- Email: [email protected]
Preliminary evaluation of a low-intensity parent training program on speech-language stimulation for children with language delay
Accepted Manuscript Preliminary evaluation of a low-intensity parent training program on speech-language stimulation for children with language delay Vipula Rajesh, Lakshmi Venkatesh PII:
S0165-5876(19)30161-2
DOI:
https://doi.org/10.1016/j.ijporl.2019.03.034
Reference:
PEDOT 9448
To appear in:
International Journal of Pediatric Otorhinolaryngology
Received Date: 15 February 2019 Revised Date:
22 March 2019
Accepted Date: 31 March 2019
Please cite this article as: V. Rajesh, L. Venkatesh, Preliminary evaluation of a low-intensity parent training program on speech-language stimulation for children with language delay, International Journal of Pediatric Otorhinolaryngology, https://doi.org/10.1016/j.ijporl.2019.03.034. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title: Preliminary evaluation of a low-intensity parent training program on speech-language stimulation for children with language delay Authors:
Speech Language Pathologist and Audiologist Elixir Multi Speciality Therapy Centre Velachery, Chennai, 600042, Tamil Nadu, India
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Email: [email protected]
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Vipula Rajesh
Phone: 99529 57813
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Lakshmi Venkatesh Associate Professor
Department of Speech, Language and Hearing Sciences
Sri Ramachandra Institute of Higher Education and Research (Deemed to be University)
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Porur, Chennai, 600116, Tamil Nadu, India Email: [email protected] Phone: 9940074052
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Conflict of Interest: None
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Address for correspondence: Dr. Lakshmi Venkatesh Associate Professor
Department of Speech, Language and Hearing Sciences Sri Ramachandra Institute of Higher Education and Research (Deemed to be University) Porur, Chennai, 600116, Tamil Nadu, India Email: [email protected] Phone: 9940074052
ACCEPTED MANUSCRIPT 1. Introduction Parent-implemented intervention has found a niche in the field of childhood language disorders where parents are trained to improve language skills of children [1-4]. Parents are empowered to work with children through training programs to gain knowledge, and enhance
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their abilities to participate increasingly in the intervention process and make treatment
decisions jointly with the speech-language therapist. Extensive research has evaluated parentimplemented interventions for children with language disorders secondary to conditions such
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as autism [5-8], intellectual disability [9,10], Down syndrome [11,12], developmental delays
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and behavioural problems [13,14]. A meta-analysis on the efficacy of parent-implemented interventions reported improvement in children’s communication skills [15]. Parentimplemented language intervention resulted in improvements in language skills of children with a range of language and cognition abilities in comparison to a control group. Intervention strategies common across studies included, responsiveness towards the child’s
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communication attempts, enhancing the quality of parental language input, bringing a balance between adult-child turns at communication and reflecting on the child’s communication.
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More recently, there has been increasing interest in parent-implemented intervention exclusively for children with primary language impairment, or late-talkers, who are younger
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than 36 months of age [1-4]. Such research has been driven by the need for building an evidence base for early intervention of language deficits among children considered to be ‘atrisk’ for persistent delay in language or later literacy deficits [16]. A recent meta-analysis on parent-implemented intervention for late talkers revealed that parents could be potentially more effective than clinicians in improving the language skills of their child [17]. Parent-implemented intervention approaches for young children with delay in language range in the amount of structure during implementation. Three broad approaches
ACCEPTED MANUSCRIPT identified by Rescorla and Dale [18] include, general language stimulation [19,20], focused stimulation [12,21] and Enhanced Milieu Teaching [22,23]. Other amorphous approaches have included the use of video feedback during home training [2,3] and broad parent-child interaction therapy [1]. Broadly, general language stimulation focuses on providing rich
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language input to a child to provide opportunities for the child to listen to adult’s language input [20]. In contrast, specific target words or syntactic structures are identified and
emphasized in the language input provided as focussed stimulation [21]. Parent-implemented
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EMT is based on a conversation model of early language intervention. It involves coaching parents to respond contingently to child’s communication and use the child’s interest and
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opportunities to provide child-specific language models and promote language use by the child [23]. Clinicians may use manuals, information leaflets, videos and conduct workshops for training and coaching parents for parent-implemented intervention [15]. Research using these approaches to training have demonstrated that parents learn and acquire skills in
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responsive-interaction and can maintain the newly learned strategies in interaction to benefit their child’s communication skills. There is increasing research evidence to support that training parents can improve quality and quantity of the language input parents provide for
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their child and verbal responsiveness to the child’s attempt to communicate [11,14,24,25,26].
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Research on parent-implemented language intervention has mainly focussed on children above 24 months of age. Few research studies have included children aged between 20 and 24 months [14,21]. However, support for empowering parents of children younger than 24 months can be drawn from parallel research in the area of early infant stimulation programs for infants born prematurely and with low-birth weight, which has emphasized the need to enhance parent-infant relationship in addition to infant development alone [27]. Early intervention in general, and specifically those focussing on the parent-infant relationship and
ACCEPTED MANUSCRIPT infant development, resulted in significant improvements in cognitive outcomes in the birthto-three years segment. Service providers and parents are keen on addressing early speech-language delays among children between 12 and 24 months due to the notion that early language delays could
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indicate significant risk factors for other disorders. Children born with birth-risk factors such as, prematurity and low-birth-weight, present with lowered language performance at 12
months of corrected age [28] [29] [30]. Proportion of children with significant language
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delays at 12 months of corrected age ranged from 7-10% across studies. An additional 22%
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[30] and 33% [29] were at-risk for language delays. Within the Indian context, Mukhopadhyay, Malhi, Mahajan and Narang [31] found that 16% of very-low-birth-weight infants exhibited delay in language development or were ‘at-risk’ for language delay at 12 months of corrected age. These findings highlight that close monitoring of language development is needed for children as young as 12 months. Early language deficits may often
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be the first sign of several other neurodevelopmental disorders. Parent-education/training holds promise as a service delivery model for providing
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speech-language intervention services to young children identified with language delay or ‘at-risk’ for delay. A training program based on general speech-language stimulation can
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serve as the first step in the intervention for children identified as having delay or ‘at-risk’ for delay in language. The current study was motivated by the need to empower families of children to initiate home-based intervention to improve the child’s language development earlier than 24 months of age. A specific target group included parents of children born with birth risk factors visiting the developmental follow-up clinic in a tertiary care hospital. The current study aimed to develop and assess implementation of a brief training program for parents to provide speech-language stimulation to their child.
ACCEPTED MANUSCRIPT 2. Method 2.1 Framework for the training program A manual with content of the training program was developed and validated in the first phase
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of the study to serve as a framework for the intervention sessions. The manual comprised of three broad sections 1) speech-language milestones, 2) play development and 3) speech-
language stimulation strategies. The section of speech-language/communication milestones
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included three receptive and expressive language milestones each occurring in the age ranges of 7-9, 10-12, 13-15, 16-18, 19-21 and 22-24 months of age. The section on play
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development described development of various types of play exhibited by typically developing children including exploratory play, functional play, social play and pretend play with suitable illustrations. The section on speech-language stimulation strategies focussed on description of strategies to provide rich linguistic input to the child (paying attention to the
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child’s interest and responding/commenting, self-talk, parallel-talk, pairing words with action, modelling), reflect on the child’s verbal productions (echoing, expanding child’s utterance) and increase the child’s verbal output by encouraging interaction rather than being
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directive and asking questions (prompting, time delay, choices). The manual concluded with a few general tips for communicating with the child.
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The manual developed in English and Tamil simultaneously was validated by five
SLPs each who rated their agreement of ten statements on a 10 cm visual analogue scale. Statements covered appropriateness of content, examples, concepts, vocabulary and script of the manual as well as the need and benefits of using the manual. The scores were interpreted as strongly agree (8.1-10 cm), agree (6.1-8 cm), neither agree nor disagree (4.1- 6 cm), disagree (2.1- 4 cm) and strongly disagree (2 cm - 0). Mean ratings for all statements were above eight for both English and Tamil versions of the manual, indicating strong agreement
ACCEPTED MANUSCRIPT with suitability of content and benefits of using the manual. Suggestions provided by the validators were also incorporated in the manual. 2.2 Implementation of the training program
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2.2.1. Participants: Ten parent-child dyads with Tamil as home language and no prior speech-language intervention participated in the study. Enrolment occurred during their visit to the speech-language pathologist as part of the high-risk follow-up clinic between 12 and 24
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months of corrected age. Children exhibited delay of at least 4-5 months in expressive language skills, as revealed by assessments using a criterion-referenced Language
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Assessment Tool [32]. Table 1 provides the characteristics of all children enrolled in the study. All parent-child dyads had been recommended to attend regular clinic-based speechlanguage intervention. Parents who expressed challenges in enrollment into clinic-based speech-language intervention programs were invited to participate in the current study. All
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the children had normal hearing sensitivity during the study, as tested using Visual Reinforcement Audiometry.
The enrolled children included two pairs of twins. Two fathers and five mothers
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participated in the study. Families belonged to either the lower-middle class (7) or uppermiddle class (3), as assessed by Kuppuswamy’s Scale of Socio-Economic Status [33]. All
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caregivers had completed a minimum of high-school education; four caregivers had completed graduate education. Although speech-language assessments flagged delays in language in a few children during prior child developmental assessment visits, the intervention was limited to guidance on speech-language stimulation provided immediately after assessment since parents expressed inability to visit the clinic for any formal intervention. 2.2.2 Procedure
ACCEPTED MANUSCRIPT Parents provided verbal and written informed consent at the time of enrolment into the study. One parent-child dyad received the training but dropped out during the follow-up procedures due to unknown reasons. A parent-child interaction was recorded in the first session after enrolment into the study. During the first session, a 30-minute video recording of the parent
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interacting with the child was made in the natural environment of the children’s homes.
Parents were instructed to use a standard set of toys while interacting with their child that included, a ball, doll, noise maker, stack of rings, a few soft toys, animal toys, vehicles, and a
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kitchen set. This interaction served as the baseline for parent-child interaction measures.
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The training program consisted of three one-hour sessions that were delivered to the parents during second, third and fourth visits to their home. Baseline recording and the training program were completed within the same week. Parents were given the manual in their preferred language -English or Tamil. The first training session focused on speech and language milestones and play development until two years of age. Parents filled worksheets
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identifying the child’s level of understanding, speaking/communicating and play behaviour at the end of the session by referring to the manual. The second session focused on speech-
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language stimulation strategies in the contexts of free play and daily routines. Investigator demonstrated strategies and highlighted the importance of reciprocating exchanges and
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identifying meaningful communicative signals from children. A third session provided summary of the key points learned during the two prior sessions, followed by individualizing the strategies for each child. Investigator selected three to four strategies most appropriate to the child’s language level and demonstrated use of strategies within the play activities selected at the child’s level. Children with developmental delay were unable to hold or manipulate objects/toys due to limitations in motor control when compared to children with primary language delay. Investigator guided parents of children with motor limitations to suitably seat the children with adequate support and modify play activities appropriately to
ACCEPTED MANUSCRIPT facilitate play and interaction during play. Feedback and suggestions on use of strategies were provided based on earlier observations of parent-child interaction made during the video recording. Any queries raised by the parents were clarified in this session. The fifth and sixth home visits were scheduled six and ten weeks respectively after
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baseline to record parent-child interaction. A speech-language assessment was also carried out for each child after ten weeks of enrolment into the study. Additionally, parents were also asked to identify the child’s current level of language and play(s) by referring to the manual.
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The investigator also provided feedback on the nature of play activities carried out by parents with their child. Parents were interviewed to fill a feedback questionnaire regarding use of the
2.3 Coding of parent-behaviours
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brief parent training program, and provide suggestions to improve the same.
The middle 20 minutes of each video recording taken at baseline (T1), six-weeks, (T2) and
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10-weeks (T3) post-training, were coded in a manner similar to the Dyadic Parent-Child Interaction Coding System [34] by an undergraduate research assistant who was unaware of the chronology of the videos and had not met any of the parent-child dyads previously. Each
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verbal act exhibited by the parents was coded under categories of direct commands, suggestions, comments, questions, repetitions, reflections and praise. Non-verbal acts by
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parents were coded as positive affective behaviours and positive physical behaviours. Any negative affective or physical behaviour demonstrated by the parents was also noted. The percentage ratio of occurrence of each type of verbal behaviour was calculated as a function of overall verbalizations coded within the fixed 20-minute recording. Shapiro-Wilk test revealed that the data did not meet the assumptions of normality. A non-parametric Friedman test of differences among repeated measures was conducted to determine the difference among parent-language behaviours noted at the baseline and two
ACCEPTED MANUSCRIPT follow-ups. Post-hoc comparisons between any two time-points were made using the Wilcoxon signed-rank test. Effects sizes (r) for significant effects were calculated for Wilcoxon signed-rank test using method described by Rosenthal [35]. Parental feedback on
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the manual was described qualitatively. 3. Results
Group median for the frequency of overall verbalization and positive affective behaviour
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exhibited by the parent in the 20-minute interaction sample at baseline (T1) and two followups (T2 and T3) are represented in Table 2. Post-hoc Wilcoxon signed-rank test revealed that
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the median frequency of verbalizations progressively increased from baseline (Mdn = 100) to T2 (Mdn = 125; Z = 2.66, p = 0.008, r = 0.6) and from T2 to T3 (Mdn = 155; Z = 2.66, p = 0.008, r = 0.6) with all significant effects demonstrating a moderate effect size. Results from Friedman ANOVA indicated a significant difference in the percentage of direct commands,
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comments, suggestions, reflections and questions, observed at baseline and the two followups. Concurrent to increase in the number of verbalisations from T1 to T2, the percentage of comments relating to what the child was seeing, doing or hearing that was used by parents
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also increased from T1 (Mdn = 25) to T2 (Mdn = 32.91; Z = 2.58, p = 0.011, r = 0.6) and was maintained at a similar level at T3 (Mdn = 34.86). Although no significant change in the
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percentage of suggestions (including prompts that accompanied an action, requests for an action and use of binary choices) and reflections (including contingent repetitions of utterance or vocalizations produced by the child and expansions of the child’s productions by adding more language) were observed from T1 to T2, a significant increase was observed at T3. The proportion of suggestions increased from T2 (Mdn = 11.88) to T3 (Mdn = 16.38; Z = 2.67, p = 0.008, r = 0.6) and T1 (Mdn = 9.9) to T3 (Mdn = 16.38; Z = 2.43, p = 0.010, r = 0.5). The proportion of reflections at T3 (Mdn = 7.48) was significantly higher than those at T1 (Mdn = 2.47; Z = 2.43, p = 0.015) but not at T2 (Mdn = 4.82).
ACCEPTED MANUSCRIPT Parent’s usage of direct commands significantly decreased at T3 (Mdn = 18.37) in comparison to T2 (Mdn = 25.25; Z = 2.55, p = 0.011, r = 0.6) and T1 (Mdn = 28.4; Z = 2.67, p = 0.008, r = 0.6). A similar pattern was observed for parent’s usage of “what, where, who” questions directed at the child wherein the percentage of questions significantly decreased
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from T2 (Mdn = 9.33) to T3 (Mdn = 4.61; Z = 2.66, p = 0.008, r = 0.6) and from T1 (Mdn = 14.11) to T3 (Mdn = 4.61; Z = 2.66, p = 0.008, r = 0.6). There was no change in the
percentage of repetition (including any statement/question that the parent repeated) and praise
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(any positive verbal comments) provided by the parents.
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Overall, no negative behaviours such as intrusive physical behaviour or restrain were observed in any of the interactions at baseline or at follow-up recordings. The frequency of positive physical behaviours between the parent and child occurred only once or twice for a few parents in select sessions. However, the percentage of positive affective behaviours (parent’s nonverbal expressions of enjoyment, warmth or enthusiasm directed at the child)
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increased significantly from T1 (Mdn = 4) to T2 (Mdn = 8; Z = 2.68, p = 0.007) and T3 (Mdn = 11; Z = 2.54, p = 0.011). The percentage of occurrences of comments, suggestions and
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reflections were combined for each parent to indicate the percentage of positive verbal behaviours; those of direct commands and questions were combined to form the percentage
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of negative verbal behaviours (Table 3). Improvements observed in receptive and expressive language skills, assessed using
the Language Assessment Tool [32] ten weeks post parent training, are shown in Table 3. Children demonstrated acquisition of items related to one or two age ranges above the baseline age on the criterion-referenced tool. Two children with developmental delay demonstrated a slower pace of language development in comparison to children with language delay alone.
ACCEPTED MANUSCRIPT Responses of parents on the feedback form for all statements with the Likert scale were either 4 or 5, indicating positive experiences with the training program. On probing post-training, the parents correctly identified their child’s level of comprehension and expression of language, and the type of play(s) exhibited by their child. The parents felt more
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tuned in to their child’s attempts at communicating and reported increased usage of providing comments on what the child/parent was doing/seeing/hearing, and expanding the child’s
utterances. In general, parents reported that they observed changes in the child while they
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used the strategies. However, parents of two children with development delay reported lack of significant change in their child’s levels of communication despite following the strategies.
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The parents felt that this brief training program would be useful in training other parents also to understand their child’s communication level, and in providing speech and language stimulation. Some of the suggestions provided by parents to improve the training program were: to provide a greater number of examples and training sessions, and including videos to
4. Discussion
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explain speech and language stimulation strategies and play behaviours.
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The current study demonstrated that a brief, low-intensity training program for parents on speech-language stimulation and play development increased the frequency of parent’s use of
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comments, suggestions and reflective utterances, and a decrease in the frequency of direct commands and directive questions in the follow-up sessions. Parents were able to identify play-based activities and provide opportunities for interaction in daily routines post training. An increase in overall verbalizations and comments by parents observed within a four-week period resulted from the increasing use of strategies to provide rich linguistic input to children. This suggested that parents were ‘paying attention to child’s interest’ and verbalized through ‘self-talk’, ‘parallel-talk’, ‘modelling’, and ‘pairing action with words’. Parents were now paying more attention to what their child was doing or looking at, and responding
ACCEPTED MANUSCRIPT appropriately. Parents likely took more time to incorporate strategies that increase the child’s verbal output by encouraging interaction rather than being directive and asking questions. Significant differences in behaviours like ‘suggestions’ and ‘reflections’ were observed only by the second follow up. The findings of the current study agree with the findings of earlier
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research on parent-implemented intervention that reported decrease in the use of direct
commands and increase in responsiveness by parents after training [12,14]. Several studies have reported that parents increasingly praised and used expansions and responsive
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utterances over time, and decreased use of direct commands post-parent-implemented
intervention [25]. It is possible that the increased percentage of reflections measured at T3
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was a result of increased productions by the children, in combination with parent’s increased responsiveness. Some studies have shown that parents maintained the skills learnt even after a few months post-training [14,24].
Children demonstrated improvement in receptive and expressive language levels at
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ten weeks post parent training in comparison to baseline assessments. The improvement in language was less for children with developmental delay in comparison to children with language delays alone. Indeed, improvement in the child’s language level cannot be
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attributed to changes in parental language input alone since no control group was included in
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the study. Further, only language assessment of children after ten weeks was made using the criterion-referenced tool used at baseline. Children’s attempts at communication and the language functions served by their utterances were not coded in the current study. Increased frequency of reflections in parent’s verbalizations at T3 may be due to increased vocalization and verbalizations by the children. Outcome measures of child’s communication behaviours are more proximal to and likely more contingent on changes observed in parent behaviours over time. Research on parent-implemented research has shown that the effects were
ACCEPTED MANUSCRIPT significantly higher for measures that were more proximal to intervention such as expressive morphosyntax in comparison to distal measures such as, overall language levels [15]. Parents reported satisfaction with the use of the manual and expressed confidence in understanding their child’s level of communication and play behaviours. Parents also
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reported that they used the manual regularly during and after the training sessions and felt that they were ‘talking more and better’ with their children. Changes in child’s
communication skills were also reported. Positive parental feedback about the usage of the
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module provided support for the social validity of the manual and training program [11].
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Suggestions from parents on the use of recorded video examples for explaining the strategies can be embedded in the delivery of information given in the manual. The program can be modified to follow the teach-model-coach-review model [11] to teach specific speechlanguage stimulation strategies individualised for each child.
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5. Conclusion and future directions
The current study demonstrated that a brief, low-intensity training program for parents on speech-language stimulation and play development using a manual resulted in changes in
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parents’ verbal interactions with the children in the context of free play. Such low-intensity programs surrounding a manual may be scheduled during the child's doctor
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visits/developmental assessment visits for children ‘at- risk’ for delay in language development. Lack of a control group, either a matched group of parents not receiving the training or receiving a different intervention, limits generalisation of the findings. Future studies can be planned with larger groups of parents and a control group. The child’s behaviours in the interactions were not coded in the current study. Further studies are needed to evaluate the effect of parent training on outcomes related to parent and child behaviours, and contingency between parent-child behaviours. Fidelity of conducting parent training
ACCEPTED MANUSCRIPT using the manual may also be addressed in future research. The use of tele practice for providing parent education and training within the context of the manual as a viable option for parents who are unable to receive the training directly may also be explored in future research [36].
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6. Acknowledgements
The authors sincerely thank the children and their families for their enthusiastic participation. The study received support from an ongoing research grant from the Science and Engineering
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(EMR/2016/000951) to the corresponding author.
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ACCEPTED MANUSCRIPT [28] M.F. Coletti, B. Caravale, C. Gasparini, F. Franco, F. Campi, A. Dotta, One-year neurodevelopmental outcome of very and late preterm infants: Risk factors and correlation with maternal stress, Infant Behav. Dev. 39 (2015) 11–20. doi:10.1016/j.infbeh.2015.01.003.
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[29] D.E. Ballot, Joanne Potterton, T. Chirwa, N. Hilburn, P.A. Cooper, Developmental outcome of very low birth weight infants in a developing country., BMC Pediatr. 12
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(2012) 1–10. doi:10.1186/1471-2431-12-11.
[30] M.M. Greene, K. Patra, M.N. Nelson, J.M. Silvestri, Evaluating preterm infants with
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the Bayley-III: Patterns and correlates of development, Res. Dev. Disabil. 33 (2012) 1948–1956. doi:10.1016/j.ridd.2012.05.024.
[31] A. Mukhopadhyay, K., Malhi, P., Mahajan, R., & Narang, Neurodevelopmental and behavioral outcome of very low birth weight babies at corrected age of 2 years., Indian
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J. Pediatr. 77 (2010) 963–967. doi: 10.1007/s12098-010-0149-3 [32] T.A. Subba Rao, Language Assessment Tool (LAT). In Manual for developing communication skills in mentally retarded persons. National Institute for Mentally
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Handicapped, Secunderabad, 1992.
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[33] T. Singh, S. Sharma, S. Nagesh, Socio-economic status scales updated for 2017, Int. J. Res. Med. Sci. Int J Res Med Sci. 5 (2017) 3264–3267. doi:10.18203/23206012.ijrms20173029.
[34] S.M. Eyberg, M.M. Nelson, M. Duke, S.R. Boggs, Manual for the dyadic parent-child interaction coding system, 3rd ed., 2009. [35] R. Rosenthal., Parametric measures of effect size., In H. Cooper & L. V. Hedges (Ed.), Handb. Res. Synth., New York: Russell Sage Foundation. (1994) 231–244.
ACCEPTED MANUSCRIPT [36] M.R. Snodgrass, M.Y. Chung, M.F. Biller, K.E. Appel, H. Meadan, J.W. Halle, Telepractice in speech-language therapy: The use of online technologies for parent training and coaching, Commun. Disord. Q. 38 (2017) 242–254.
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doi:10.1177/1525740116680424.
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Table 2
Friedman ANOVA (χ2(2), p)
Median, IQR (Minimum, Maximum) Time 3 (T3)
T2 -T3
T1 - T3
Frequency of verbalization
100, 39.5 (40.0, 156)
125, 56.5 (75, 166)
155, 27.5 (87, 177)
18.00, 0.000
2.66, 0.008
2.67, 0.007
2.66, 0.008
% Direct Commands
28.4, 17.8 (10.7, 50)
24.09, 12.9 (12.26, 47.62)
18.37, 10.4 (10.32, 39.66)
12.67, 0.002
1.95, 0.05
2.55, 0.011
2.67, 0.008
% Comments
25, 17.8 (7.69, 38,28)
32.91, 12.9 (15.48, 38.05)
34.86, 17.3 (22.08, 45.52)
12.67,0.002
2.58,0.011
2.19, 0.28
2.66,0.008
% Suggestions
9.9, 5.2 (4.0, 16.02)
12.9, 5.5 (6.4, 18.67)
16.38, 9.1 (9.74, 22.98)
10.89, 0.004
1.00, 0.31
2.67, 0.008
2.43,0.01
% Repetition
12.5, 4.7 (3.7,17.850
10.84, 4.6 (7.07, 14.2)
11.8, 2.0 (9.7, 14.83)
2.67, 0.264
% Praise
1.98, 8.1 (0, 10.25)
2.09, 6.8 (0, 9.3)
3.73, 4.6 (1.14, 9.33)
0.17, 0.92
% Reflections
2.47, 5.2 (0, 7.69)
4.82, 4.5 (3.2, 10.1)
7.48, 5.6 (2.26, 12.26)
8.67,0.013
1.84,0.06
1.48, 0.14
2.43, 0.015
% Questions
14.10, 9.6 (3.84, 24.6)
8.9, 7.6 (4.76, 22.5)
4.61, 2.8 (0.6, 7.45)
14.0, 0.001
1.48, 0.139
2.66,0.008
2.66,0.008
Frequency of positive affect
4, 4 (0,7)
8, 4 (3,11)
13.54, 0.001
2.68, 0.007
2.08, 0.38
2.54, 0.011
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Note: IQR – Interquartile Range
T1 - T2
11, 9 (5,18)
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Time 2 (T2)
Post-hoc comparisons (Wilcoxon rank sum - Z, p)
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Time 1 (T1)
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Proportion of parents’ behaviours across the three-time points
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Table 1
Child No
Age (months)
Corrected Age (months)
Sex
1
12
12
F
Low birth weight (2 kg); neonatal seizures; neonatal hyperbilirubinemia
2
18
17
M
Preterm (33 weeks); Neonatal seizures;
3
19
18
M
Preterm (33 weeks)
4
22
20
M
5
22
20
6
24
7
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Characteristics of children in the study Receptive Language Age range (months)
Expressive Language Age range (months)
7-8
7-8
Developmental delay
11-12
9-10
Language delay with mild motor delay
16-18
11-12
Expressive language delay
Preterm (30 weeks); low birth weight (1.6 kg); NICU stay for one month
8-9
8-9
Developmental delay
F
Preterm (30 weeks); low birth weight (1.6 kg); NICU stay for one month
12-14
11-12
Language delay
23
M
Preterm (35 weeks); low birth weight (1.9 kg); NICU stay for 8 days
12-14
10-11
Language delay
24
24
F
Neonatal seizures; encephalitis; suspected sepsis; birth dengue infection
18-20
12-14
Expressive language delay
8
24
24
M
Low birth weight; suspected sepsis;
14-16
10-11
Language delay with mild motor delay
9
26
24
M
Preterm (32 weeks); low birth weight (1.8 kg); neonatal hyperbilirubinemia; suspected sepsis
16-18
14-16
Language delay
10
26
24
M
Preterm (32 weeks); low birth weight (1.3 kg)
16-18
14-16
Language delay
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Neonatal risk factors
Impression at last child development visit
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Table 3
Clinical Impression
T1
T1
Combined Verbal Positive Behaviours (%)
Combined Verbal Negative Behaviours (%)
T1
T3
T1 40.00
T3
T1
T3
21.84
7-8
8-9
7-8
8-9
53.85
40.26
11-12
12-14
9-10
10-11
53.00
33.54
16-18
16-18
11-12
14-16
32.14
14.19
8-9
9-10
8-9
9-10
61.58
48.41
19.21
12-14
14-16
11-12
12-14
55.63
57.32
28.75
12-14
16-18
10-11
12-14
61.71
35.26
27.43
18-20
22-24
12-14
14-16
63.43
39.51
22.39
16-18
20-22
14-16
18-20
63.27
40.59
22.45
16-18
20-22
14-16
18-20
Developmental delay
37.50
60.92
2
17
Language delay with mild motor delay
21.79
38.31
3
18
Expressive language delay
28.00
50.93
4
20
Developmental delay
50.00
69.68
5
20
Language delay
34.13
6
23
Language delay
26.83
7
24
Expressive language delay
51.92
9
24
Language delay
54.32
10
24
Language delay
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12
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Expressive Language Age range (months)
T1
1
43.56
Receptive Language Age range (months)
T3
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Child No
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Comparison of verbal positive and negative behaviours of parents and language age of children at the time of recruitment (T1) and after ten weeks (T3)
S0165-5876(19)30161-2
DOI:
https://doi.org/10.1016/j.ijporl.2019.03.034
Reference:
PEDOT 9448
To appear in:
International Journal of Pediatric Otorhinolaryngology
Received Date: 15 February 2019 Revised Date:
22 March 2019
Accepted Date: 31 March 2019
Please cite this article as: V. Rajesh, L. Venkatesh, Preliminary evaluation of a low-intensity parent training program on speech-language stimulation for children with language delay, International Journal of Pediatric Otorhinolaryngology, https://doi.org/10.1016/j.ijporl.2019.03.034. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title: Preliminary evaluation of a low-intensity parent training program on speech-language stimulation for children with language delay Authors:
Speech Language Pathologist and Audiologist Elixir Multi Speciality Therapy Centre Velachery, Chennai, 600042, Tamil Nadu, India
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Email: [email protected]
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Vipula Rajesh
Phone: 99529 57813
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Lakshmi Venkatesh Associate Professor
Department of Speech, Language and Hearing Sciences
Sri Ramachandra Institute of Higher Education and Research (Deemed to be University)
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Porur, Chennai, 600116, Tamil Nadu, India Email: [email protected] Phone: 9940074052
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Conflict of Interest: None
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Address for correspondence: Dr. Lakshmi Venkatesh Associate Professor
Department of Speech, Language and Hearing Sciences Sri Ramachandra Institute of Higher Education and Research (Deemed to be University) Porur, Chennai, 600116, Tamil Nadu, India Email: [email protected] Phone: 9940074052
ACCEPTED MANUSCRIPT 1. Introduction Parent-implemented intervention has found a niche in the field of childhood language disorders where parents are trained to improve language skills of children [1-4]. Parents are empowered to work with children through training programs to gain knowledge, and enhance
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their abilities to participate increasingly in the intervention process and make treatment
decisions jointly with the speech-language therapist. Extensive research has evaluated parentimplemented interventions for children with language disorders secondary to conditions such
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as autism [5-8], intellectual disability [9,10], Down syndrome [11,12], developmental delays
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and behavioural problems [13,14]. A meta-analysis on the efficacy of parent-implemented interventions reported improvement in children’s communication skills [15]. Parentimplemented language intervention resulted in improvements in language skills of children with a range of language and cognition abilities in comparison to a control group. Intervention strategies common across studies included, responsiveness towards the child’s
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communication attempts, enhancing the quality of parental language input, bringing a balance between adult-child turns at communication and reflecting on the child’s communication.
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More recently, there has been increasing interest in parent-implemented intervention exclusively for children with primary language impairment, or late-talkers, who are younger
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than 36 months of age [1-4]. Such research has been driven by the need for building an evidence base for early intervention of language deficits among children considered to be ‘atrisk’ for persistent delay in language or later literacy deficits [16]. A recent meta-analysis on parent-implemented intervention for late talkers revealed that parents could be potentially more effective than clinicians in improving the language skills of their child [17]. Parent-implemented intervention approaches for young children with delay in language range in the amount of structure during implementation. Three broad approaches
ACCEPTED MANUSCRIPT identified by Rescorla and Dale [18] include, general language stimulation [19,20], focused stimulation [12,21] and Enhanced Milieu Teaching [22,23]. Other amorphous approaches have included the use of video feedback during home training [2,3] and broad parent-child interaction therapy [1]. Broadly, general language stimulation focuses on providing rich
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language input to a child to provide opportunities for the child to listen to adult’s language input [20]. In contrast, specific target words or syntactic structures are identified and
emphasized in the language input provided as focussed stimulation [21]. Parent-implemented
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EMT is based on a conversation model of early language intervention. It involves coaching parents to respond contingently to child’s communication and use the child’s interest and
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opportunities to provide child-specific language models and promote language use by the child [23]. Clinicians may use manuals, information leaflets, videos and conduct workshops for training and coaching parents for parent-implemented intervention [15]. Research using these approaches to training have demonstrated that parents learn and acquire skills in
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responsive-interaction and can maintain the newly learned strategies in interaction to benefit their child’s communication skills. There is increasing research evidence to support that training parents can improve quality and quantity of the language input parents provide for
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their child and verbal responsiveness to the child’s attempt to communicate [11,14,24,25,26].
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Research on parent-implemented language intervention has mainly focussed on children above 24 months of age. Few research studies have included children aged between 20 and 24 months [14,21]. However, support for empowering parents of children younger than 24 months can be drawn from parallel research in the area of early infant stimulation programs for infants born prematurely and with low-birth weight, which has emphasized the need to enhance parent-infant relationship in addition to infant development alone [27]. Early intervention in general, and specifically those focussing on the parent-infant relationship and
ACCEPTED MANUSCRIPT infant development, resulted in significant improvements in cognitive outcomes in the birthto-three years segment. Service providers and parents are keen on addressing early speech-language delays among children between 12 and 24 months due to the notion that early language delays could
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indicate significant risk factors for other disorders. Children born with birth-risk factors such as, prematurity and low-birth-weight, present with lowered language performance at 12
months of corrected age [28] [29] [30]. Proportion of children with significant language
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delays at 12 months of corrected age ranged from 7-10% across studies. An additional 22%
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[30] and 33% [29] were at-risk for language delays. Within the Indian context, Mukhopadhyay, Malhi, Mahajan and Narang [31] found that 16% of very-low-birth-weight infants exhibited delay in language development or were ‘at-risk’ for language delay at 12 months of corrected age. These findings highlight that close monitoring of language development is needed for children as young as 12 months. Early language deficits may often
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be the first sign of several other neurodevelopmental disorders. Parent-education/training holds promise as a service delivery model for providing
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speech-language intervention services to young children identified with language delay or ‘at-risk’ for delay. A training program based on general speech-language stimulation can
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serve as the first step in the intervention for children identified as having delay or ‘at-risk’ for delay in language. The current study was motivated by the need to empower families of children to initiate home-based intervention to improve the child’s language development earlier than 24 months of age. A specific target group included parents of children born with birth risk factors visiting the developmental follow-up clinic in a tertiary care hospital. The current study aimed to develop and assess implementation of a brief training program for parents to provide speech-language stimulation to their child.
ACCEPTED MANUSCRIPT 2. Method 2.1 Framework for the training program A manual with content of the training program was developed and validated in the first phase
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of the study to serve as a framework for the intervention sessions. The manual comprised of three broad sections 1) speech-language milestones, 2) play development and 3) speech-
language stimulation strategies. The section of speech-language/communication milestones
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included three receptive and expressive language milestones each occurring in the age ranges of 7-9, 10-12, 13-15, 16-18, 19-21 and 22-24 months of age. The section on play
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development described development of various types of play exhibited by typically developing children including exploratory play, functional play, social play and pretend play with suitable illustrations. The section on speech-language stimulation strategies focussed on description of strategies to provide rich linguistic input to the child (paying attention to the
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child’s interest and responding/commenting, self-talk, parallel-talk, pairing words with action, modelling), reflect on the child’s verbal productions (echoing, expanding child’s utterance) and increase the child’s verbal output by encouraging interaction rather than being
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directive and asking questions (prompting, time delay, choices). The manual concluded with a few general tips for communicating with the child.
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The manual developed in English and Tamil simultaneously was validated by five
SLPs each who rated their agreement of ten statements on a 10 cm visual analogue scale. Statements covered appropriateness of content, examples, concepts, vocabulary and script of the manual as well as the need and benefits of using the manual. The scores were interpreted as strongly agree (8.1-10 cm), agree (6.1-8 cm), neither agree nor disagree (4.1- 6 cm), disagree (2.1- 4 cm) and strongly disagree (2 cm - 0). Mean ratings for all statements were above eight for both English and Tamil versions of the manual, indicating strong agreement
ACCEPTED MANUSCRIPT with suitability of content and benefits of using the manual. Suggestions provided by the validators were also incorporated in the manual. 2.2 Implementation of the training program
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2.2.1. Participants: Ten parent-child dyads with Tamil as home language and no prior speech-language intervention participated in the study. Enrolment occurred during their visit to the speech-language pathologist as part of the high-risk follow-up clinic between 12 and 24
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months of corrected age. Children exhibited delay of at least 4-5 months in expressive language skills, as revealed by assessments using a criterion-referenced Language
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Assessment Tool [32]. Table 1 provides the characteristics of all children enrolled in the study. All parent-child dyads had been recommended to attend regular clinic-based speechlanguage intervention. Parents who expressed challenges in enrollment into clinic-based speech-language intervention programs were invited to participate in the current study. All
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the children had normal hearing sensitivity during the study, as tested using Visual Reinforcement Audiometry.
The enrolled children included two pairs of twins. Two fathers and five mothers
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participated in the study. Families belonged to either the lower-middle class (7) or uppermiddle class (3), as assessed by Kuppuswamy’s Scale of Socio-Economic Status [33]. All
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caregivers had completed a minimum of high-school education; four caregivers had completed graduate education. Although speech-language assessments flagged delays in language in a few children during prior child developmental assessment visits, the intervention was limited to guidance on speech-language stimulation provided immediately after assessment since parents expressed inability to visit the clinic for any formal intervention. 2.2.2 Procedure
ACCEPTED MANUSCRIPT Parents provided verbal and written informed consent at the time of enrolment into the study. One parent-child dyad received the training but dropped out during the follow-up procedures due to unknown reasons. A parent-child interaction was recorded in the first session after enrolment into the study. During the first session, a 30-minute video recording of the parent
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interacting with the child was made in the natural environment of the children’s homes.
Parents were instructed to use a standard set of toys while interacting with their child that included, a ball, doll, noise maker, stack of rings, a few soft toys, animal toys, vehicles, and a
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kitchen set. This interaction served as the baseline for parent-child interaction measures.
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The training program consisted of three one-hour sessions that were delivered to the parents during second, third and fourth visits to their home. Baseline recording and the training program were completed within the same week. Parents were given the manual in their preferred language -English or Tamil. The first training session focused on speech and language milestones and play development until two years of age. Parents filled worksheets
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identifying the child’s level of understanding, speaking/communicating and play behaviour at the end of the session by referring to the manual. The second session focused on speech-
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language stimulation strategies in the contexts of free play and daily routines. Investigator demonstrated strategies and highlighted the importance of reciprocating exchanges and
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identifying meaningful communicative signals from children. A third session provided summary of the key points learned during the two prior sessions, followed by individualizing the strategies for each child. Investigator selected three to four strategies most appropriate to the child’s language level and demonstrated use of strategies within the play activities selected at the child’s level. Children with developmental delay were unable to hold or manipulate objects/toys due to limitations in motor control when compared to children with primary language delay. Investigator guided parents of children with motor limitations to suitably seat the children with adequate support and modify play activities appropriately to
ACCEPTED MANUSCRIPT facilitate play and interaction during play. Feedback and suggestions on use of strategies were provided based on earlier observations of parent-child interaction made during the video recording. Any queries raised by the parents were clarified in this session. The fifth and sixth home visits were scheduled six and ten weeks respectively after
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baseline to record parent-child interaction. A speech-language assessment was also carried out for each child after ten weeks of enrolment into the study. Additionally, parents were also asked to identify the child’s current level of language and play(s) by referring to the manual.
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The investigator also provided feedback on the nature of play activities carried out by parents with their child. Parents were interviewed to fill a feedback questionnaire regarding use of the
2.3 Coding of parent-behaviours
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brief parent training program, and provide suggestions to improve the same.
The middle 20 minutes of each video recording taken at baseline (T1), six-weeks, (T2) and
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10-weeks (T3) post-training, were coded in a manner similar to the Dyadic Parent-Child Interaction Coding System [34] by an undergraduate research assistant who was unaware of the chronology of the videos and had not met any of the parent-child dyads previously. Each
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verbal act exhibited by the parents was coded under categories of direct commands, suggestions, comments, questions, repetitions, reflections and praise. Non-verbal acts by
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parents were coded as positive affective behaviours and positive physical behaviours. Any negative affective or physical behaviour demonstrated by the parents was also noted. The percentage ratio of occurrence of each type of verbal behaviour was calculated as a function of overall verbalizations coded within the fixed 20-minute recording. Shapiro-Wilk test revealed that the data did not meet the assumptions of normality. A non-parametric Friedman test of differences among repeated measures was conducted to determine the difference among parent-language behaviours noted at the baseline and two
ACCEPTED MANUSCRIPT follow-ups. Post-hoc comparisons between any two time-points were made using the Wilcoxon signed-rank test. Effects sizes (r) for significant effects were calculated for Wilcoxon signed-rank test using method described by Rosenthal [35]. Parental feedback on
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the manual was described qualitatively. 3. Results
Group median for the frequency of overall verbalization and positive affective behaviour
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exhibited by the parent in the 20-minute interaction sample at baseline (T1) and two followups (T2 and T3) are represented in Table 2. Post-hoc Wilcoxon signed-rank test revealed that
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the median frequency of verbalizations progressively increased from baseline (Mdn = 100) to T2 (Mdn = 125; Z = 2.66, p = 0.008, r = 0.6) and from T2 to T3 (Mdn = 155; Z = 2.66, p = 0.008, r = 0.6) with all significant effects demonstrating a moderate effect size. Results from Friedman ANOVA indicated a significant difference in the percentage of direct commands,
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comments, suggestions, reflections and questions, observed at baseline and the two followups. Concurrent to increase in the number of verbalisations from T1 to T2, the percentage of comments relating to what the child was seeing, doing or hearing that was used by parents
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also increased from T1 (Mdn = 25) to T2 (Mdn = 32.91; Z = 2.58, p = 0.011, r = 0.6) and was maintained at a similar level at T3 (Mdn = 34.86). Although no significant change in the
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percentage of suggestions (including prompts that accompanied an action, requests for an action and use of binary choices) and reflections (including contingent repetitions of utterance or vocalizations produced by the child and expansions of the child’s productions by adding more language) were observed from T1 to T2, a significant increase was observed at T3. The proportion of suggestions increased from T2 (Mdn = 11.88) to T3 (Mdn = 16.38; Z = 2.67, p = 0.008, r = 0.6) and T1 (Mdn = 9.9) to T3 (Mdn = 16.38; Z = 2.43, p = 0.010, r = 0.5). The proportion of reflections at T3 (Mdn = 7.48) was significantly higher than those at T1 (Mdn = 2.47; Z = 2.43, p = 0.015) but not at T2 (Mdn = 4.82).
ACCEPTED MANUSCRIPT Parent’s usage of direct commands significantly decreased at T3 (Mdn = 18.37) in comparison to T2 (Mdn = 25.25; Z = 2.55, p = 0.011, r = 0.6) and T1 (Mdn = 28.4; Z = 2.67, p = 0.008, r = 0.6). A similar pattern was observed for parent’s usage of “what, where, who” questions directed at the child wherein the percentage of questions significantly decreased
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from T2 (Mdn = 9.33) to T3 (Mdn = 4.61; Z = 2.66, p = 0.008, r = 0.6) and from T1 (Mdn = 14.11) to T3 (Mdn = 4.61; Z = 2.66, p = 0.008, r = 0.6). There was no change in the
percentage of repetition (including any statement/question that the parent repeated) and praise
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(any positive verbal comments) provided by the parents.
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Overall, no negative behaviours such as intrusive physical behaviour or restrain were observed in any of the interactions at baseline or at follow-up recordings. The frequency of positive physical behaviours between the parent and child occurred only once or twice for a few parents in select sessions. However, the percentage of positive affective behaviours (parent’s nonverbal expressions of enjoyment, warmth or enthusiasm directed at the child)
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increased significantly from T1 (Mdn = 4) to T2 (Mdn = 8; Z = 2.68, p = 0.007) and T3 (Mdn = 11; Z = 2.54, p = 0.011). The percentage of occurrences of comments, suggestions and
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reflections were combined for each parent to indicate the percentage of positive verbal behaviours; those of direct commands and questions were combined to form the percentage
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of negative verbal behaviours (Table 3). Improvements observed in receptive and expressive language skills, assessed using
the Language Assessment Tool [32] ten weeks post parent training, are shown in Table 3. Children demonstrated acquisition of items related to one or two age ranges above the baseline age on the criterion-referenced tool. Two children with developmental delay demonstrated a slower pace of language development in comparison to children with language delay alone.
ACCEPTED MANUSCRIPT Responses of parents on the feedback form for all statements with the Likert scale were either 4 or 5, indicating positive experiences with the training program. On probing post-training, the parents correctly identified their child’s level of comprehension and expression of language, and the type of play(s) exhibited by their child. The parents felt more
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tuned in to their child’s attempts at communicating and reported increased usage of providing comments on what the child/parent was doing/seeing/hearing, and expanding the child’s
utterances. In general, parents reported that they observed changes in the child while they
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used the strategies. However, parents of two children with development delay reported lack of significant change in their child’s levels of communication despite following the strategies.
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The parents felt that this brief training program would be useful in training other parents also to understand their child’s communication level, and in providing speech and language stimulation. Some of the suggestions provided by parents to improve the training program were: to provide a greater number of examples and training sessions, and including videos to
4. Discussion
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explain speech and language stimulation strategies and play behaviours.
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The current study demonstrated that a brief, low-intensity training program for parents on speech-language stimulation and play development increased the frequency of parent’s use of
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comments, suggestions and reflective utterances, and a decrease in the frequency of direct commands and directive questions in the follow-up sessions. Parents were able to identify play-based activities and provide opportunities for interaction in daily routines post training. An increase in overall verbalizations and comments by parents observed within a four-week period resulted from the increasing use of strategies to provide rich linguistic input to children. This suggested that parents were ‘paying attention to child’s interest’ and verbalized through ‘self-talk’, ‘parallel-talk’, ‘modelling’, and ‘pairing action with words’. Parents were now paying more attention to what their child was doing or looking at, and responding
ACCEPTED MANUSCRIPT appropriately. Parents likely took more time to incorporate strategies that increase the child’s verbal output by encouraging interaction rather than being directive and asking questions. Significant differences in behaviours like ‘suggestions’ and ‘reflections’ were observed only by the second follow up. The findings of the current study agree with the findings of earlier
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research on parent-implemented intervention that reported decrease in the use of direct
commands and increase in responsiveness by parents after training [12,14]. Several studies have reported that parents increasingly praised and used expansions and responsive
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utterances over time, and decreased use of direct commands post-parent-implemented
intervention [25]. It is possible that the increased percentage of reflections measured at T3
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was a result of increased productions by the children, in combination with parent’s increased responsiveness. Some studies have shown that parents maintained the skills learnt even after a few months post-training [14,24].
Children demonstrated improvement in receptive and expressive language levels at
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ten weeks post parent training in comparison to baseline assessments. The improvement in language was less for children with developmental delay in comparison to children with language delays alone. Indeed, improvement in the child’s language level cannot be
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attributed to changes in parental language input alone since no control group was included in
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the study. Further, only language assessment of children after ten weeks was made using the criterion-referenced tool used at baseline. Children’s attempts at communication and the language functions served by their utterances were not coded in the current study. Increased frequency of reflections in parent’s verbalizations at T3 may be due to increased vocalization and verbalizations by the children. Outcome measures of child’s communication behaviours are more proximal to and likely more contingent on changes observed in parent behaviours over time. Research on parent-implemented research has shown that the effects were
ACCEPTED MANUSCRIPT significantly higher for measures that were more proximal to intervention such as expressive morphosyntax in comparison to distal measures such as, overall language levels [15]. Parents reported satisfaction with the use of the manual and expressed confidence in understanding their child’s level of communication and play behaviours. Parents also
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reported that they used the manual regularly during and after the training sessions and felt that they were ‘talking more and better’ with their children. Changes in child’s
communication skills were also reported. Positive parental feedback about the usage of the
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module provided support for the social validity of the manual and training program [11].
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Suggestions from parents on the use of recorded video examples for explaining the strategies can be embedded in the delivery of information given in the manual. The program can be modified to follow the teach-model-coach-review model [11] to teach specific speechlanguage stimulation strategies individualised for each child.
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5. Conclusion and future directions
The current study demonstrated that a brief, low-intensity training program for parents on speech-language stimulation and play development using a manual resulted in changes in
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parents’ verbal interactions with the children in the context of free play. Such low-intensity programs surrounding a manual may be scheduled during the child's doctor
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visits/developmental assessment visits for children ‘at- risk’ for delay in language development. Lack of a control group, either a matched group of parents not receiving the training or receiving a different intervention, limits generalisation of the findings. Future studies can be planned with larger groups of parents and a control group. The child’s behaviours in the interactions were not coded in the current study. Further studies are needed to evaluate the effect of parent training on outcomes related to parent and child behaviours, and contingency between parent-child behaviours. Fidelity of conducting parent training
ACCEPTED MANUSCRIPT using the manual may also be addressed in future research. The use of tele practice for providing parent education and training within the context of the manual as a viable option for parents who are unable to receive the training directly may also be explored in future research [36].
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6. Acknowledgements
The authors sincerely thank the children and their families for their enthusiastic participation. The study received support from an ongoing research grant from the Science and Engineering
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(EMR/2016/000951) to the corresponding author.
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Table 2
Friedman ANOVA (χ2(2), p)
Median, IQR (Minimum, Maximum) Time 3 (T3)
T2 -T3
T1 - T3
Frequency of verbalization
100, 39.5 (40.0, 156)
125, 56.5 (75, 166)
155, 27.5 (87, 177)
18.00, 0.000
2.66, 0.008
2.67, 0.007
2.66, 0.008
% Direct Commands
28.4, 17.8 (10.7, 50)
24.09, 12.9 (12.26, 47.62)
18.37, 10.4 (10.32, 39.66)
12.67, 0.002
1.95, 0.05
2.55, 0.011
2.67, 0.008
% Comments
25, 17.8 (7.69, 38,28)
32.91, 12.9 (15.48, 38.05)
34.86, 17.3 (22.08, 45.52)
12.67,0.002
2.58,0.011
2.19, 0.28
2.66,0.008
% Suggestions
9.9, 5.2 (4.0, 16.02)
12.9, 5.5 (6.4, 18.67)
16.38, 9.1 (9.74, 22.98)
10.89, 0.004
1.00, 0.31
2.67, 0.008
2.43,0.01
% Repetition
12.5, 4.7 (3.7,17.850
10.84, 4.6 (7.07, 14.2)
11.8, 2.0 (9.7, 14.83)
2.67, 0.264
% Praise
1.98, 8.1 (0, 10.25)
2.09, 6.8 (0, 9.3)
3.73, 4.6 (1.14, 9.33)
0.17, 0.92
% Reflections
2.47, 5.2 (0, 7.69)
4.82, 4.5 (3.2, 10.1)
7.48, 5.6 (2.26, 12.26)
8.67,0.013
1.84,0.06
1.48, 0.14
2.43, 0.015
% Questions
14.10, 9.6 (3.84, 24.6)
8.9, 7.6 (4.76, 22.5)
4.61, 2.8 (0.6, 7.45)
14.0, 0.001
1.48, 0.139
2.66,0.008
2.66,0.008
Frequency of positive affect
4, 4 (0,7)
8, 4 (3,11)
13.54, 0.001
2.68, 0.007
2.08, 0.38
2.54, 0.011
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Note: IQR – Interquartile Range
T1 - T2
11, 9 (5,18)
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Time 2 (T2)
Post-hoc comparisons (Wilcoxon rank sum - Z, p)
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Time 1 (T1)
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Proportion of parents’ behaviours across the three-time points
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Table 1
Child No
Age (months)
Corrected Age (months)
Sex
1
12
12
F
Low birth weight (2 kg); neonatal seizures; neonatal hyperbilirubinemia
2
18
17
M
Preterm (33 weeks); Neonatal seizures;
3
19
18
M
Preterm (33 weeks)
4
22
20
M
5
22
20
6
24
7
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Characteristics of children in the study Receptive Language Age range (months)
Expressive Language Age range (months)
7-8
7-8
Developmental delay
11-12
9-10
Language delay with mild motor delay
16-18
11-12
Expressive language delay
Preterm (30 weeks); low birth weight (1.6 kg); NICU stay for one month
8-9
8-9
Developmental delay
F
Preterm (30 weeks); low birth weight (1.6 kg); NICU stay for one month
12-14
11-12
Language delay
23
M
Preterm (35 weeks); low birth weight (1.9 kg); NICU stay for 8 days
12-14
10-11
Language delay
24
24
F
Neonatal seizures; encephalitis; suspected sepsis; birth dengue infection
18-20
12-14
Expressive language delay
8
24
24
M
Low birth weight; suspected sepsis;
14-16
10-11
Language delay with mild motor delay
9
26
24
M
Preterm (32 weeks); low birth weight (1.8 kg); neonatal hyperbilirubinemia; suspected sepsis
16-18
14-16
Language delay
10
26
24
M
Preterm (32 weeks); low birth weight (1.3 kg)
16-18
14-16
Language delay
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Neonatal risk factors
Impression at last child development visit
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Table 3
Clinical Impression
T1
T1
Combined Verbal Positive Behaviours (%)
Combined Verbal Negative Behaviours (%)
T1
T3
T1 40.00
T3
T1
T3
21.84
7-8
8-9
7-8
8-9
53.85
40.26
11-12
12-14
9-10
10-11
53.00
33.54
16-18
16-18
11-12
14-16
32.14
14.19
8-9
9-10
8-9
9-10
61.58
48.41
19.21
12-14
14-16
11-12
12-14
55.63
57.32
28.75
12-14
16-18
10-11
12-14
61.71
35.26
27.43
18-20
22-24
12-14
14-16
63.43
39.51
22.39
16-18
20-22
14-16
18-20
63.27
40.59
22.45
16-18
20-22
14-16
18-20
Developmental delay
37.50
60.92
2
17
Language delay with mild motor delay
21.79
38.31
3
18
Expressive language delay
28.00
50.93
4
20
Developmental delay
50.00
69.68
5
20
Language delay
34.13
6
23
Language delay
26.83
7
24
Expressive language delay
51.92
9
24
Language delay
54.32
10
24
Language delay
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12
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Expressive Language Age range (months)
T1
1
43.56
Receptive Language Age range (months)
T3
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CA (months)
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Child No
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Comparison of verbal positive and negative behaviours of parents and language age of children at the time of recruitment (T1) and after ten weeks (T3)