Increasing deictic gesture use to support the language development of toddlers from high poverty backgrounds

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Early Childhood Research Quarterly

Increasing deictic gesture use to support the language development of toddlers from high poverty backgrounds夽 Mollie K. Romano a,b,∗ , Kelly S. Windsor b a b

School of Communication Science and Disorders Communication and Early Childhood Research and Practice Center at Florida State University

a r t i c l e

i n f o

Article history: Received 19 December 2017 Received in revised form 15 November 2018 Accepted 7 December 2018 Available online xxx Keywords: Gesture intervention Prelinguistic Toddler Poverty

a b s t r a c t This study uses a single-case, multiple probe design to investigate the effects of a naturalistic intervention on deictic gesture use in toddlers who are from low-SES backgrounds. The month-long study included strategies drawn from the literature on early communication interventions to increase the rate of child gesture use in toddlers at-risk for later delays. These strategies include frequent modeling of deictic gestures (points, shows, reaches, and gives), creating opportunities for the child to gesture by using environmental arrangements, choices, and wait time, and by responding and expanding each gesture. All three child participants made gains in their rates of deictic gestures after the onset of intervention with no overlap between the intervention and baseline conditions. Children also made gains to gesture + vocalization combinations and gesture + word combinations in this short-term intervention. This study offers preliminary evidence that prelinguistic interventions for children at-risk can be used to increase rates of communication in toddlers in poverty. © 2019 Elsevier Inc. All rights reserved.

While the contrast in language outcomes between children with low and middle SES is stark by the time children reach three years of age (Hart & Risley, 1995; Pan, Rowe, Singer, & Snow, 2005; Huttenlocher, Waterfall, Vasilyeva, Vevea, & Hedges, 2010), significant between-group differences in communication skills are evident during toddlerhood (Fernald, Marchman, & Weisleder, 2013). By 18 months, children with middle and upper SES have larger receptive vocabularies and faster word processing speeds than children whose families experience poverty (Fernald et al., 2013). By 24 months, children from low-SES backgrounds have processing speeds and receptive vocabularies similar to middle income children who were just 18 months old, equating to a six-month lag in foundational communication skills by the age of two (Fernald et al., 2013). Consistent with prior research (Hart & Risley, 1995; Huttenlocher et al., 2010), early differences in receptive vocabularies are mediated by the amount of language directed to the child during their first years of life (Fernald et al., 2013) and by the

夽 We are grateful for the children and families who participated in this project. We also extend special thanks to Kayla Ramsey, whose hard work and dedication to coding and analysis was critical to the completion of this manuscript. ∗ Corresponding author at: School of Communication Science and Disorders, 201 W. Bloxham St., Tallahassee, FL 32306, United States. E-mail address: [email protected] (M.K. Romano).

quality of caregiver–child interactions during the toddler period (Guttentag et al., 2014). State and national policy makers are attempting to bridge this “word gap” by supporting initiatives to help children with low-SES develop stronger language skills (Hindman, Wasik, & Snell, 2016). Many interventions aim to help families and teachers of preschoolers to provide descriptive language, offer exposure to print, and engage in positive interactions with children in preliteracy activities (Guttentag et al., 2014; Hindman et al., 2016). While these strategies are critical, efforts to support infant and toddler prelinguistic development could target children’s communication skills before the word gap fully takes shape. There is a need for experimental studies that support prelinguistic skills in children who are at risk for delays due to their SES (Vallotton, 2009). Wellestablished responsive parenting interventions such as My Baby and Me (Guttentag et al., 2014) and Play and Learning Strategies (Landry, Smith, Swank & Guttentag, 2008) include responsiveness to a child’s prelinguistic cues as part of a wider curriculum, although increases in prelinguistic communication were not measured as a primary outcome in these studies. Guttentag et al. (2014) indicates that there could be a need for short-term, focused interventions that support specific skills during the earliest months of a child’s life to supplement broader interventions. At the same time, research highlights the pivotal role that gestures play in language development for all children, and interventions for toddlers at risk for

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delays due to SES could support foundational communication skills that “prime the pump” for later language development (LeBarton, Goldin-Meadow, & Raudenbush, 2015). 1. Gesture use as a prelinguistic predictor of language outcomes Developmental research consistently indicates that before words emerge, gestures serve a critical function in the child’s growing expressive communication abilities (Crais, Douglas, & Campbell, 2004; Iverson & Goldin-Meadow, 2005; Watt, Wetherby, & Shumway, 2006). Towards the end of a child’s first year and into the second, deictic gestures like reaching, pointing, showing, and giving offer children a mechanism to seek linguistic input from their caregivers while engaging with a familiar adult in a social context (Iverson & Goldin-Meadow, 2005). Data indicate that children who gesture earlier and with higher frequencies develop stronger language outcomes than those who do not (Rowe, Özc¸alıs¸kan, & Goldin-Meadow, 2008; Rowe & Goldin-Meadow, 2009). The predictive relationship between gestures and vocabulary development is also present in special populations like children with Down Syndrome (te Kaat-van den Os, Jongmans, Volman, & Lauteslager, 2015). Gestures seem to impact language outcomes by first increasing a child’s receptive vocabulary, which then leads to an increase in the number of words the child uses expressively (Hsu & Iyer, 2016; Zammit & Schafer, 2011). In this way, gestures serve as a bridge between a child’s growing intent to communicate with symbolic language that makes use of arbitrary referents in the form of spoken words (Crais et al., 2004). During the late infant and early toddler period, children communicate at a rate of about once per minute, which increases to twice per minute by 18 months, and can reach levels of nearly five per minute by age two (Wetherby, Cain, Yoncles, & Walker, 1988). Gestures are one of the primary means of communicating during this period, along with vocalizations and early word forms. As children become more skilled in their gesture use, they also develop the ability to coordinate or synchronize gestures with vocalizations (Crais, Watson, & Baranek, 2009; Iverson & GoldinMeadow, 2005; Murillo & Capilla, 2016; Wetherby et al., 1988). Combining gestures and speech sounds is an intermediary step between gesturing and word use (Esteve-Gilbert & Prieto, 2014), and it is an important milestone in a child’s language development. During the toddler period, children reduce the proportion of utterances that are gesture-only or vocalization-only and begin to increase their rates of combinations (Wetherby et al., 1988). There is preliminary data that suggests that as gestures increase, so do rates of vocalizations (Miller & Lossia, 2013). 2. The caregiver’s role in gesture development Caregivers play a critical role in supporting a child’s gesture development by responding to child gestures with words that “translate” the gesture into language and by modeling gestures to provide supportive cues that augment the adult’s linguistic input. A caregiver’s responsiveness to an infant or toddler’s gestures predicts how quickly and how well a child’s symbolic language skills develop (Dimitrova, Özc¸alıs¸kan, & Adamson, 2016; Rowe & GoldinMeadow, 2009). When a caregiver responds with words related to the child’s gesture, the child is better able to understand the adult’s verbal input because the caregiver’s words match their focus of attention (Colonnesi, Stams, Koster, & Noom, 2010; Kishimoto, Shizawa, Yasuda, Hinobayashi, & Minami, 2007; Olson & Masur, 2015). Caregivers also respond to gestures more often than vocalizations alone, perhaps because the intent behind the gesture is

often clearer to the caregiver than in vocalizations (Wu & GrosLouis, 2015; Kishimoto et al., 2007). There is also evidence that caregivers’ interaction style can alter the frequency of child gesture use. In a sample of 38 infants who were typically developing, children gestured more often in an experimental context in which their adult caregivers were instructed to consistently respond to a child’s gestures compared to a “yoked control condition” in which the caregivers gave language input that was not temporally linked to the child’s gesture (Miller & Lossia, 2013). These results indicate that child gestures are influenced by the level of responsiveness and the type of contingent input offered by the caregiver, and that children calibrate their own use of gestures based on the responses offered from the adult caregiver. Another longitudinal study indicates that children whose parents modeled pointing contingently after a child’s point produced the pointing gesture more frequently seven months later (Kishimoto, 2017). Both these studies indicate that caregiver interactional style is linked both proximally and distally to child gesture use. Yet caregivers from low SES backgrounds model and respond to gestures less frequently in the infant and toddler period than do caregivers who are middle and upper income (Rowe & Goldin-Meadow, 2009). On average, children from low-income backgrounds gesture later and less often than their middle and upper income peers (Rowe & Goldin-Meadow, 2009), and delayed gesture development may contribute to later language delays. It is possible that delays in gesture use set the stage for a slower transition to symbolic language, and that targeting gestures specifically could support a child’s ability to build his or her receptive and expressive vocabularies.

3. Interventions to support gesture use While there are a number of language interventions that seek to support child language in the preschool period, fewer interventions target gesture use in young children who are at risk for communication delays due to their low-SES backgrounds (Vallotton, 2009). Some studies have taught “baby signs” or symbolic gestures to support infant and toddler communication (Vallotton, 2012), but fewer interventions teach deictic gestures as a primary outcome. In one recent experimental study of 15 children of middle and upper SES backgrounds, researchers prompted children to point during interactions with the experimenter (LeBarton et al., 2015). Findings indicate that the experimental condition led to increased gesture types and an increase in gestures used with caregivers in a generalization condition. This study offers evidence that an adult’s use of prompts can facilitate an increase in gesture use in a structured experimental condition. LeBarton et al. (2015) were careful to note that the children in this study were from middle and upper SES backgrounds, and that it was possible that caregivers “picked up” modeling and prompting gestures in the generalization context based on their observations of clinicians’ interactions during the intervention. Further examinations of gestural interventions are needed to establish evidence-based practices in supporting early deictic gesture use in toddlers experiencing poverty (LeBarton et al., 2015). While few approaches aim to increase deictic gesture use in toddlers at risk due to poverty, there is a large body of work that teaches gestures and other early communication skills to children with disabilities. These approaches contain strategies that could facilitate word learning for children who are at risk due to SES. Chief among these interventions are prelinguistic milieu teaching (PMT; Yoder & Warren, 2002) and enhanced milieu teaching (EMT; Kaiser & Roberts, 2013). Both PMT and EMT are naturalistic, play-based approaches that emphasize noticing and responding contingently

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to a child’s prelinguistic and symbolic utterances, arranging the environment to create opportunities for the child to communicate (i.e., in sight out of reach/sabotage/assistance needed), and modeling gestures in conjunction with simple, targeted word labels. PMT and EMT also use contingent imitation (termed mirroring in EMT), and prompting hierarchies aimed at encouraging child communication. PMT was designed for use with children who are not yet symbolic language users to increase their rates of communication (Yoder & Warren, 2002) and EMT primarily targets children who are symbol users (Kaiser & Roberts, 2013; Brown & Woods, 2016). Both PMT and EMT have been evaluated in single-case and group designs, and have sizeable evidence bases. These approaches serve as the theoretical and empirical foundation of the intervention evaluated here. Both approaches support gesture use by emphasizing noticing and responding to gestures with an adult gesture and words, and both emphasize creating opportunities through environmental arrangements to encourage child communication. In order to develop an intervention tailored to infants and toddlers with low SES backgrounds, we took the core components of PMT and EMT and modified some components for use with toddlers at risk for delays due to SES. Based on the findings in the developmental literature base regarding the link between caregiver modeling of gestures, we emphasized this component in the strategies used in this work and included minimum numbers of adult modeling of each deictic gesture type (POINT, SHOW, GIVE, and REACH). Unlike EMT and PMT, we did not include prompting procedures to encourage child gesture use, though we did set up opportunities for the child to communicate. We hypothesized that because children in this study were typically developing, they were not likely to need high levels of specific prompting. Rather, we suspected that communication temptations would be sufficient to create opportunities for the child to gesture. If a child did not respond to an opportunity to gesture, we followed their attentional lead and instead modeled a gesture rather than following a specific prompting hierarchy. Also, EMT includes an emphasis on contingent imitation of the child’s actions. Imitation of play actions was not included in the fidelity measure used in this study, although the interventionists may have imitated the child’s play actions incidentally. Interventionists did imitate the child’s gesture when expanding their utterances. The intervention tested in this study has three primary components based on PMT and EMT that will be referred to by the acronym MORE (Modeling, Opportunities, and Respond/Expand: (1) explicitly teaching deictic gestures by modeling them at a high frequency in interactions (2) setting up opportunities to communicate by intentionally managing materials to create communication temptations and (3) by responding/expanding each gesture with another gesture and a short phrase (if the child points to a dog, we pointed and said “dog!”). By teaching foundational prelinguistic skills like deictic gesture use, it may be possible to accelerate a child’s acquisition of symbolic language by increasing the number of word-learning opportunities that children are able to access (LeBarton et al., 2015). This pilot examination of the use of MORE as a brief intervention uses a single-case, multiple probe design to examine whether the systematic use of strategies embedded in typical everyday activities increases the rate at which toddlers who are at risk for language delays due to poverty gesture and use other forms of prelinguistic and early symbolic communication. Research questions are as follows: 1. Does the use of a naturalistic gesture intervention increase deictic gesture use in toddlers who are at risk of language delays due to low-SES during commonly occurring play and book reading routines? 2. Does the use of a naturalistic gesture intervention increase the child’s overall rate of combining gestures and vocalizations in

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Table 1 Child demographics.

Age in months at entry PLSTM -5 CSBSTM at entry IGDI-ECI at entry IGDI-ECI post intervention

Child 1

Child 2

Child 3

18 112 86 28 42

14 101 74 13 21

18 105 73 19 36

Note. PLS-5 = Preschool Language ScaleTM 5 (Zimmerman et al., 2012). CSBS = Communication and Symbolic Behavior Scales-Developmental ProfileTM (Wetherby & Prizant, 2002). IGDI-ECI = Individual Growth and Development Indicator-Early Communication Index (Luze et al., 2001).

toddlers who are at risk of language delays due to low-SES during in commonly occurring play and book reading routines? 3. Do children maintain rates of deictic gesture use when intervention strategies are not used, or do their rates return to baseline levels when the intervention condition is withdrawn? 4. Method 4.1. Participants Two girls and one boy between the ages of 13 months and 18 months at entry participated in the study. Children were included if they were not eligible for Part C services, were between 12 and 18 months of age, and met the income qualifications of EHS programs. Participant children attended an Early Head Start (EHS) center, and their families qualified for services based on their low-income levels. Two of the three children were African-American and one child was biracial (African-American and Caucasian). See Table 1 for descriptive data on child participants. None of the children had identified delays or disabilities and all fell within normal limits on the Preschool Language Scale 5TM , ([PLS-5]; Zimmerman, Steiner, & Pond, 2012). All three children, though, were beginning to show evidence of delays on the behavior sample of the Communication and Symbolic Behavior Scales-Developmental ProfileTM , (CSBS; Wetherby & Prizant, 2002). Standard scores are reported in Table 1. Both the PLS-5 and the CSBS were administered by the first author prior to baseline to establish that children met the inclusionary criteria for the study. 4.2. Interventionists The interventionists in the study were the first and second authors of this paper, with backgrounds in speech-language pathology and early childhood special education respectively. The first author had five years of clinical experience with children and families in early intervention, and the second author has 20 years’ experience working with children and families. Each interventionist was paired with a child, and except in the cases of interventionist illness or travel, was the primary partner for the child. The first author was the interventionist for Child 1 and Child 3. The second author was the interventionist for Child 2. 4.3. Materials Materials included a set of toys and books that were selected based on two criteria: (1) that they were commonly found in early childhood settings, and (2) that they could be used to create opportunities to gesture. We chose not to use classroom materials in the EHS classrooms because there were not enough to put aside for the intervention without taking materials away from the other children in the classroom. Also, using a standardized set of materials helped us to keep control over the intervention since different materials were available in each room. Toys included: a set of clear

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Table 2 Deictic gesture and gesture combination coding definitions. Communication act

Definiton

Examples

Non-examples

Point (proximal and distal)

The child extends their arm and index finger in the direction of an object, in contact with an object, or toward an individual in an effort to direct the caregiver’s attention toward it. Points are separated when the child moves her point to a new referent, or when she retracts and extends her arm again.

The child sees a bag of toys on the table he/she is curious about and extends their arm with their index finger out toward the bag of toys.

The child is holding a doll and uses her index finger to open and shut the doll’s eyes.

Show

The child holds an object up in front of the caregiver in her line of sight.

The child has a toy block in her palm, with the block still in their hand they raise it up toward the adult. The child does not release the object to the adult.

The child holds up a clock in front of herself to examine it and then places it back down on the table.

Give

The child hands an object to the interventionist and releases the object. If she does not release the object and orients it toward the interventionist, code as a SHOW.

The child gives the interventionists a container when she is unable to open it herself.

The child has a toy ball in their possession and then places it down on the table near the adult.

Reach

The child opens their hand and extends it toward an object of interest (typically repeating the action of opening and closing their hand).

The child sees the caregiver has the toy car he/she wants to play with and in an effort to communicate that she wants it, the child extends their arm toward the object and opens and closes their hand, while shifting their gaze to an adult.

The child extends their arm toward an object that is on the table in an effort to take it.

Vocalization + gesture

Child produces a vocalization and a gesture, both produced with temporal overlap.

Child says “amadada” when reaching with an open hand toward the baby doll.

The child vocalizes, pauses, then shows the adult her toy phone.

Single word + gesture

Child produces a word and a gesture, both produced with temporal overlap. Words must contain at least half the phonemes (sounds) of the adult form for the word.

Child points and says “doggie” when looking at a book.

Child says word but does not combine with a gesture.

®

blocks with objects inside (Fisher Price Peek a BlocksTM ), a shape ® sorter, rolling toys (Little People ), a helicopter with a pull string that activates it, a baby doll with cups, pretend food, utensils, diaper, wipes, and comb. Books were chosen if they had pictures with people or animals doing everyday activities (i.e., eating, playing, taking a bath), as well as multiple items to label on each page. Two of the four books were lift-the-flap books and all four had short written phrases on each page.

4.4. Setting All intervention sessions took place in the childcare setting (EHS) with the interventionist. Interactions were one-on-one between the interventionist and the child. If other children came over to engage, the interventionist gave them toys from the classroom and resumed interacting with the focal child. Because two of the three children were in the same class, interventionists ensured that the other the focal child was engaged with the classroom teacher when the other participated in intervention sessions. This supported a consistent dosage of intervention across children and maintained control when staggering the introduction of the intervention.

4.5. Measures 4.5.1. Preschool Language Scale 5TM (PLS-5; Zimmerman et al., 2012) The PLS-5, a standardized measure of expressive and receptive communication for children ages birth through age seven. The assessment was administered to provide a description of each child’s language skills before intervention.

4.5.2. Communication and Symbolic Behavior Scales-Developmental ProfileTM (CSBS; Wetherby & Prizant, 2002) The CSBS is standardized measure of early communication in children ages eight to 24 months that uses communication temptations to encourage communication. In addition to early language, the CSBS examines joint attention, communicative functions, gestures, and rate of communicating. The CSBS was also administered to describe each child’s early communication skills prior to intervention. 4.5.3. Language sample analysis and gesture coding Each baseline, intervention, and maintenance session was video-recorded, uploaded, and coded using the Systematic Analysis of Language Transcripts (SALT; Miller & Chapman, 2000) to identify the child’s rate of each type of deictic gesture (show, point, reach, give) and the rate of overall communication including vocalizations and words if applicable. Deictic gestures were chosen as the primary dependent variable because they emerge earlier than conventional gestures like nodding or shaking the head, and because strengths in the use of deictic gestures, especially pointing, is a predictor of later language development. Definitions of deictic gestures drawn from Rowe and Goldin-Meadow (2009). Gestures were defined to be distinct from play actions that were not oriented to the adult communication partners. Vocalizations and single words were scored and reported as secondary measures used in combinations with gestures and were transcribed according to SALT guidelines. Definitions and examples for gestures and gesture combinations are found in Table 2. 4.5.4. Individual Growth and Development Indicator-Early Communication Index (IGDI-ECI) The IGDI-ECI (Luze et al., 2001) is a tool used for monitoring growth in expressive communication in children from six to 42 months. This six-minute, play-based communication sample

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Baseline Intervention Maintenance

Interobserver agreement (Cohen’s kappa) 0.86 Procedural fidelity 28.20% Interventionist 1 Interventionist 2 17.23%

0.90

0.82

90.20% 88.00%

23.50% 19.50%

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Table 4 MORE fidelity protocol. Strategy type

Specific strategies

Model

1. Model point gesture a minimum of 3 times. 2. Model show gesture a minimum 3 times. 3. Model give gesture a minimum 3 times. 4. Multiple models occur in at least two routines-play and books.

Opportunities

measures the child’s vocalizations, gestures, words and word combinations through direct observation and event recording. During the play sample, the administrator minimizes his or her use of questions and responds naturally to the child’s communication. The IGDI-ECI is intended to be repeatable in order to track the child’s communication development over time. A weighted Total Communication score is generated by multiplying the number of single words by a factor of two and multiple words by a factor of three; gestures and vocalizations are counted individually. The IGDI-ECI weighted Total Communication score has concurrent validity of 0.62 with the PLS-3 (Zimmerman, Steiner, & Pond, 2002). The IGDI-ECI has been used as a tool to measure the expressive communication of young children at risk for delays due to poverty (Greenwood, Walker et al., 2013; Greenwood, Buzhardt, Walker, McCune, & Howard, 2013) The IGDI-ECI was administered during baseline and after the intervention as a measure of generalization.

5. Use at least one environmental arrangement strategy per routine (in sight and out of reach, assistance needed) 6. Use wait time a minimum 3 times. 7. Offer at least two choices in the interaction. Respond/expand 8. Respond with a gesture and a single word or 2–3 word phrase at least 80% of the time the child reaches. 9. Respond with a gesture or a single word at least 80% of the time the child shows a toy/object. 10. Respond with a gesture and a single word or 2–3 word phrase at least 80% of the time the child points to a toy/object. 11. Respond with a single word or 2–3 word phrase at least 80% of the time child gives to a toy/object. 12. Follow the child’s lead if he or she shows interest in another toy.

4.6. Interobserver agreement (IOA) Undergraduate researchers were trained to 80% criterion on SALT transcription and on the gesture coding by using samples of caregiver–child interactions from another study. Coders were all blind to the purposes of the study. The initial training included written and practice materials on SALT and on definitions and examples of gesture use. Coders transcribed and coded three segments which were scored against the master transcript, and each reached 80% agreement. Thereafter, coders conducted IOA analysis on thirty percent of sessions. Final reliability data were analyzed using Cohen’s Kappa to correct for the possibility of chance agreements. See Table 3 for a detailed report of IOA for gesture coding in each condition. 4.7. Intervention fidelity Intervention fidelity was conducted on baseline, intervention and maintenance sessions. The fidelity protocol included 12 items listed in Table 4. Some use of items was expected during baseline and maintenance (i.e., items 7 and 12), but the interventionists did not complete the remaining items during baseline and maintenance. A discussion of items on the protocol follows in the intervention description. Each intervention session lasted about ten minutes (range = 9–13 min). Intervention fidelity was measured by an independent observer on all sessions and averaged 89.75 during intervention. Intervention sessions occurred three times a week until children reached at least ten intervention sessions. 4.8. Experimental design and conditions This study used a multiple-probe, across-subjects single case design that included replications across three children (Gast, Lloyd, & Ledford, 2014). The study was designed to meet the What Works ClearinghouseTM Standards for Single-Case Design (Kratochwill et al., 2010). We gathered a minimum of five points in the baseline condition and in the intervention condition for each child, and at least three consecutive points were collected immediately prior to the introduction of the intervention. A second and third participant began intervention when there was a consistent upward trend

established for the child that preceded them. Participants entered the maintenance condition after they met the a priori criterion of ten intervention sessions in which they had rates of deictic gesture use above the baseline condition. The primary dependent variable was the child’s rate of deictic gesture use. Secondary outcome measures included the child’s rate of gesture + vocalization combinations and gesture + word combinations. Experimental control was established by staggering the introduction of the intervention condition between participants. 4.9. Baseline During the baseline condition, the interventionists used the materials described above to engage the child in play and in book reading three times per week for about 10–15 min sessions. The interventionist used the materials to describe what the child was doing and responded to the child’s vocalizations and gestural attempts to communicate with descriptive language. During baseline, the interventionist did not model gestures or set up temptations to communicate (i.e., by offering choices, using wait time, or other strategies). Each baseline session included time spent in play and reading books, though the exact proportion of time differed between children depending on his or her interest. Book reading was the shorter of the two interactions and lasted at least three minutes of each session. 4.10. Intervention Once the first child reached five baseline sessions, with at least three consecutive sessions exhibiting a stable rate of gesture use, he or she moved to the intervention condition described below. The intervention fidelity protocol for the MORE strategies (see Table 2) was drawn from the literature on EMT and PMT (Kaiser & Roberts 2013; Yoder & Warren, 2002). 4.10.1. Modeling The interventionist intentionally modeled gestures like showing objects (showing a cup to the child and pairing it with the word “cup!”), pointing (pointing to objects placed out of reach—“there’s

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the helicopter!”), and by doing an open handed reach toward the child. Gestural models were done at a high frequency in this intervention at a rate of at least three models per gesture type (point, show, give) per interaction. Fidelity coding indicated that interventionists exceeded the minimum requirements for gestural modeling. 4.10.2. Opportunities The interventionist used the materials to set up opportunities to gesture via choices (“Blocks or books first?” while holding up the objects); wait time (holding up a block near her face with an expectant look to set up a reach from the child) and in sight but out of reach (putting a desired toy on the table just a bit out of reach). Choices, wait time, and in sight but out of reach are used in PMT/EMT to set up an opportunity to communicate (Kaiser & Roberts, 2013). These strategies are naturalistic because they can be used in everyday interactions and do not rely on heavy prompts to the child. They are also adaptable for different levels of child communication because the adult can add support if the child does not respond with a gesture by offering additional cues. Intentional use of the materials was a major focus of this intervention. For instance, if the child had all the blocks in front of her, the interventionist would take a few back so that she could set up wait time or another other occasion for the child to reach. If she knew a child had a particular interest in a certain toy, she would set it up across the table with a few other toys to encourage a gesture. 4.10.3. Respond/expand The interventionists then expanded the child’s communication by adding on a word or short phrase in response to the child’s gesture. If the child points to a picture of a muddy dog in a picture book, the adult could respond and expand by pointing at the same picture and saying “muddy doggie!” The interventionist had to respond to the child’s gesture with a gesture and short phrase of her own at least 80% of the time to be credited for that item. Responses and expansions are found in EMT and PMT and are known to predict child vocabulary development in descriptive research. 4.11. Maintenance After completing at least ten sessions with an upward or stable trend, children entered the maintenance phase. As in the baseline phase, interventionists did not create specific opportunities to gesture by offering choices, using wait time, or modeling points, shows, give or reach gestures. As in baseline, the interventionist engaged with the child and the materials by playing and reading together and by responding with contingent language when the child communicated with vocalizations, gestures, or words and by using general descriptive talk but not with expansions that included gestures. The interventionists’ responses only included contingent language. Like intervention sessions, maintenance sessions lasted about ten minutes each and were gathered in the weeks after intervention concluded. 4.12. Generalization The IGDI-ECI (Luze et al., 2001) was used as a generalization probe before and after intervention. As described in the measures section, the IGDI-ECI uses a toy barn set with animals as well as an alternate toy form (www.igdi.ku.edu). Like the baseline and maintenance phases, the adult who conducted the IGDI-ECI did not create specific opportunities for the child to gesture and she did not deliberately model gestures for the child. With one exception, the IGDI-ECI was administered by the interventionist who was not the child’s primary partner. The one exception was Child 3, who had

Table 5 Ranges of child deictic gesture use across phases. Baseline

Intervention

Maintenance

Child 1 Rate of deictic gesture use Rate of gesture + vocalizations Rate of gesture + words

0.33–1.38 0.0–0.28 0.00–0.14

2.38–4.95 0.57–2.07 0.0–2.86

0.91–3.0 0.27–0.55 0.27–1.09

Child 2 Rate of deictic gesture use Rate of gesture + vocalizations Rate of gesture + words

0.64–1.33 0.0–0.74 0.00

2.4–5.3 0.74–2.24 0.0–0.29

2.0–3.0 0.0–0.06 0.1–0.3

Child 3 Rate of deictic gesture use Rate of gesture + vocalizations Rate of gesture + words

0.3–1.28 0.0–0.4 0–0.29

1.5–2.6 0.2–0.5 0.5–1.25

2.82 0.20 1.25

Note: All values represent rates per minute.

Interventionist 1 for his intervention sessions and for his first IGDIECI before beginning intervention. These probes were intended to see if children would generalize their skills to a new partner and new set of materials.

4.13. Data analysis Results were analyzed with a standard protocol for visual analysis (Kratochwill et al., 2010) and with a design-comparable, between-case effect size measure that estimates an intervention effect that is on the same scale as the standardized mean difference commonly used in group design research (Pustejovsky, Hedges, & Shadish, 2014; Shadish, Hedges, Horner, & Odom, 2015). Data were first examined for changes in level, trend, immediacy, and variability. Functional relationships were determined by establishing that changes to the primary dependent variable – the rate of child deictic gesture use – occurred only after the onset of intervention (Kratochwill et al., 2010). See Table 5 for rate of child gesture use by condition. Next, we used the Pustejovsky et al. (2014) method to determine an effect size for the primary dependent variable, the rate of deictic gesture use (Pustejovsky et al., 2014). This between-case effect size measure estimates a hierarchical linear model based upon the single case data, and is increasingly used in single case research, in systematic reviews, and in meta-analyses (Odom, Barton, Reichow, Swaminathan, & Pustojovsky, 2018). This method was chosen because it offers an effect size on a scale that is comparable to group design studies (the d statistic), enabling it to be reported in future meta-analyses (Shadish et al., 2015). It also has advantages over other measures because it corrects for auto-correlation in a way that other within case effect size estimators do not (Pustejovsky et al., 2014). We calculated the d statistic by using a web application designed to generate the between-case standardized mean difference effect size for single case research that includes a correction for small sample size and which used the restricted maximum likelihood estimator (https://jepusto.shinyapps.io/scdhlm/) The between-case standardized mean is limited in that it does not have an alternative for use in multiple baseline designs across behaviors or settings, but which are replicated across participants (Odom et al., 2018). However, this study employed a multiple probe design across participants, which is suited to this effect size measure. For the primary dependent variable (rate of deictic gesture use), we used a model that included a stable baseline trend and a linear growth predictor in the intervention phase. The linear term was added because a visual inspection of the data indicated a positive upward trend during intervention.

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Fig. 1. Rates of child deictic gesture use and gesture combinations across participant.

5. Results All three participants showed an increase in their use of deictic gestures subsequent to intervention. Specific trends and secondary dependent variables are described below and are displayed in Fig. 1. 5.1. Child 1 5.1.1. Deictic gesture use Child 1 had a stable baseline rate of deictic gesture use that ranged between 0.33 and 1.38 per minute. At the onset of the intervention condition, her rate of deictic gestures increased with a range of 2.38–4.95 deictic gestures per minute. A subsequent change in level between baseline and intervention is evident, with little variability after the first three sessions. There was no overlap between baseline and the intervention condition. Data in the intervention condition displayed an increasing trend that became level once Child 1 reached four gestures per minute. During the maintenance condition, Child 1 remained well above baseline, but lower than the intervention condition. 5.1.2. Gesture and vocalization combinations Child 1 had a rate of gesture and vocalization combinations near zero in baseline (range = 0–0.28). Immediately after intervention began, her rate of gesture + vocalization combinations increased (range = 0.57–2.07). There was a visible change in level, and increasing trend as the sessions progressed. Midway through the intervention, these combinations decreased as gesture + word combinations increased. These two skills appeared to cross one another around session six and seven. During maintenance, her ges-

ture + vocalization combinations decreased to levels slightly above baseline. 5.1.3. Gesture + single word combinations Child 1 had a low and stable rate in baseline near zero (range = 0.0–0.14). During the intervention condition, her rate of gesture word combinations stayed near zero until about half way through the intervention (6 sessions), at which point her rate of gesture + word combinations increased and her gesture + vocalization combinations decreased. During maintenance, her rate of gesture + word combinations decreased from its peak in the intervention condition. 5.1.4. Generalization Child 1 decreased her rate of deictic gestures during the IGDI-ECI from 1.8 to 0.85. However, her overall weighted communication score on the IGDI-ECI increased from 28 to 42. Her gains were attributable to a greater use of single words and a few word combinations. This trend is similar to her results in the intervention data in which she decreased vocalizations combinations in favor of gesture + word combinations. During this probe, the alternate interventionist administered the play sample in a manner similar to baseline conditions without the use of MORE strategies. 5.2. Child 2 5.2.1. Deictic gesture use The baseline condition for Child 2’s use of deictic gestures ranged from 0.64 to 1.33, with a stable trend. After beginning intervention, her rate of gesture use immediately increased and the data

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indicated an increasing trend thereafter in the intervention phase (range = 2.4–5.3). There are no points in the intervention phase that overlap with the baseline phase for the rate of deictic gesture use. When the intervention was withdrawn in the maintenance phase, Child 2’s rate of deictic gestures dropped from the intervention phase to levels above the baseline condition. 5.2.2. Gesture + vocalization combinations Child 2 had a low and stable rate of gesture and vocalization combinations during baseline, at levels slightly below her rate of deictic gesture use (range = 0.0–0.75). After the onset of intervention, her rate of gesture + vocalization combinations increase slightly, with some points overlapping with the baseline condition. Her rate of gesture + vocalization use mirrored her deictic gesture use until the end of intervention, when her combinations decrease slightly. At the end of the intervention, she continued to have a high rate of gesture use, but her combinations fell from her mid-intervention highs. Her range in the intervention phase was 0.74–2.24. During maintenance, her gesture + vocalization combinations returned to baseline levels. 5.2.3. Gesture + word combinations Child 2 had near zero rates of gesture + word combinations in baseline and did not show any change during intervention. Child 2 was the youngest of the three participants at 14 months, and since the intervention was one month in duration, she did not make a transition to single word use during that time. Her maintenance levels remained near zero for gesture + word combinations. 5.2.4. Generalization Child 2 increased her rate of deictic gestures during the IGDI-ECI from 1.1 gestures per minute pre-intervention to 1.7 gestures per minute. Her overall weighted communication score on the IGDI-ECI rose from 13 to 21. During this probe, the alternate interventionist administered the play sample in a manner similar to baseline conditions without the use of MORE strategies. 5.3. Child 3 5.3.1. Deictic gesture use Child 3 had a rate of deictic gesture use during baseline between 0.29 gestures per minute and 1.2 gestures per minute. His baseline phase was the longest of the three participants, spanning about five weeks. After the start of intervention, Child 3 immediately doubled his deictic gesture use and maintained that increase throughout the intervention condition (range = 1.5–2.7). There was no overlap with baseline on the primary dependent variable of rate of deictic gesture use. Child 3’s rates during intervention were largely stable with a slight increase in trend toward the end of intervention. Because Child 3 was the final participant to begin in the multiple probe design, his intervention occurred during the last month of the school year. As such, it was not possible to gather additional maintenance data for him. During the maintenance probe, he continued to gesture at a rate similar to the end of intervention at about three gestures per minute. 5.3.2. Gesture + vocalization combinations Child 3 had gesture + vocalization combinations near zero in the baseline phase. After the start of intervention, he increased his rate of combinations slightly, representing a small change in level (range = 0.21–0.47). The trend during the intervention phase was fairly stable. His rate of gesture + vocalization combinations during maintenance decreased to a level near baseline at 0.19 per minute.

5.3.3. Gesture + word combinations Child 3 had baseline levels of gesture + word combinations near zero in baseline (range = 0.00–0.28). After the start of intervention, he immediately increased his rate of gesture + word combinations with a range of 0.49–1.25. His rate of gesture + word combos was somewhat variable with an increasing trend initially, a slight dip, then another increasing trend at the end of intervention. His maintenance probe showed a rate higher than the intervention phase at 1.25 gesture + vocalization combinations per minute. 5.3.4. Generalization Child 3 increased his rate of gesture use in the generalization probe from 0.17 gestures per minute to 0.5 gestures per minute in the post-test probe. His overall weighted communication score rose from 19 to 36. Like Child 1, his gains included the use of single words, which increased his Total Weighted Communication score. 5.4. Between case standardized mean difference The between-case standardized mean difference for the primary dependent variable, the rate of deictic gesture use, was 3.42 (SD = 1.02). As described above, this effect size is drawn from a hierarchical linear model based on the single-case data, calculated with a 95% confidence interval. This effect size was calculated as a supplement to the visual analysis of the data. 6. Discussion This study offers preliminary data about the effectiveness of an intervention designed to increase the rate of deictic gesture use in toddlers at risk for language delays due to their SES. All three children showed immediate and positive changes in their rates of deictic gesture use that only occurred after the onset of intervention, and all obtained rates of gesture use outlined in descriptive research as being typical of their age range (Wetherby et al., 1988). Two of the three children showed effects in their rate of gesture + vocalization combinations and two showed effects in their gesture + single word combinations. While this investigation does not offer data about the long-term impact on child language outcomes, it does illustrate a functional relationship between the use of this specific set of naturalistic strategies and rates of child gesture use. For children who are at risk for language delays due to poverty, this intervention offers a naturalistic means to help boost children’s rate of deictic gesture use during a critical period of early development. While we were not able to measure the long-term impact on child outcomes, we can see that the strategies themselves lead to higher rates of deictic gesture use in an experimental context. If these strategies can be shared with caregivers who can embed them frequently in daily routines, the prospects for long-term change in child gesture use and subsequent language development increase. 6.1. Utility of environmental arrangement, wait-time, and modeling to encourage gestures The findings from this study are important for several reasons. First, while it is well established that responsive language interactions are important for child language development (Rowe & Goldin-Meadow, 2009; Guttentag et al., 2014), there may be rationale for using additional strategies to support the use of gestures in toddlers from low-SES backgrounds at-risk for delays. Frequent gestural models and environmental arrangement strategies were key components in the intervention phase. Because baseline and maintenance phases included responsive interaction strategies alone, the gains in the intervention phase were due to some combination of modeling gestures, managing the materials to set up communication temptations, and by using wait time (i.e. the MORE

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strategies). The increase in the intervention context offers preliminary evidence that using additional supports could increase child gesture use during a critical developmental window. While we cannot pinpoint which of the MORE strategies was the most impactful via the experimental design used in this study, we do see evidence that the combination of strategies led to a higher rate of gesture use than responding with contingent language alone. The MORE strategies used in this study differ from that of earlier experimental work on deictic gestures that are based on specific prompts like asking children to point (LeBarton et al., 2015) and could increase the strategies available for increasing child rates of gesturing in naturalistic contexts. While we used a standardized set of toys for consistency between children, the materials were common in early care settings, and were based upon typical play and book reading interactions. This allowed the interventionists to individualize strategy use based on child interest. For example, Child 3 enjoyed block play, so the interventionist set up occasions for him to reach by taking possession of a few, offering choices between blocks with different objects inside, and putting some out of reach to encourage a point. He also enjoyed pretend play with the dolls and taking turns with those materials gave him chances to develop play skills as well as functional occasions to reach and give in the context of a play routine. Child 2 preferred book reading, so the interventionist engineered choices between books, intentional modeling of points to items of interest on the page, and setting desired books in sight but out of reach. Tailoring strategies to child interest allowed us to follow the child’s lead while still facilitating gestures within contexts naturally occurring contexts. If this intervention is used with caregivers in homes and centers, caregivers could play an important role in identifying child preferences, everyday materials, and in problem-solving how to use the child’s interests to encourage gestures. These data also seem to indicate that the adult’s modeling of gestures could also be critically important, which aligns with findings from descriptive research (Kishimoto, 2017). Kishimoto (2017) found that toddlers whose caregivers also gestured within 7 s of the child’s point gestured more and continued to do so months later. The toddlers in this study seemed to calibrate their gesture use to the adults’ interaction style between phases. When the gestural models and environmental arrangement strategies were withdrawn in the maintenance phase, their rates of deictic gesture use dropped, though still above baseline. Child 2, in particular, seemed to drop the most quickly to near baseline levels. She was the youngest of the three at 14 months and may have been the most sensitive to the adult’s interaction style. This data seems to indicate that children match their gestural use to that of their communication partner, which also echoes the Miller & Lossia (2013) data in which a child’s gesture use dropped when caregivers ended their contingent responses.

not only did children increase their rates of gesture use, they also became more sophisticated in how they used them by pairing them with either a vocalization or a word. While studies of this nature always face threats to external validity due to maturation, it is evident that the changes to the child’s rate of deictic gesture use was immediate, making it less likely that these changes were unfolding in the course of development.

6.2. Impact on gestural combinations

6.4. Limitations

A second important finding in this intervention was that children’s increase in deictic gesture use seemed to be accompanied by gains in gesture + vocalization combinations or gesture + word combinations. Which of these two secondary outcomes illustrated gains depended somewhat on the child’s overall developmental level. For instance, Child 3 did not markedly increase his gesture + vocalization combinations, but because he had single words in his expressive vocabulary, he made gains in the gesture + word combinations outcome, a more complex developmental skill. Child 1 was transitioning from vocalizations to single words, so she first increased gesture + vocalization combinations, and then increased gesture + word pairs. The increase in the participants’ combinations may have been in response to the interventionists’ consistent paring of a gestural model with a short phrase. These data indicate that

The data from this study face limitations inherent in single-case designs (SCDs). SCDs use a small number of children to tightly control an intervention and to measure its differential effects across participants, so it is difficult to make claims about how well other children would respond to the same intervention. We chose children who demographically represent other toddlers who are from low-SES backgrounds. These participants attended an EHS center, which are generally of higher quality than other private child-care arrangements for children in poverty at the preschool level (Coley, Votruba-Drzal, Collins, & Cook, 2016). Children who experience the most severe poverty and the lowest quality language environments may respond differently than the children in this sample. Maturation is typically a limitation in SCDs involving very young children, and it is possible that some gains were achieved because

6.3. Future directions The relationship between adult communication style and strategy use and rates of toddler gesture use underscores the need to share these strategies with caregivers in home and community settings, particularly with children at-risk for delays. While this study was conducted via one-on-one interactions with children to test its effects before coaching caregivers to use it, the strategies are adaptable for use in small groups of toddlers in early care and education settings and for use with caregivers in home-based models. Prior research has indicated that EHS teachers, in particular, can embed strategies in their daily classroom routines when engaged with systematic coaching approaches (Romano & Woods, 2017), and it is well established that caregivers can implement communication supports in their daily routines and activities (Brown & Woods, 2016; Kashinath, Woods, & Goldstein, 2006). The MORE strategies can be embedded in daily childcare routines in homes and in centers, in part because it uses everyday materials and because the strategies build upon responsive interventions that can be used across routines and contexts. We also felt that it was important to use two routines when examining these strategies – both play and book sharing – to ensure that center-based caregiver and parents would have a range of options when embedding these strategies. Future research should evaluate whether caregivers can implement this intervention with fidelity when coached with and evidence-based approach, whether child gains are achievable with a somewhat lower dosage of strategy use that is inevitable in a small group of toddlers or in less controlled community settings, and whether the strategies have social validity for caregivers in early care and education programs. These strategies should also be tested in home-based settings, both in Part C services for children with multiple risks and in Early Head Start home visiting programs. It is also important to examine the long-term effects of gestural interventions like the one presented here by scaling up the intervention and measuring changes longitudinally. While increasing gestures is a critical first step, the long-term goal remains supporting children’s language outcomes well beyond the infant-toddler period. Longitudinal studies that examine the impact of early gestural interventions on child language outcomes are critical to establishing the impact of targeting gestures as an early communication support to children at risk for delays due to poverty.

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the children developed during the study. However, we were able to demonstrate that changes to children’s rates of gestures were seen after the onset of intervention, and the study itself only lasted about one month for each child. While we gathered maintenance data, Child 3 only had one data point because the school year ended before we could gather more, limiting our ability to interpret his trends after intervention. 6.5. Implications The impact of poverty on child communication development begins at birth, and its cumulative effects can last into adulthood. Efforts to combat the word gap should begin early (Guttentag et al., 2014), although there is far less research on how to support infant and toddler communication outcomes before symbolic language emerges. This study contributes evidence regarding specific strategies that can increase deictic gesture use in toddlers at risk for delays due to low SES. Supporting gesture use increases the word learning opportunities that a child can access, empowering toddlers to seek information about the world around them. These findings also remind us, though, that children match their communication to that of their adult partners and that their rates of communication seem to depend on the strategies the adult communication partner uses. To maximize a child’s gestural and language development, the adults around them must consistently model, respond, and create opportunities to communicate with deictic gestures. Data from this study indicate that toddlers respond quickly and make gains in their rates and combinations of gesture use, which in turn could set the stage for greater gains in receptive and expressive language. If children who are from low SES backgrounds are equipped with stronger gestural communication skills, it is possible that they will access more word learning opportunities that support their receptive and expressive language development, if they continue to gesture at high rates. We can see in these data, though, that child gesture in the early toddler months appears to be dependent on the continued adult use of gesture-supporting strategies. With continued research and investment in gestural development and translating interventions to practice in the field among early care providers as well as parents and other caregivers, it might be possible to bridge the word gap before it fully takes shape. References Brown, J. A., & Woods, J. J. (2016). Parent-implemented communication intervention: Sequential analysis of triadic relationships. Topics in Early Childhood Special Education, 36(2), 115–124. Coley, R. L., Votruba-Drzal, E., Collins, M., & Cook, K. D. (2016). Comparing public, private, and informal preschool programs in a national sample of low-income children. Early Childhood Research Quarterly, 36(3), 91–105. http://dx.doi.org/ 10.1016/j.ecresq.2015.11.002 Colonnesi, C., Stams, G. J., Koster, I., & Noom, M. J. (2010). The relation between pointing and language development: A meta-analysis. Developmental Review, 30, 352–366. http://dx.doi.org/10.1016/j.dr.2010.10.001 Crais, E., Douglas, D. D., & Campbell, C. C. (2004). The intersection of the development of gestures and intentionality. Journal of Speech, Language, and Hearing Research, 47, 678–694. Crais, E., Watson, L. R., & Baranek, G. T. (2009). Use of gesture development in profiling children’s prelinguistic communication skills. American Journal of Speech-Language Pathology, 18, 95–108. Dimitrova, N., Özc¸alıs¸kan, S¸., & Adamson, L. (2016). Parents’ translations of child gesture facilitate word learning in children with autism, Down syndrome and typical development. Journal of Autism & Developmental Disorders, 46(1), 221–231. http://dx.doi.org/10.1007/s10803-015-2566-7 Esteve-Gilbert, N., & Prieto, P. (2014). Infants temporally coordinate gesture-speech combinations before they produce their first words. Speech Communication, 57, 301–315. Fernald, A., Marchman, V. A., & Weisleder, A. (2013). SES differences in language processing skill and vocabulary are evident at 18 months. Developmental Science, 16(2), 234–248. Gast, Lloyd, & Ledford (Eds.). (2014). Single-case research methodology: Applications in special education and behavioral sciences. New York, NY: Routledge. Greenwood, C., Buzhardt, J., Walker, D., McCune, L., & Howard, W. L. (2013). Advancing the construct validity of the Early Communication Indicator for

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Please cite this article in press as: Romano, M. K., & Windsor, K.S. Increasing deictic gesture use to support the language development of toddlers from high poverty backgrounds. Early Childhood Research Quarterly (2019), https://doi.org/10.1016/j.ecresq.2018.12.004