and to identify, evaluate, and apply high-quality evidence in their clinical practice.
Furthermore, in order to ensure that EBP becomes a part of the culture of the clinical professions,
it is necessary to incorporate EBP into the pre-service education of SLPs (ASHA, 2004a).
Clinical education programs in universities must begin to routinely instruct beginning clinicians
in the principles and procedures of EBP.

Implications for Personnel Preparation: Knowledge of Evaluation and
Intervention Techniques That Are Supported by Scientific Evidence

SLPs entering the workforce need to come to the job with a firm knowledge about the specific
language treatment methods that are proven to be effective and that are supported by evidence.
Universities need to stress this content-specific information as they prepare entry-level SLPs who
choose to work with school-age children. As we have previously noted, a specific area of need is
knowledge of effective service delivery options for language intervention, because there are
significant discrepancies among recommended practice, reported practice, and graduate training
(Whitmire & Eger, 2003). For SLPs already working in schools, continuing education providers
must be encouraged to develop continuing education activities that address current best evidence
for language intervention and critically assess the quality of that evidence in the course of
educational offerings.

Implications for Personnel Preparation: Development of Action
Research Protocols with School-Age Children and Collaborative
Arrangements with Universities and Schools

The school setting as a laboratory for conducting research presents many challenges to research
design and methodology. As previously mentioned, RCTs may not prove to be the design of
choice for studies carried out in the schools. Random assignment to treatment groups and blind
assignment of treatment providers is fraught with practical and legal issues. Applied research
conducted in actual school environments may be more relevant to the provision of language
intervention than research carried out in university labs or other controlled settings. Universities
need to foster and train clinician-researchers who have the set of tools and techniques that allow
them to conduct action research in real-life school settings. ASHA and other research-funding
agencies should develop funding criteria with preference given to research proposals that identify
research questions relevant to assessment, intervention, and service delivery for school-age
children and that specifically demonstrate that these questions were developed through
collaborative efforts with SLPs working in schools.









CONCLUSIONS

In conclusion, this systematic review of EBP of language intervention for school-age students
with language disorders is a narrow sample of what needs to be done given the extensive scope
of practice of communication disorders in schools. This review has identified a number of
critical gaps in the evidence base for language intervention practices. In general, the quantity and
quality of research for informing EBP optimally in schools must be enhanced. Specifically,
resources are needed for studies on effective language intervention practices for school-age
children (i.e., in grades K-12). To support the full scope of school-based speech-language
services, funding is needed for research on effective intervention strategies for students with
speech-language disorders in areas such as articulation, phonology, voice, fluency, reading, and
written language. Finally, priority must be given to optimizing the research base supporting EBP
for SLP conducted in schools and the eventual development of well-supported clinical practice
guidelines.









Acknowledgments


The authors gratefully acknowledge the contributions of our colleagues without whose support
this project would not have been possible:

* Kathleen Whitmire, Director of School Services, American Speech-Language-Hearing
Association
* Rob Mullen, Gretchen Gould and Andrea Castrogiovanni, National Center for Evidence-
Based Practice in Communication Disorders, American Speech-Language-Hearing
Association
* Anonymous reviewers for their insightful comments on earlier versions of this paper.

The development of this manuscript was supported in part by the Center for Personnel Studies in
Special Education (COPSSE) funded by the Office of Special Education Programs (OSEP, U.S.
Department of Education) located at the College of Education, University of Florida,
Gainesville, Florida.










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^^^^ ^^^ ^^^^ ^^^ ^^^ ^^^^ ^^^ ^^^ ^^^^ ^^^ ^^^ ^^^^ ^^^ ^^^ ^^^^ ^^^ ^^^ ^^^^ ^^^ ^^^ ^^^^ ^^ v









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Appendix A. Databases Searched and Search Terms Used


Databases:
Campbell Collaboration
Cochrane Database of Systematic Reviews
CINAHL
Education Abstracts
ERIC
Exceptional Child Education Resources
Health Source: Nursing
Linguistics and Language Behaviour Abstracts
Medline (CSA)
Medline (EBSCO)
Medline (PubMed)
Pre-CINAHL
PsycARTICLES
PsycINFO
Science Citation Index
ScienceDirect
Social Science Citation Index
What Works Clearinghouse

Search Terms:
* Language AND child*
* Language AND school-based and child*
* Language AND treatment AND child*
* Language AND (specific language impairment OR language disorders in children OR
aphasic children OR specific language impairment in children OR specific language
disability in children)
* Language AND (syntax OR (syntax AND semantics)) OR (grammatical morphemes OR
morphemics OR agrammatism OR grammatical speech disorders OR speech disorder,
grammatical) OR vocabulary/semantics OR pragmatics OR (narration AND expository text)
OR phonological awareness OR comprehension
* ("Child language" OR "language research" OR "phonological awareness" OR "speech
pathology") AND ("control groups" OR "case studies")
* ("Speech" OR "speech pathology" OR "language research") AND "school"
* ("Language disorders in children" OR "phonological awareness")
* (Speech-language pathology OR child language OR language development/disorders) AND
(schools OR students)
* Language OR language development disorders OR language tests OR language therapy OR
speech-language pathology OR language development OR rehabilitation of speech and
language disorders OR child language









AND


* Randomized controlled trials OR cohort studies OR meta-analysis

AND

* School health services OR schools OR Students
* "Phonological Awareness" AND "Language" OR "Figurative Language" OR "Form Classes
(Language)" OR "Phrases" OR "Sentences" OR "Vocabulary" OR "Language Delay" OR
"Language Disorders"

AND

* "School Environment" OR "School Facilities" OR "Classrooms" OR "Educational
Laboratories" OR "Learning Centers (Educational)" OR "Classroom Environment"

AND

* "Cohort Analysis" OR "Randomized Controlled Trials" OR "Single-Subject Designs"
* Language and education OR language awareness OR language attrition OR language
awareness in children OR child language OR language disorders OR language disorders in
children


OR


* Grammar OR comparative and general OR phonological awareness


Literature search was conducted from October to November 2005 by Gretchen Gould and
Andrea Castrogiovanni. References were managed using the bibliographic database EndNote.












Appendix B. Key Features to Consider for Evaluating the Quality of Evidence
from Individual Studies of Treatment (ASHA, 2004a)



Note: Studies categorized as Level 1 and 2 were included for review in the present article.


Level Design features Bias control Importance Precision Harm potential
1 Data-based, controlled, Selection/group, Large effect size Narrow confidence Minimal potential for
experimental, measurement, analysis (ES), in and outside interval (CI) any harm
randomized, prospective of therapy context
(RCT)
Systematic reviews

2 Data-based, controlled, Selection/group, Large ES in therapy Moderately narrow CI Low potential for any
nonexperimental, measurement context harm
nonrandomized,
prospective (cohort;
cross-sectional)
Well designed single-
subject designs with
evidence of experimental
control

3 Data-based, controlled, Selection/group, high Medium ES in Wide CI Moderate potential for
nonexperimental, interrater reliability therapy context mild, short-term harm is
nonrandomized, outweighed by potential
retrospective (case- benefit
control)

4 Data-based, uncontrolled, No blinding; prospect of Small ES No CI reported or Potential for serious,
nonexperimental, direct benefit to calculable short-term harm
nonrandomized (case principal investigator outweighed by potential
series/study) benefit

5 No empirical data No independent No ES reported or Potential for serious,
(opinion, belief, inductive evaluation; conclusions calculable lasting harm not clearly
logic) may benefit those outweighed by potential
making assertions benefit









Appendix C. Overview of Distinguishing Features of Evidence Levels in
Proposed Adaptation of the Oxford System for Evaluating Individual Studies of
Treatment Efficacy (Oxford Centre for Evidence-Based Medicine, 2001)


A. Design characteristics

Design Level 1: Data-based, controlled, experimental, randomized, prospective (random-
ized clinical trials with parallel groups and crossover designs)


In a study at Design Level 1, the investigator actively compares (= controlled) two
different treatment conditions that he or she has created (= experimental) by randomly
assigning participants to conditions. In order to be experimental and randomized, all
Level 1 studies are automatically prospective as well. There are two main kinds of Level
1 study designs: A parallel groups experiment is used to compare the outcomes of
patients who have been randomly assigned to a treatment group or to a no-treatment
group. Each participant is exposed to one treatment only. By contrast, in a crossover
experiment two or more treatments are administered sequentially to randomized groups
of participants, and each group receives exposure to both treatments in a different order.

A systematic review is an analysis of a number of related studies. In this case, the author
of the systematic review selects the best RCTs from a thorough literature search and
analyzes these in a way that allows for a summarization of findings across multiple
experiments.

Design Level 2: Data-based, controlled, nonexperimental, nonrandomized, prospective (co-
hort and cross-sectional studies)

Level 2 studies include comparisons of treatment groups without random assignment.
Another type of Level 2 investigation is a cohort study, which evaluates behavioral
change in a number of participants who are receiving one kind of treatment in
comparison with behavioral change in another group of participants who are receiving
another kind of treatment. For example, an investigator may compare changes in
language scores in a group of children who receive therapy three times per week in five
school districts with changes in language scores in a group of children who receive
therapy twice each week in five different school districts.

Most researchers in speech-language pathology also include multiple-baseline, single-
subject design studies in Level 2. The main requirement of a single-subject design study
is that each participant serves as his or her own control. One way this can be
accomplished is by measuring two or more behaviors across alternating no-treatment and
treatment phases. In this design, one behavior should improve when it is the focus of
treatment while the other behavior remains stable. When the focus of treatment changes
to the second behavior, it should improve. Systematic reviews of nonrandomized group
studies, cohort studies, and single-subject design studies also fit into Level 2.

"C- '-r









B. Control of subjective bias


Bias Control Level 1: Participant selection, group assignment, measurement, and analysis of
results are conducted by examiners who are unaware of participant characteristics
Bias Control Level 2: Blinding at group assignment and measurement



C. Impact/importance of treatment


Importance Level 1: Large effect size within treatment context and evidence of generalization
to external contexts/observers (e.g., social validity)
Importance Level 2: Large effect size within treatment context; generalization to other contexts
unknown


D. Precision of results


Precision Level 1: Narrow confidence interval
Precision Level 2: Moderately narrow confidence interval


E. Potential for harm


Harm Level 1: Minimal potential for any harm is outweighed by potential benefit
Harm Level 2: Low potential for any harm is outweighed by potential benefit











Table 1. Syntax/Morphology


Citation Participants Research Design Maior Findings


Weismer, S., &
Murray-Branch,
J. (1989).
Modeling versus
modeling plus
evoked
production
training: A
comparison of
two language
intervention
methods.
Journal of
Speech and
Hearing
Disorders, 54,
269-281.


Number of
participants: 4


Age/grade: 5;5-6;11
(years;months)

Disability: Specific
language impairment
(SLI)

Three participants (A,
B, D) were -1
standard deviation
(SD) on production
(mean length of
utterance [MLU];
normed test); 1
participant (C) was -1
SD in both production
and comprehension.

Class placement:
Students in public
schools, also
receiving service at
university clinic

Service provider:
Investigator provided
intervention.


Single-subject
(alternating treatment
design with baseline)
Treatment targets
Each participant had
different grammatical
targets as per a language
evaluation.
Participants:A: present
progressive -ing, 3rd
person singular -s,
auxiliary "be" forms,
copula "be" forms
B: regular & irregular
past tense, nominative
case pronouns, auxiliary
inversion for questions
C: articles, present
progressive -ing, 3rd
person singular -s,
auxiliary "be" forms,
copula "be" forms
D: articles, present
progressive -ing,
auxiliary "be" forms,
copula "be" forms,
prepositions (in, to, at)
Therapy methods
Treatment 1: Modeling
(M) focused models of
target form provided by
clinician; no verbal
responses required from
child; activities included
storytelling, art
construction activities,
puppet play.
Treatment 2: Modeling
plus evoked production
(MEP) focused
models of target form
with intermittent
opportunities for
participant to produce
the form and receive
feedback regarding
correctness of
production; training
environment structured
to evoke spontaneous
(non-imitative) produc-
tions of target form.


Dependent variables were
number of correct
productions of target
grammatical form and total
attempts at target form.

No marked difference in
outcome between modeling
and modeling plus evoked
production training for any
participant.

For the 3 participants with
only production delay, both
treatments were equally
effective; experimental
control demonstrated across
participants from baseline to
treatment phase (increase in
use of specific targets).

For the 1 participant with
delay in both production and
comprehension, neither
treatment led to increase from
baseline over 15 treatment
sessions.

Effect sizes (Percent
nonoverlapping data [PND]
for either treatment over
baseline):


Participant A PND
(moderate)
Participant B PND
(very high)
Participant C PND
(ineffective)
Participant D PND
(mildly effective)











Table 1. Syntax/Morphology (cont.)


Citation Participants Research Design I Maior Findings


Connell, P. & Stone,
C. (1992).
Morpheme learning
of children with
specific language
impairment under
controlled
instructional
conditions. Journal
ofSpeech and
Hearing Research,
35, 844-852.


Number of participants: 32
SLI; 24 age-matched and
20 language-matched
controls

Age/grade: 5;0-6;11

Disability: SLI; -1 SD on
either MLU or normed
language test.

Classroom placement:
Participants selected from
caseloads of SLPs in
schools and clinics, but no
other breakdown described.

Service provider: Assumed
to be investigators, but not
described


Level 2 cohort
(split-plot factorial)


Treatment targets

Investigator-designed
invented morphemes: one
of four suffixes attached to
concrete nouns capable of
being represented by
pictures, to indicate one of
the following meanings
(large/small, whole/part,
whole/broken) (e.g.,
"TVum" to indicate a
broken TV)

Therapy methods

Participants taught set of
invented morphemes by
computerized language
teaching program (to
standardize teaching
procedures and minimize
unintentional examiner
bias).

Modeling treatment:
Participant heard
morpheme being used in
meaningful way but was
not asked to repeat or use
the morpheme in any way.

Imitation treatment: Same
as modeling with additional
step of instructing
participant to give a
direction to a computer
cartoon figure that contains
the target morpheme.

Participants received four
computerized language-
teaching sessions over 2-
week period.


Dependent variables were
pretest and posttest
performance on both
production and comprehension
probes of invented morphemes.

Modeling alone did not
significantly increase SLI
participants' use of morphemes;
imitation training did result in
SLI participants' increased
performance for morpheme
production. Both modeling and
imitation training appeared
equally effective for increasing
SLI participants' performance
on morpheme comprehension
probes.

However, results from study
were confounded by large
effects of order of treatment
procedure (whichever treatment
strategy administered first
overrode any differential effect
within the counterbalanced
design).

Effect sizes cannot be
computed from data presented
in article. No pre/post scores
presented to measure treatment
effectiveness.








Table 2. Semantics/Vocabulary/Concepts/Word-Finding


Citation Participants Research Design Major Findings


McGregor, K. &
Leonard, L.
(1989).
Facilitating word-
finding skills of
language-impaired
children. Journal
ofSpeech and
Hearing
Disorders, 54,
141-147.


Number of
participants: 4


Age/grade: 9;1-10;5

Disability: All
diagnosed as SLI; all
students scored more
than -1 SD on at least
two normed tests of
language and word
finding

Class placement: All
enrolled in class for
SLI students at their
school.

Service provider: Not
specified but assumed
to be investigator


Level 2 data-based
cohort
Two participants
participated in 6 weeks
of language therapy
with word-finding
focus; other 2 served as
controls and participated
in narrative and syntax
activities. Nonrandom
assignment of partici-
pants to treatment and
control groups. Controls
matched on age and
word-finding abilities.
Treatment targets
Investigator-designed
elaboration strategies (to
provide child with a richer
knowledge of target
words) and retrieval
strategies (teach child to
use information already
known about target
words) thought to aid
word retrieval taught via a
set of 120 concrete nouns
capable of being
represented by pictures.
Therapy methods
Elaboration strategy:
Clinician presents
pictures/words that
rhyme with target word
(phonemic) and
pictures/words that are
similar to and different
from the target word
(semantic).
Retrieval strategy:
Clinician presents
retrieval cues related to
target words (cues are:
category membership,
beginning sound, and
customary location of the
object/name).
Treatment was 12
sessions, each 1 hr, with
both elaboration &
retrieval strategy
training.


Dependent variables were
number of errors on
naming task; number of
words recalled in free
recall task

On naming and recall tasks,
treatment participants
improved from pretest to
posttest, while controls
either made smaller gains or
no gains. Performance on
maintenance tasks, however,
was sometimes lower than
posttest for all groups. Data
did not clearly indicate
whether elaboration or
retrieval training was more
effective.

Effect sizes cannot be
computed from data
presented in article.
Difference scores for each
participant are presented
from pretest to posttest on
number of errors on naming
task; number of words
recalled in free recall task.








Table 2. Semantics/Vocabulary/Concepts/Word-Finding (cont.)

Citation Participants Research Design Major Findings


Wing, C. (1990). A
preliminary
investigation of
generalization to
untrained words
following two
treatments of
children with word
finding problems.
Language, Speech,
and Hearing
Services in Schools,
21, 151-156.


Number of participants:
10

Age/grade: Range = 71-
85 months, mean = 77
months; first grade.

Disability: Identified by
school as having severe
language impairment.

Class placement: All
children were in self-
contained class for
language disabilities;
intervention was provided
in school.

Service provider:
Investigator was students'
regular SLP.


Level 2 cohort


Students divided into two
groups: one received
semantic treatment; the
other received
phonological treatment;
not random assignment

Each group received 30
group therapy sessions,
each 25 min long, over
2.5 months

Treatment targets
Investigator-designed
semantic or phonological
strategies thought to aid
word retrieval taught via set
of vocabulary items similar
to but not duplicating items
on Test of Word Finding.

Therapy methods
Semantic treatment:
Activities to improve
elaboration and
organization of semantic
storage (put pictures/
words in categories;
supply attributes; use
categories and attributes
to define words; explain
function and attributes of
objects).

Phonological treatment:
Activities for
phonological
segmentation (count
syllables and phonemes,
match and supply
rhyming words); and
activities for auditory
imagery (hear picture
name in their mind, silent
verbal rehearsal).


Dependent variables were
pretest and posttest scores on
Test of Word Finding (TWF)

Significant gains on TWF
scores for phonological
treatment group;
nonsignificant gain for
semantic treatment group,
even though all participants
but one (who was in semantic
group) improved TWF scores
from pretest to posttest.

Effect sizes:

Semantic treatment group:
d= .6 (moderate)

Phonological treatment group:
d= .7 (moderate)








Table 2. Semantics/Vocabulary/Concepts/Word-Finding (cont.)

Citation Participants Research Design I Major Findings


Masterson, J., &
Perrey, C. (1999).
Training
analogical
reasoning skills in
children with
language
disorders.
American Journal
ofSpeech-
Language
FLail. I.- 8, 53-
61.


Number of participants:
12

Matched 6 treatment to 6
controls (not randomly
assigned; treatment
volunteers expressed
willingness to attend extra
treatment sessions)

Age/grade: Between 9 and
14 years (mean= 11;11)

Disability: SLI

Class placement: All
receiving services for
language in public
schools or private schools

Participants received
treatment in small groups;
assume in pullout school
setting but not described.

Service provider:
Training administered by
one investigator


Level 2 cohort


Treatment targets

Investigator-designed
mediated learning and
bridging strategies thought
to aid in analogical
reasoning (verbal analogy
performance) taught via a
set of verbal analogies
from 5 categories
(synonyms, antonyms,
function, linear order, and
category membership).

Therapy method

Phase 1 treatment:
Mediated learning, which
included direct instruction
in component processes
of analogical thinking
(encoding, inferring,
mappings, applying);
Phase 1 treatment
consisted of 8 sessions
over 2 weeks.

Phase 2 treatment:
Bridging, which included
exercises designed to help
participants incorporate
the component processes
of analogical thinking into
everyday activities; Phase
2 treatment consisted of 8
sessions over 2 weeks.


Dependent variable was
performance on 100-item
verbal analogies test (20 from
each of the following
categories: synonym,
antonym, functional, linear
order, category membership).
None of specific analogies in
pretest and posttest were used
in treatment.

Average gain made by
students receiving treatment
was 2.37 SDs more than
participants who did not
receive treatment (large effect
size). Performance appeared
to be consistent across all 5
semantic analogy categories.

Direct instruction in
analogical reasoning has
positive effects in children
with language disorders. No
measure of generalization of
trained strategies to
classroom curricular
activities.

Effect sizes

Treatment group
d= 1.1 (large)
Control group
d= .02








Table 2. Semantics/Vocabulary/Concepts/Word-Finding (cont.)

Citation Participants Research Design Major Findings


Crowe, L. (2003).
Comparison of two
reading feedback
strategies in
improving the oral
and written
language
performance of
children with
language-learning
disabilities.
American Journal
ofSpeech-
Language
2F.di. r. -, 12, 16-
27.


Number of participants:
12

Age/grade: Between 8
and 11 years

Disability: Classified as
having language-learning
disabilities, scores of at
least -1 SD on normed
test of language; all were
identified as "poor
readers," scoring below
50th percentile on normed
test of reading
achievement.

Class placement:
Receiving special
education services for
language, learning, and
reading problems

Service provider:
Intervention provided by
the investigator at the
children's school


Level 2 cohort
(non-randomized controlled
trial)

Treatment targets
Investigator-designed
traditional reading decoding
strategies or meaning-based
Communicative Reading
Strategies thought to aid oral
language performance (e.g.,
receptive and expressive
vocabulary performance).

Therapy methods (and groups)
T1: Traditional decoding
feedback (student reads
passage, sounds out words,
answers questions after
reading, and retells what was
read; interventionist
provided cues and feedback
during reading [sound out,
reread, provide word, divide
word, phonemic cues])
T2: Communicative Reading
Strategies (CRS); Interactive
conversational style (student
reads small portion of text,
asking and answering
questions during and after
reading, commenting,
summarizing, reacting to
story events, and retelling
what was read;
interventionist provided cues
and feedback during reading
[preparatory set, summarize,
explain, pronoun reference,
cohesive ties])

Treatment groups received 2
group treatment sessions,
each 1 hr long, per wk for 6
wks; Control group: No
treatment


Dependent variables were
pretest and posttest
difference scores on the
Gray Oral Reading Test-
Revised (reading
comprehension questions,
oral reading rate/accuracy,
and combined score) and on
the Comprehensive
Receptive and Expressive
Vocabulary Test (CREVT)
normedd test of expressive
and receptive vocabulary;
participants had to point to
pictures and verbally define
vocabulary items).

Standardized measures of
receptive and expressive
vocabulary indicated that
children in the CRS group
performed better than children
in either T1 or control group,
but group differences were not
statistically significant. All
groups performed worse on
posttest receptive and general
vocabulary measures (an
alternate form of the CREVT
given as pretest); CRS group
increased performance on
alternate form expressive
posttest, while T1 and control
groups performed worse.

Effect size:

For the CRS treatment
group's increase on
expressive post-test: d= .5
(moderate)








Table 2. Semantics/Vocabulary/Concepts/Word-Finding (cont.)

Citation Participants Research Design I Major Findings


Throneburg, R.,
Calvert, L., Sturm,
J., Paramboukas, A.,
& Paul, P. (2000). A
comparison of
service delivery
models: Effects on
curricular
vocabulary skills in
the school setting.
American Journal of
Speech-Language
Fli. i. ,. 9, 10-20.


Number of participants:
32 (who were eligible
for S/L service out of
177 total students in 12
classrooms)

Age/grade: Grades K-3

Disability: 13 eligible
for speech services; 19
eligible for language
services; criteria for
placement was a score
of -1 SD or greater on
two normed tests of
language, or one
normed test of
articulation.

Class placement:
Regular education
classrooms

Service provider:
Students regular school
SLP; classroom
teachers; graduate
students


Level 2 cohort
(nonrandomized controlled
trial)

Treatment targets
Meanings of a set of 60
vocabulary words from
each classroom's general
education curriculum.

Therapy methods

(a) Collaborative: SLP and
classroom teacher
collaboratively planned
and implemented activities
to target curriculum
vocabulary words in
classroom (large group
vocabulary instruction and
hands-on activities for
topic units with embedded
vocabulary words).

(b) Classroom-based:
Teacher and SLP
independently planned and
implemented vocabulary
activities, similar to (a)
above; SLP provided
independent classroom
lesson.

(c) Traditional pullout:
SLP provided vocabulary
instruction for S/L
impaired students in
traditional pullout sessions
averaging 50 min per
week. SLP used same
materials that were used in
collaborative and
classroom-based settings.


Dependent variables were
pretest/posttest performance
on 20-item vocabulary test
(scores included points for
adequacy of defining target
word, using target word in a
sentence, and recognizing
definition of target word in
multiple-choice format).

Students who received
services through a
collaborative model had
higher scores on curricular
vocabulary tests than
students who received
services through a
classroom-based or pullout
model, though all 3 service
delivery models were
effective for teaching
vocabulary.

Effect sizes

(a) Collaborative
d = 2.5 (large)
(b) Classroom-based
d = 3.5 (large)
(c) Traditional pullout
d= 1.2 (large)








Table 2. Semantics/Vocabulary/Concepts/Word-Finding (cont.)

Citation Participants Research Design Major Findings
Weismer, S., & Number of participants: Level 2 cohort Dependent variables were
Hesketh, L. 16 (8 SLI and 8 normal (repeated measures groups by number of novel words
(1993). The language) rate/stress/visual) comprehended and
influences of produced.
prosodic and Age/grade: 5;1-6;7/ Treatment targets
gestural cues on kindergarten For therapy group and
novel word Meanings of a set of 9 controls, acquisition of novel
acquisition by Disability: Treatment investigator-designed novel words was affected by
children with group: SLI; controls: words (one-syllable, alterations in speaking rate
specific language normal language consonant/vowel/consonant and by the use of gestures
impairment. forms with early developing accompanying spoken
Journal of Speech Class placement: sounds) representing either language, but not by stress
and Hearing Treatment group: Self- object labels or locatives. manipulations. Slower
Research, 36, contained classroom for presentation rate helped SLI
1013-1025. children with severe Therapy methods performance as did addition
language disorders in a of gesture cues.
public school
kindergarten 3 experimental treatment Effect sizes cannot be
Controls: Regular conditions: computed from data
kindergarten class Rate stimulus sentences with presented in article. Means
target words presented at 3 and standard deviations are
Service provider: rates (slow, normal, fast) presented for comprehension
Assume investigator, Stress target words presented and production of novel
but not stated with and without stress words by group for each of
Visual stimulus word the 3 stimuli presentation
presented verbally or verbally + conditions. No pre/post
visual cues (gestures) scores presented to measure
treatment effectiveness.








Table 3. Phonological Awareness/Metalinguistics

Citation Participants Research Design Major Findings


van Kleeck, A.,
Gillam, R., &
McFadden, T.
(1998). A study of
classroom-based
phonological
awareness training
for preschoolers
with speech and/or
language disorders.
American Journal
ofSpeech-
Language
Fai i .. i. 7, 66-
77.


Number of participants: 24

Disability: Speech and/or
language disorder

Age/grade: Preschool age
mean = 48 months and
prekindergarten mean = 60
months

Class placement: Preschool
and prekindergarten
classrooms in a private
school for children with
language disorders

Service provider: SLPs and
graduate students in SLP


Level 2 cohort:
nonrandomized
comparison of treatment
groups with a group of
older children who had
attended the same
classrooms (without the
phonological awareness
treatment) the previous
year

Treatment targets
Rhyming: rhyme
identification, rhyme
judgment, and rhyme
generation

Phoneme awareness:
matching and identifying
initial sounds, generating
words, phoneme blending,
and phoneme segmentation

Therapy methods
Children in the 2 treatment
groups received rhyming
instruction during the fall
semester and phoneme
awareness instruction
during the spring semester.


Both treatment groups made
significant improvements in
rhyming and phoneme
awareness. Gains in rhyming
fell below the lower
boundary of the 95%
confidence interval of the
control group, suggesting that
the development in rhyming
was not dependent on
treatment. However, gains in
phoneme awareness were
above the upper limits of the
control group's confidence
interval, suggesting that
training contributed to
improvements in phonemic
awareness. The children in
the treatment groups
performed better on the
phonological awareness tasks
than older kindergartners and
first graders who had
previously attended the pre-K
class.

Effect sizes

d (preschool vs. control)
1.58 (large)
d (pre-K vs. control) = 1.76
(large)








Table 3. Phonological Awareness/Metalinguistics (cont.)

Citation Participants Research Design Major Findings


Gillon, G. (2000).
The efficacy of
phonological
awareness
intervention for
children with
spoken language
impairment.
Language, Speech,
and Hearing
Services in Schools,
31, 126-141.


Number of participants:
91

Age/grade: 5;6-7;6

Disability: Speech and
language disorder

Class placement: Pullout
services in clinic and
school settings compared
to classroom consultation
or classroom instruction

Service provider: SLPs
and graduate students in
SLP


Level 2: nonrandomized
(matched) assignment to
treatment and control
groups compared with a
cohort of typically
achieving children

Treatment targets
Experimental Group:
identification of
phonological similarities,
phoneme manipulation,
sound identification,
phoneme segmentation,
grapheme-phoneme
correspondence, phoneme
production

Traditional Control:
phoneme production in
isolation, syllables, words
and phrases

Therapy methods

4 groups:
1. Experimental
Intervention Gillon
phonological awareness
training program
2. Traditional Control -
Van Riper speech
therapy
3. Minimal Intervention
4. Classroom Consultation
-normal comparison


Children in Group 1 made
more improvement on tests of
phonological awareness and
reading than children in
Groups 2 and 3. At the end of
the study, the phonological
awareness performance of the
children in Group 1 was
similar to the normal
controls.

Effect sizes were not supplied
by the author and could not
be computed because means
and standard deviations were
not provided.








Table 3. Phonological Awareness/Metalinguistics (cont.)

Citation Participants Research Design Major Findings
Gillon, G. (2002). Number of participants: Level 2: nonrandomized Treatment led to sustained
Follow-up study 20 of the original 23 SLI (matched) assignment to growth in phoneme awareness
investigating the and all the normal treatment and control and word recognition. The
benefits of phoneme controls groups compared with a majority of the children were
awareness cohort of typically reading at or above age-level
intervention for Age/grade: 5;6-7;6 achieving children expectations and improved on
children with spoken nonword spelling.
language impairment. Disability: Speech and Treatment targets
International Journal language disorder Same as Gillon, 2000 Effect sizes
ofLanguage and
Communication Class placement: Pullout Therapy methods Means and standard deviations
Disorders, 37, 381- services in clinic and were not provided for the
400. school settings compared 4 groups: phoneme awareness measure
to classroom consultation Same as Gillon (2000) but were provided for the word
or classroom instruction recognition measure.
Tested 11 months later on
Service provider: SLPs phoneme awareness, d (SLI, pre- to follow-up)
and graduate students in reading, and spelling 2.42 (large)
SLP d (Controls, pre- to follow-up)
= 1.52 (large)
d (SLI vs. controls at follow-
up) = .64 (moderate)

Blischak, Shah, Number of participants: 3 Multiple-baseline single- Phoneme-grapheme
Lombardino, & subject design across correspondence and phonemic
Chiarella (k' -i4). Age/grade: 5;6-7;6 behaviors and participants awareness instruction
Effects of phonemic increased the encoding skills
awareness instruction Disability: Severe speech Treatment targets of 2 of the 3 participants and
on the encoding skills impairment with Phoneme-grapheme generalized these skills to
of children with concomitant language correspondence, phoneme untrained pseudo- and real
severe speech disorder segmentation, phoneme words.
impairment. manipulation, pseudo word
Disability and Class placement: Not spelling Effect sizes (Percent
Rehabilitation, 26, stated nonoverlapping data [PND]
1295-1304. Therapy methods for either treatment over
Service provider: SLPs baseline):
Treatment Phoneme-
grapheme instruction and Phoneme manipulation -
phonemic awareness moderate PND, 85% of probes
instruction in instruction phase were
above baseline levels.

Encoding large PND, 98%
of probes in instruction phase
were above baseline levels.








Table 4. Computer-based Language Intervention


Citation Participants Research Design Major Findings
Cohen, W., Number of participants: Level 1: RCT Similar gains on
Hodson, A., 60 Clinical Evalution of
O'Hare, A., Boyle, Treatment targets Language
J., Durrani, T., Age/grade: 6-10 years FFW-L: discrimination Fundamentals, Third
McCartney, E., et of tones, phonemes, Edition, for the
al. (2005). Effects Disability: mixed syllables, and words; treatment and control
of computer-based (receptive/expressive) memory for commands; groups at 9-week and 6-
intervention language impairment comprehension of month follow-up
through grammatical periods. Suggests that
acoustically Class placement: morphology and the computer
modified speech Regular classroom plus complex sentences intervention plus school
(Fast ForWord) in pullout for language therapy was no more
severe mixed therapy Other computer effective than school
receptive- programs: listening, therapy alone.
expressive Service provider: spelling, phonological
language Computer plus school awareness, reading, Effect sizes:
impairment: clinicians writing, vocabulary,
Outcomes from a problem solving, 9 weeks:
randomized narration, syntax, and d = -.09 for FFW vs.
controlled trial, morphology Control (no effect)
Journal ofSpeech, d = .27 for FFW vs.
Language, and Therapy methods Computer (small)
Hearing Research,
48, 715-729. 3 groups: 6 months:
1. Fast ForWord- d = .05 for FFW vs.
Language (FFW-L) Control (no effect)
2. Other computer d = -.27 for FFW vs.
programs Computer (small)
3. Control (school
therapy services only)








Table 4. Computer Language Instruction (cont.)


Citation Participants Research Design Major Findings
Tallal, P., Miller, Number of participants: Level 2: Participants in the
S., Bedi, G., 22 nonrandomized experimental group
Byma, G., Wang, (matched) comparison showed significantly
X., Nagarajan, S., Age/grade: 5;2-10;0 of treatment and control larger improvements on
et al. (1996). groups measures of speech
Language Disability: mixed discrimination, language
comprehension in (receptive/expressive) Treatment targets processing, and
language-learning language impairments Speech discrimination grammatical
impaired children and on-line language comprehension.
improved with Class placement: comprehension
acoustically Unknown Therapy methods Effect sizes were not
modified speech. Treatment group early reported and cannot be
Science, 271, 81- Service provider: versions of FFW-L calculated because
84. Computer games and games (block means and standard
trained clinicians commander, phonic deviations were not
match, phonic word, provided.
and language
comprehension builder
with modified speech
stimuli)
Control group -
Computer versions of
these same tasks
without modified speech
stimuli
Gillam, R., Number of participants: Level 2: multiple- All 4 children made
Crofford, J., Gale, 4 baseline single-subject clinically significant
M., & Hoffman, I. design gains on the Oral and
(2001). Language Age/grade: 6-8 years Treatment Targets Written Language
change following FFW-L: discrimination Scales. Both children
computer-assisted Disability: SLI of tones, phonemes, who received the LLS
language syllables, and words; games and 1 of the 2
instruction with Class placement: memory for commands; children who received
Fast ForWord or Regular classroom plus comprehension of FFW-L made clinically
Laureate Learning pullout SLP services grammatical significant gains on
Systems software, morphology and MLU computed from
American Journal Service provider: complex sentences language samples.
ofSpeech- Research assistants Laureate Learning
Language software: Effect sizes (for MLU):
F i. '/. .. 10, comprehension and
231-247. memory of words, FFW d= .39
grammatical (small) and 1.37 (large)
morphemes, sentences, LLS d= .99 (large)
and stories, and 1.7 (large)
Therapy methods
Two children received
FFW-L, 2 other children
received a group of
language games
produced by Laureate
Learning Systems (LLS)








Table 4. Computer Language Instruction (cont.)


Citation Participants Research Design Major Findings
Merzenich, M., Number of participants: Level 2: nonrandomized The students in the
Jenkins, W., 22 (matched) comparison of experimental group
Johnston, P., experimental and control improved on the Tallal
Schreiner, C., Age/grade: 5;2-10;0 groups Repetition Test (a
Miller, S., & measure of auditory
Tallal, P. (1996). Disability: mixed Treatment targets temporal processing),
Temporal (receptive and Perceptual identification but the students in the
processing deficits expressive) language of tone sequences and control group did not.
of language- impairment phoneme recognition
learning impaired Effect sizes were not
children Class placement: Therapy methods reported and cannot be
ameliorated by Unknown calculated because
training. Science, Experimental group means and standard
271, 77-80. Service provider: received FFW-L games: deviations were not
Computer games Circus Sequence and provided.
Phoneme Identification
Seger, E., & Number of participants: Level 2: nonrandomized Positive treatment
Verhoeven, L. 36 (matched) comparison of results were found for
(2005). Computer- 2 experimental groups Experimental Group 1
supported Disability: SLI and 1 control group when the phonological
phonological awareness task results
awareness Age/grade: 4;6- Treatment targets were combined into
intervention for 6;1 /kindergarten Rhyming and phoneme difference z scores. The
kindergarten synthesis positive results were no
children with Class placement: longer significant 18
specific language Special schools for Therapy methods weeks after completion
impairment. children with SLI in the Group 1 10 Rhyming of the intervention.
Language, Speech, Netherlands and Sound Synthesis
and Hearing computer games with Effect size:
Services in Service provider: normal speech
Schools, 35, 229- Computer games The effect size of
239. Group 2 10 Rhyming treatment for
and Sound Synthesis Experimental Group 1
computer games with compared with the
modified speech (slower control group: d = 0.29
and amplified formant (small)
transitions)

Control Group -
Vocabulary computer
games

All children received 14
sessions, 15 min long,
across 5 weeks








Table 5. Pragmatics/Conversation/Discourse/Narratives


Citation Participants Research Design Major Findings


Beilinson, J., &
Olswang, L.
(2003). Facilitating
peer-group entry in
kindergartners
with impairments
in social
communication.
Language, Speech,
and Hearing
Services in
Schools, 34, 154-
166.


Number of participants:
3

Age/grade: 5;6-
6;3/kindergarten

Disability: "Social
communication deficits"
identified by SLP and
teachers based on
observation and
comparison with normal
peers; also, scores on
normed language tests
(range from -2 SD to
"average" on Peabody
Picture Vocabulary Test,
Test of Language
Development)

Class placement: Full-
day integrated classroom
in university lab school

Service provider:
Second-year master's
student in speech-
language pathology and
teacher in classroom


Single-subject
(multiple baseline across
subjects)

Treatment targets

Investigator-designed peer-
group entry behaviors
(general and specific
statements to peers, and
use of desirable toys as
entry props), and
investigator-designed steps
in a peer-group entry
sequence taught via a set
of Meyer-Johnson picture
symbols.

Therapy methods

Direct instruction in use of
high-risk entry behaviors
(general and specific
statements to peers) and use
of props (desirable toy) to
gain entry.

Direct instruction included
use of Mayer-Johnson
symbols for steps in an
entry sequence (e.g., watch
your friend, get a toy like
your friend is using, do the
same thing as your friend,
tell an idea). Teachers were
instructed to prompt
students to use entry
sequence in classroom.

Treatment lasted 3 to 5
weeks for each participant.


Dependent variables were
frequency of low- and
high-risk entry behaviors;
frequency of prop use;
investigators also
measured frequency of
solitary vs. cooperative
play.

Experimental control
demonstrated for the
intervention across all
participants between
baseline, treatment, and
withdrawal phases.

Effect sizes: For
participants between
baseline and treatment,
and treatment and
withdrawal

High-risk entry: All 3
students increased
frequency of high-risk
entry behaviors: d from
2.2 to 4.5 (large)

Prop use: All 3 showed
increase in prop use: d
from 2.5 to 10.2 (large)

Cooperative play: All 3
showed increase in
frequency of cooperative
play: from 1.5 to 13.2
(large)








Table 5. Pragmatics/Conversation/Discourse/Narratives (cont.)



Citation Participants Research Design Major Findings


Bedrosian, J., &
Willis, T. (1987).
Effects of
treatment on the
topic performance
of a school-age
child. Language,
Speech, and
Hearing Services
in Schools, 18,
158-167.


Number of participants:
1

Age/grade: 60
months/kindergarten

Disability: SLI;
expressive syntax at
Brown's Stage 4; only 2
of Brown's 14
morphemes mastered
(ing, on);
few topics initiated
spontaneously, and
limited to "here and
now"

Class placement:
Regular kindergarten
class

Service provider: Not
specified


Single subject (multiple
baseline across behaviors)

Treatment targets

Increase in frequency of
topic initiations in
child/clinician conversation
related to memory (past
events), and topic
initiations related to future
events.

Therapy methods

Two 30-min therapy
sessions per week for 6
months.

Treatment: Direct
instruction, modeling and
feedback within a
communicative context; for
past topics, clinician
modeled using appropriate
grammatical markers (e.g.,
what we did yesterday),
direct/indirect requests to
elicit comments from child,
and visual sequence cards.
Similar procedures used to
increase frequency of future
topics.


Dependent variables were
number of here/now topic
initiations, past/memory
topic initiations, and
future topic initiations in
5-min probe sessions.

Experimental control and
effectiveness of treatment
demonstrated across
behaviors.

Increase in the frequency
of past topic initiations,
even though the absence
of toys was related to
number of past topics,
thus confounding the
interpretation.

Increase in the frequency
of future topic initiations.

Also, increase in
participant's use of
appropriate syntactic
forms to mark past and
future topics, as well as a
general increase in syntax
level and use of Brown's
morphemes.


Effect sizes:

Past topics
d= .6 (moderate)
Future topics
d= 1.5 (large)




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