THE EFFECTS OF ENHANCED MILIEU TEACHING WORDS + SIGNS ON THE COMMUNICATION OF TODDLERS WITH LANGUAGE DELAYS
by
Lillian Mae Bushong
Thesis
Submitted to the Faculty of
Peabody College of Vanderbilt University in Partial Fulfillment of the Requirements
for the Degree of MASTER OF EDUCATION
in
Special Education May 2023
© 2023 Lillian Mae Bushong All Rights Reserved
THE EFFECTS OF ENHANCED MILIEU TEACHING WORDS + SIGNS ON THE COMMUNICATION OF TODDLERS WITH LANGUAGE DELAYS
by
Lillian Mae Bushong
Peabody College of Vanderbilt University May 2023
Major Area: Special Education Number of Words: 214
It is common for toddlers under the age of 3 to have language delays, though few studies have focused on improving communication within this population. Enhanced Milieu Teaching paired with Words + Signs is an evidence-based practice that has been used to increase
communication in toddlers by targeting functional communication skills during play and routines. Combining both interventions, EMT and Words + Signs, creates multiple pathways of communication for toddlers by using both signs and spoken word. EMT has been used primarily with children with Autism and Down Syndrome and was designed primarily for parents.
Building upon previous research, this study implemented EMT Words + Signs in the classroom during free play to two toddlers with language delays and their classroom teachers. A multiple baseline design across word sets was used to measure participants’ use of target words, as well as the frequency of spontaneous words used in each session. Findings show that there was a
presence of a functional relation for both participants between target word use and EMT Words + Signs. Data on spontaneous total word use and target word use were also consistently higher during intervention sessions than during baseline sessions. Data were inconsistent during generalization and maintenance sessions, though some words were maintained for each participant to a variable degree.
TABLE OF CONTENTS
Chapter I Page
I. INTRODUCTION………...1
Enhanced Milieu Teaching………...…2
Purpose of the Study……….3
II. METHODS………...4
Participants………4
Setting and Materials……….5
Response Definitions and Measurement Systems……….6
Interobserver Agreement………...…7
Experimental Design……….8
Procedures……….9
Procedural Fidelity………11
Social Validity………..12
III. RESULTS………...13
Data Analysis………13
Research Question 1………..14
Research Question 2………..14
Research Question 3………..14
Research Question 4………..14
Research Question 5………..15
Reliability and Fidelity………..15
IV. Discussion………15
Major Findings………..16
Study Limitations………..16
Future Research……….17
Implications for Practice………17
Conclusion……… 18
REFERENES ………..19
APPENDIX………..22
INTRODUCTION
Language delays are common for toddlers. Horwitz and colleagues (2003) reported that an average of 15% of 2-year-olds have language delays that are not caused by any known factor.
Although language delays are so prevalent for toddlers, fewer studies have focused on improving the communication of children with language delays who are younger than three years of age.
According to the American Speech-Language-Hearing Association (ASHA, Definition of
Communication and Appropriate Targets,) communication involves the receptive and expressive exchanging of information with a communication partner. Individuals may use a variety of modes to communicate including, but not limited to, verbalizations, signs, written text, and AAC devices.
The use of augmentative and alternative communication (AAC) adds variety to toddlers’
communication opportunities. AAC is a tool used both in addition to speech (augmentative) and instead of speech (alternative). Beukelman and colleagues (2012) posited that the ultimate goal of AAC is to enable individuals to efficiently and effectively engage in a variety of interactions and participate in activities of their choice, not to find a solution to communication problems.
Specifically, AAC aids in communication and participation with others.
One form of AAC is gestures, defined as using fingers, hands, and arms to express an idea or meaning. Interventions promoting the use of signing to encourage more communication have been successful with young children (Goodwyn, 2000; Wright, 2011). A three-year study completed to determine the relationship between children’s receptive English vocabulary and a teacher’s inclusion of sign language into a prekindergarten curriculum showed a correlation between the use of sign language and improvement in children’s English vocabulary (Daniels
1997). These findings confirm that presenting words in various forms (e.g., visually, orally) offers an advantage to young learners.
Additionally, a study completed by Goodwyn and colleagues (2000), found that when parents encouraged the use of signs, their children outperformed children whose parents encouraged the use of vocalizations in receptive and expressive vocal language, extending research on the benefit of presenting language in varying forms.
Enhanced Milieu Teaching
One intervention that has been used effectively to increase communication of young children with and without disabilities is Enhanced Milieu Teaching (EMT; Hancock & Kaiser, 2006). EMT has three basic components; responsive interactions (e.g., expansions, turn taking, conversations used to maintain child attention slightly above child’s current language level), environmental arrangement (e.g., selecting preferred toys, arranging the toys to easily initiate conversation), and milieu teaching (e.g., time delays, prompting, modeling) (Hancock & Kaiser, 2006). Those components are embedded within child-led interactions between an adult and a child, to teach communication and language skills (Hancock & Kaiser, 2006). Hemmeter and Kaiser (1994) taught parents to use these EMT strategies with their preschool-age children with developmental delays. Data indicated positive effects for all four participants’ language
(Hemmeter & Kaiser, 1994). Numerous studies have been conducted since this seminal study, demonstrating positive effects of EMT on targeted language skills for young children (e.g., Kaiser & Hester ,1994; Peredo et al., 2022; Roberts & Kaiser, 2015).
A small body of research has been conducted examining the effectiveness of an adaptation of EMT in which words and signs are paired and presented simultaneously during play (Words + Signs; Wright, 2011; Wright, 2016). One study examined the effects of EMT
Words + Signs; paired with Joint Attention Symbolic Play Engagement and Regulation (JASPER), a play-based intervention targeting communication needs of children with autism (Wright et al., 2013). Wright et al. (2013) identified a functional relation between the
researcher’s use of intervention strategies and participants’ use of signs, with a gradual increase in spoken words for all four participants. Further, the participants generalized their newly learned signs to interactions with their parents in their home (Wright et al., 2013).
EMT was designed originally for parents to use with young children (Kaiser & Hancock, 2006). Caregiver implemented EMT has been shown to increase language outcomes for toddlers with language delays. Parents have primarily been coached to implement the intervention
through the Teach-Model-Coach-Review method (Hatcher & Page, 2020; Wright & Kaiser, 2017). However, no studies have been conducted which measured generalization of newly learned signs to classroom interactions which is an important context for young children.
EMT has been shown to be effective with children who have a range of needs, with most studies being conducted in home and clinic settings with parents and trained interventionists (Kaiser & Hancock, 2006).
Purpose of the Study
The purpose of this study is to expand the use of EMT Words + Signs by changing the context from home to the classroom to increase toddlers’ use of gestures and spoken words.
Pairing sign language with verbal language has been shown to help children develop pathways to communicate, and this study was designed to extend those findings. I hypothesize that the use of EMT Words + Signs will result in an increase in toddlers’ use of signs and spoken words, which will generalize to communicative interactions with their classroom teacher. This study will address the following research questions:
1. Will researcher-implemented EMT Words + Signs during play increase the use of target words (spoken or signed) in toddlers with language delays?
2. Will researcher-implemented EMT Words + Signs during play increase the spontaneous use of words in toddlers with language delays?
3. Will toddlers with language delays generalize newly learned signs and spoken words with the lead teacher during free play?
4. Will teachers and families report changes in their toddler’s use of signs and words as a result of EMT Words + Signs?
5. Will toddlers with language delays maintain newly learned signs and spoken words 2- 4 weeks after intervention is withdrawn?
METHODS Participants
After receiving approval from the Institutional Review Board, three toddlers were
recruited, based on teacher recommendation, from an inclusive preschool program to be included in this study. To participate in this study, children had to (a) be between 12 and 36 months of age, (b) have English as their primary home language, (c) be absent from school less than 15% of the previous 30 school days, and (d) have no previous sign training on the target words selected for this study. Assessments were conducted to measure motor imitation, expressive language, and receptive language skills to determine if children were motorically imitative (a pre-requisite for signing) and had a language delay. Additional information about inclusion criteria can be found in Table 1. Participants failing to meet all aspects of inclusion criteria were excluded from
generalization. For this study, one of three recruited participants did not meet the inclusion criteria.
G is a 25-mo-old white male. G does not receive therapy services. The classroom lead teacher in G’s classroom is a 50-yr-old white female who has taught at this school for seven years. V is a 30-mo-old white female with Down Syndrome. V receives speech and physical therapy once a week. At the time of this study, V used ASL to communicate and received a 9- picture AAC device in the middle of the study. Not all target words were provided on the device, so the researcher did not incorporate the device into study sessions. The classroom lead teacher in V’s classroom is a 35-yr-old white female who has taught at this school for one year.
The implementer, and first author, is a 24-yr-old white female enrolled in an early
childhood special education graduate program, with a K-6 teaching license. The implementer had previously used sign language as a communication technique, though she was not fluent in sign language.
Setting and Materials
This study was conducted in an inclusive, university-affiliated preschool in the southeastern United States. All sessions for all participants took place during morning or afternoon free play in their classroom. Each classroom included two to three adults and ten children. Though there were other children and teachers present in the classroom at the time of each session, sessions took place with the implementer and participant in an area away from peers to minimize distractions. If a participant became distracted or tried to leave the area, the child was redirected to “play first.” If peers attempted to enter the session area, they were redirected by a classroom teacher or the implementer to another play area in the classroom.
Materials used during experimental play sessions included a variety of age-appropriate toys. The toys were preferred by the participant, selected by teacher and parent referral or implementer observation. Examples of toys used during sessions include blocks, cars, books, and pretend food. Toys were related to target words, such as cat or bath. Target words were chosen in pairs to encourage imitation, commenting, and their functional use for each participant. Target words were chosen from a list of early occurring words on the MacArthur-Bates Communicative Development Inventory (MCDI; Fenson et al., 2006) that the participants’ parent indicated were unknown by the participant. Examples of target words that a participant might functionally use in their classroom environment are ‘book,’ ‘on,’ ‘car,’ ‘happy,’ or ‘open.’
All sessions were recorded for data collection using a video camera. Videos were stored on a Box drive shared only with key study personnel. ProCoderDV was used for digital data coding of videos. The researcher summarized data on Excel.
Response Definitions & Measurement Systems
The primary dependent variable, used to make experimental decisions, was participant use (verbal or sign) of target words. Signing was defined as the participant forming their hands in a way that represented a conventional sign or consistently approximated the appropriate hand formation and movement. Examples of sign approximations included patting chest when trying to say “please” or “my” or putting fists together when trying to say “help”. Non-examples of signing include moving fingers, hands, and arms in an action that was not a close approximation of the word they were trying to communicate, such as clapping hands when trying to say “thank you”, or using other body parts, such as their eyes to look at a desired object.
The secondary dependent variable was participant use of spoken word, defined as a word that is verbally spoken aloud that a native speaker can identify. Examples of spoken word
included “ball”, “puppy”, an exclamation, such as “wow” or “boo”, a word that closely imitates the correct phonemes of a word, such as “wellow” for “yellow” or “dada” for “dad”. Non- examples included babbling, such as “dadada” or “labada”, “wa,” for “water”, grunting, crying, or non-English words.
All sessions were coded for participant use of target and spontaneous words using a recording sheet (see, Appendix A. Each word used by the participant was tallied and it was noted whether or not word was a target word. Words were also coded for modality: sign (z) or spoken word (w), and level of independence: imitated response (i), prompted response (p), or
unprompted response (u). Each target word was modeled, in spoken word and sign, and prompted a minimum of three times per session. Examples of each independence level can be found in Table 3.
Interobserver Agreement
The primary data coder for this study was the interventionist. The interventionist is a second-year graduate student in the special education program. A first-year special education graduate student was trained to collect IOA data. Training included meeting to review the operational definitions and study procedures, watching and coding practice sessions that had been coded by the implementer, until reaching 85% agreement or higher, and discussing any disagreements.
IOA was collected for an average of 40%-50% of randomly selected sessions across all conditions, word sets, and participants. IOA of 80% or higher was considered acceptable. If IOA dropped below criterion, the implementer and IOA observer met to discuss and resolve any disagreements, review operational definitions, and retrain using practice videos until 85%
agreement was reached. For example, when beginning to code baseline sessions, the
implementer and second coder were unclear on whether to code sound effects and exclamations as words. This uncertainty made the first baseline video unreliable, so the implementer and second coder met and coded two more videos until agreement of 85% or higher was met.
Agreement was calculated using the point-by-point method in which the number of agreements was divided by the number of agreements plus disagreements and multiplied by 100 (Ledford et al., 2018). An overview of IOA data can be found in Table 4.
Experimental Design
A multiple-baseline (MB; Ledford et al., 2018) design across four word-sets was used for each participant. There were two words per set and the introduction of each set was time-lagged.
Intervention on subsequent tiers was implemented only after an effect was seen in the previous tiers to control for threats to internal validity. After data indicated a stable level or increasing trend above baseline levels, the next set of words, chosen at random, was introduced, and the previous tier was moved into maintenance. If the participant had three consecutive data points indicating use of target word three times during intervention, the next tier was introduced.
The design included three experimental conditions (baseline, intervention, and maintenance), and generalization observations, which occurred across all experimental
conditions. Continuous data collection occurred across all participants, conditions, and word sets.
A multiple probe (MP) design was considered, but a MB was chosen because data could be collected on all word sets in each session. A MP typically reduces the amount of data collection needed with its use of non-continuous probes across each tier, but the use of a MP for this study would have reduced the amount of data and may have reduced the implementer’s ability to detect and control for threats to internal validity.
Initially, a withdrawal design was also considered due to communication being a reversible behavior but removing the intervention from participants wasn’t practical when the long-term goal of the intervention was a gradual increase in communication and the learning of words.
Common threats to internal validity within a MB design are history and maturation. Both threats were controlled for by continuing conditions across tiers until data were stable. Data on the frequency of target words usage across sets and the number of spontaneous spoken words and signs by each participant were graphed daily. Visual analysis was used to make decisions regarding condition changes and to detect potential threats to internal validity.
Procedures Pre-Baseline
Three assessments were conducted prior to baseline to describe each participant’s current communication and motor imitation abilities. These assessments included the Motor Imitation Scale (MIS; Stone, et. al., 1997), the MacArthur-Bates Communicative Development Inventories (MCDI; Fenson, et. al., 2006), and the Preschool Language Scale (PLS; Zimmerman, et al., 2002). A summary of assessment results for each participant can be found in Table 2.
Baseline
During baseline, the implementer and the participant played with a toy set, that included a variety of preferred toys and related to target words, while seated on the floor in a center in the participant’s classroom, away from peers. Each session was 10-min in length. Specific EMT strategies (e.g., matched turns, expansions), prompting procedures and modeling of target words were not implemented during baseline sessions. The control variables for this condition included the implementer, the setting, and the materials. If the child initiated communication during
baseline sessions, the implementer responded by describing her play actions and those of the participant (e.g., “I see that you have a dog”). If the participant did not initiate communication, the implementer asked questions (“where should the dog go next?”) or directed the participant to complete a play act (“walk the dog”).
Upon the completion of a play session, the implementer thanked the participant for playing (“Thank you for playing with me today!”) and the participant returned to scheduled classroom activities.
Intervention
Intervention sessions were 10-min in length and the environment and materials remained identical to those present during baseline. The independent variable (i.e., EMT Words + Signs) was used during intervention sessions to teach four sets of two target words. There were six specific EMT strategies implemented during intervention; 1) environmental arrangement, 2) responsive interactions, 3) language modeling, 4) language expansions, 5) time delays, and 6) milieu teaching prompts. Descriptions of each component can be found in Table 5. The implementer modeled each target word, in spoken word and sign, a minimum of 3 times per session.
A prompting procedure was embedded into the EMT approach. Three prompting trials for each target word were embedded throughout the 10-min sessions. For example, if the
participant was reaching for a car, the implementer would pause play and prompt the participant to “say car,” before the participant was given a car to continue play. When prompting, the implementer would sign “car” and use spoken word to say “car” simultaneously. If a prompt was given twice, and the participant did not give a communication attempt, the implementer
abandoned the prompt and continued playing. If the participant said or signed ‘car,’ the
implementer expanded on the child communication attempt and a prompted response was recorded.
Generalization
To assess the participants’ generalization to teachers in their classroom, 10-min
observation probes were conducted during all conditions. Generalization probes occurred in the participant’s classroom during free play with the lead classroom teacher. Teachers were asked to interact as they typically do when playing with toys and books with the participant. Teachers did not have prior knowledge of target words before generalization sessions. Materials used were toys within their classroom. Generalization probes occurred across all conditions, tiers, and participants.
Maintenance
To assess if participants maintained their use of target words post-intervention,
maintenance data were continuously collected after the completion of intervention on each word set for each participant. Maintenance data on a previously taught word set were collected during each intervention session in subsequent tiers. Maintenance words were not being prompted for during the intervention sessions but could be coded in the proceeding tiers.
Procedural Fidelity
Procedural fidelity (PF) was measured using a checklist and direct systematic observation of environmental set up and implementation of EMT Words + Signs. A special education
graduate student was trained in EMT Words + Signs fidelity. Training included meeting with the implementer to review the operational definitions of EMT components and study procedures, watching and coding practice sessions until reaching 85% or higher agreement, and discussing any disagreements.
To collect PF, an observer watched and coded recorded sessions using a checklist (see, Appendix B). The presence or absence of each EMT strategy was recorded. The number of strategies present used divided by the total number possible and multiplied by 100 to provide an average percentage of PF. Procedural fidelity of 85% or higher was accepted and PF data was collected on an average of 34%-38% of randomly selected sessions across all participants, word sets, and conditions. If PF dropped below 85%, the implementer reviewed the procedural steps of the study and PF was collected for 100% of sessions until PF returned to criterion (or higher) for two consecutive sessions. An overview of PF data can be found in Table 6.
Social Validity
Social validity was measured using normative and subjective measures. Social validity from families and teachers was collected both pre- and post- intervention. Before the
intervention, target words were suggested by families and teachers to ensure they were functional in the participant’s everyday environment. After the study, a 5-item questionnaire (see appendix C) was given to both participant’s families and lead teachers, and they were asked to rate each item on a 5-point scale. The higher the overall score, the more the individual(s) considered the intervention to be socially valid. The questionnaire results, which can be found in Table 7, assessed family and teacher perspective on intervention outcomes and appropriateness for the participant. Observational notes were also taken during intervention to note student enjoyment and growth. The PLS was conducted pre-intervention and post-intervention to measure
participants’ overall language growth across their participation, providing additional evidence of the social validity of this study. Results from the PLS assessment conducted post-intervention are still being calculated.
RESULTS Data Analysis
The implementer graphed data in Excel after every session and were used to analyze and make decisions. Decisions were made based on visual analysis of the overlap, consistency, trend, level, immediacy of change, and variability of data. Data based decisions were made based on the primary dependent variable, which was participant use of target words. Formative visual analysis was used to make decisions about changing conditions or tiers after every session.
Participants moved from baseline to intervention when data were low and stable for at least three data points. When data showed a clear, stable positive trend, and three or more uses of each target word; for three consecutive data points, the participant moved into maintenance, and the intervention was introduced in the subsequent tier. If data fell below a frequency of three for either target word, the participant remained in that tier until the data were stable. Summative visual analysis was conducted after the completion of intervention for each participant. Vertical analysis across tiers/word sets was conducted to observe three replications of effect across tiers/word sets.
Research Question 1
Figure 1 provides data on in-session target word use for G, and Figure 4 provides data on in-session target word use for V. There was a functional relation between the implementation of EMT W+S and the participant use of prompted words, for both participants with three
replications for each. For G, there was a gradual change in level and trend, primarily in spoken word. For V, there was a gradual increase in sign from baseline to intervention in the first tier..
There were 9 overlapping sessions in the first tier for G and 11 for V, but no overlapping data between baseline and intervention in the remaining three tiers for either participant. Each
participant quickly learned to respond to the prompting procedure, and there was a consistent increase in level from baseline to intervention. Because maintenance data were low for G, a second round of intervention was implemented to increase the learning period for each target word.
Research Question 2
Figures 3 and 6 show the spontaneous word use for G and V respectively. For both participants, spontaneous word use was variable with some overlap between baseline and intervention but an overall increasing trend across intervention. There are not enough
replications, however, to determine the presence of a functional relation between EMT Words + Signs and participant use of use spontaneous words. G’s data are likely due to the interventionist introducing more vocabulary at the start of intervention, leading to a decrease in new words and an increase in imitated words being produced by the participant. G had a consistently low level of spontaneous signs and a steady increase in spontaneous verbal speech. V had a consistently low level of spontaneous verbal speech and a variable increase in spontaneous sign.
Research Question 3
Generalization results can be found in the graphs of in-session target word use in Figures 1 for G and 4 for V. G generalized target words to a variable degree, but only in response to the teacher verbally saying the target word. V did not show any evidence of generalization. There was not enough evidence of generalization to determine the presence of a functional relation for either participant.
Research Question 4
Social validity is in the process of being conducted. Results of the family/teacher questionnaire can be found in Table 7. On average, the intervention, procedures, and target words chosen were found to be appropriate and effective by the participants’ families and teachers. Anecdotally, G’s teachers stated throughout the study that they could tell a noticeable increase in G’s spontaneous word use.
Research Question 5
Both participants maintained their use of target words to some degree, but data were variable across tiers and inconsistent. Maintenance results can be found in the graphs of in- session target word use in Figures 1 for G and 4 for V or combined in-session target word use in Figures 2 for G and 5 for V.
Reliability and Fidelity
IOA was conducted for 60% of sessions across all participants and conditions. IOA for G, conducted across all conditions and tiers, was 85%. IOA for V was 95%. A breakdown of IOA results can be found in Table 4.
PF was completed incorrectly for the first three session of intervention, due to prompting errors. The interventionalist went back through the PF guidelines and corrected the error in the future sessions. Following this, the second coder coded 100% of sessions until PF met criteria.
PF was conducted for 38% of sessions across all participants. PF for G, conducted across all conditions and tiers, was 90%. PF for V was 89%. A breakdown of PF results can be found in Table 6.
DISCUSSION Major Findings
Overall, the intervention was effective in increasing the in-session target word use and spontaneous word use of both participants. Though a functional relation was only present between EMT Words +Signs and the increase in in-session target word use, both participants demonstrated growth in their use of spontaneous communication throughout the study. The study also sought to expand research into a classroom setting, by conducting sessions in the classroom and measuring generalization of target words classroom teachers. V did not demonstrate
generalization of target words to her classroom teacher, and generalization data were variable and inconsistent for G. There was some evidence of maintained use of target words after the completion of each intervention tier to some degree, indicating that EMT Words + Signs has the potential to be an effective tool in teaching children target words that can be maintained over time. Both participants quickly learned to respond to the prompting procedures during intervention sessions, but maintenance of each target word was variable across tiers.
Study Limitations
There were several limitations to this study. V did not generalize her newly learned target words to her lead teacher in free play. This is possibly due to V’s teacher not verbally stating or signing any target words during generalization sessions, therefore limiting the opportunities for V to imitate the target words. A second limitation was that the IOA coder did not know many of the signs and approximations of the participants as well as the implementer. Some participant signs and verbal speech were known by the implementer, but unrecognizable by the second coder. The implementer and second coder met and coded more sessions which helped the second coder understand more of the participants’ vocabulary as the study progressed. A third limitation
was the occurrence of a winter break in the middle of this study, delaying the completion of the study. V’s sessions were also halted before intervention could begin in the fourth tier because of a prolonged absence due to illness. A final limitation was the implementer and second coder were only briefly trained in EMT prior to this study. A doctoral student trained in EMT provided in-classroom training sessions for the implementer and provided video training for the second coder.
Future Research
Research should replicate this study with more participants and focus on spontaneous word use and maintenance and generalization. Findings from this study were inconsistent, indicating that more research is needed to understand the effectiveness of EMT Words + Signs.
More replications are also needed to show a functional relation for spontaneous in-session word use. Future researchers should consider performing another replication to show the effects of a design and criteria different than the ones chosen by the implementer. The implementer chose a MB design, which led to a high number of sessions, but the set criteria in each intervention tier (i.e., three imitated uses of each target words over three consecutive days) led to short learning periods for each word set. This led to another round of intervention sessions for G. Another replication could be performed with a design or criteria that allows for a longer learning period but fewer sessions overall. More data also are needed on teacher-implemented EMT to broaden the research on primary implementers. EMT was designed primarily for parents, and there is little research on the effects of teacher-implemented EMT within the classroom setting.
Implications for Practice
Data from this study suggest that EMT Words + Signs might be effective for expanding communication of young children within a classroom setting. This would allow educators to help
develop sign and spoken word simultaneously, creating multiple pathways for communication for children in their classroom. During this study, the target participants were highly engaged and seemed to enjoy the intervention play sessions. When the implementer walked into the
classroom, both participants would show excitement, (i.e., immediately going to the corner where sessions would take place, signing the word ‘play,’ smiling when greeted, verbally saying
‘ready’). There was also interest from classroom peers throughout the study, indicating that EMT could be used with multiple children in the classroom. Lastly, participants were extremely imitative and likely to use words if used by implementer. All words by G in the generalization setting were due to the lead teacher verbally stating them and G imitating them. This indicates that if children in the classroom are imitative, they are more likely to use words regularly heard in their environment. Vocabulary-rich classrooms are an essential factor in strong
communication growth.
Conclusion
This study demonstrated a functional relation between EMT Words + Signs and both participants’ target word use. The data indicated an increase in spontaneous word use for both participants, but more replications are needed to demonstrate a functional relation. Additional replications are recommended to provide more information on maintenance and generalization of target words.
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APPENDIX APPENDIX A
TOTAL # OF DV FREQUENCY
Participant: _________________ Observer Initials: _________ Date: _________
Session #: ___________ Start Time: ______________ End Time: ______________
Condition: Baseline Intervention Generalization
Time Target Word Independence Form Word
1 :00 Y Imitated (i) Gesture (z) Open
3 :03 N Prompted (p) Spoken Word (w) Ball
3 :40 N Unprompted (u)
Note: word used written in appropriate box; if more than one word used per interval, write each word given in appropriate box
APPENDIX B
PROCEDURAL FIDELITY EMT CHECKLIST
Participant: _________________ Observer Initials: _________ Date: _________
Session #: ___________ Start Time: ______________ End Time: ______________
Condition: Baseline Intervention Engagement Strategies
1. Physical Space.
The adult sits face-to-face and has defined a space for the child to play with preferred objects
available without too many distractions.
The adult attempts to maintain this space during the session.
□ 1 = set up/maintai n a
defined space, face-to- face, toys available, distraction s removed
□ 0.5 = ≥ 1 criteria missing
□ 0 = criteria not attempted
2. Follow Lead.
The adult follows the child's lead when appropriate.
The adult does not recruit the child to other materials when the ones the child is playing with can be used appropriately.
□ 1 = 0 instances of recruiting inappropriat ely
□ 0.5 = 1 instance
□ 0 = ≥ 2 instances
3. Imitate Actions.
The adult joins in the child's play by
imitating their actions appropriately.
□ 1 = ≥ 5 instances
□ 0.5 = 3-4 instances
□ 0 = 0-2 instances
4. Give.
The adult attempts to hand the child objects while verbally pairing them with their label to promote engagement . The intention must be to totally transfer the object to the child.
Giving following requesting and milieu episodes does not count.
□ 1 = ≥ 2 gives + labels
□ 0.5 = 1 give + label
□ 0 = 0
5a. Respond.
The adult responds to all child
communicatio n.
□ 1 =
responsive a majority of communicatio n attempts (including gesture, vocs, and words)
□ 0 = at least 3 instances of missed
responsiveness opportunities
6. Directive Statements.
The adult uses language that is open-ended and that is not directive or overly questioning.
□ 1 = 0 instances of directive statements or closed- ended questions
□ 0.5 = 1 direction or closed question
□ 0 = ≥ 2 instances of
directions or closed ended questions 5b. Pause.
The adult waits at least 3 seconds before taking another turn.
□ 1 = Majority of adult utterances leave 3s of wait time prior to next adult utterance
□ 0 = Majority
gives + labels
of adult utterances are back-to-back, leaving <3s for child to speak
Engagement Strategies Raw Score:
___________
Language Strategies 7c. Overall Modeling of Linguistic
Input per EMT
The adult uses labels (e.g., “Ball”,
“it’s a cat!”) and Toy Talk sentences (e.g., “The ball is rolling!”, “Cats say meow”) often during their communicative turns.
□ 1 = uses labels and Toy Talk sentences fluently and throughout the majority of session
□ 0 = Inconsistent use of labels and ToyTalk sentences- much of the adult’s language are non-target utterances. See examples below and cheat sheet.
8. Expanding Language.
The adult expands the child’s language by adding words or signs to create a sentence/add to a sentence.
□ 1 = adult expands at least 50%
of child communicati on attempts
□ 0 = adult expands on no
communicati on attempts
□ N/A = no
opportunities for
expansion
*if child signs, expand with signs
9a. Point/Show.
The adult clearly points to or shows objects while verbally labeling to make the object names more salient.
□ 1 = ≥ 3
□ 0 = 0
11. Pantomime.
The adult pantomimes (or acts out) an action that either the child or the object is doing. This action needs to be paired with an active declarative sentence (e.g., “the alligator is chomping!”)
□ 1 = ≥ 1 pantomimes
□ 0 = 0 pantomimes 10a. Model
Target Signs.
The adult will use ASL to label or show target words while verbally labeling.
□ 1 = ≥ 3 per appropriate target words for that tier and 3 ≥ per target words for untrained tiers
□ 0 = 0 or ≥ 3 per target words for untrained tiers
10b. Model Target Verbal Words.
use verbal speech to label target words.
1 = ≥ 3 per appropriate target words for that tier and 3 ≥ per target words for untrained tiers
□ 0 = □ 0 = 0 or
≥ 3 per target words for untrained tiers□
0 = 0 or ≥ 3 per target words for untrained tiers
Language Strategies Raw Score:
______________
Play Strategies 12. Set the Focus of
the Base Routine.
The adult joins in play with the child and verbally sets the focus of the routine (e.g., "let's make a cake").
□ 1 = establishes at least 1 base routine when child is
attending to the object(s) that will be used
□ 0.5 = only
establishes base routines when child is NOT attending to the object(s) that will be used
□ 0 = does not
13. Add Objects.
The adult adds objects to play to grow established routines. Objects added must be paired with a label.
□ 1 = adds ≥ 2 objects + labels
□ 0.5 = adds 1 object + label
□ 0 = adds 0 objects with a label
14. Add Actions.
The adult (1) imitates a child action and (2) extends play by adding a related action while pairing with an ADS. To count, the adult must add an action with the same object recently used to imitate the child's play within 5 seconds.
The same "added action" may be used again later in the session if the adult and child are playing with new objects.
□ 1 = adds ≥ 2
15. Re-Start Routine.
The adult re- starts the base routine when appropriate.
□ 1 = ≥ 1 restarted routine
□ 0 = 0 restarted routines
16. Behavioral Strategies.
The adult uses behavioral strategies to extend engagement and play (e.g., timers, first/then boards, countdowns, H.O.H.).
□ 1 = behavior strategies used appropriately
□ 0 = behavior strategies not used
appropriately / when needed
□ N/A = no strategies needed
establish at least 1 base routine
actions with an ADS after imitating (within 5 s)
□ 0.5 = adds 1 action
□ 0 = adds 0 actions
Play Strategies Raw Score:
______________
Prompting and Time Delay Strategies 17. Frequency of
Prompt Attempts.
The adult attempts to set up a sufficient number of milieu prompting episodes.
Prompts can be set up by the adult OR initiated after a spontaneous request.
This includes setting up a time delay that the child independently responded to.
□ 1 = ≥ 2 prompts attempted
□ 0.5 = 1 prompt attempted
□ 0 = 0 prompts attempted, or prompts are attempted too frequently (higher than 1x/min on average)
18. Flexibility in Setting Up Strategies.
The adult sets up prompts in more than one way (e.g., choices, inadequate proportions, assistance, waiting with a routine, waiting with a cue, OR in response to a natural request).
A score of "1" can be given if two different types are
attempted OR one type is used with two different materials.
□ 1 = ≥ 2 different types
□ 0 = < 2 types
19. Quality of Episode.
The adult consistently implements high-quality prompting episodes for the
appropriate target word.
Don't consider abandoned episodes when scoring this item.
□ 1 = a majority of prompts attempted were high- quality and for correct target words for that tier
□ 0 = a majority of prompts
20. Appropriately Abandons.
The adult appropriately stops prompting as soon as the child loses interest (or they realize the child never had interest).
□ 1 = appropriately abandons a majority of instances when child loses instances
□ 0 = adult does not stop prompting after child loses interest for a majority of instances
□ N/A = no prompts attempted
were not high- quality or for the incorrect target words for that tier
□ N/A = no prompts attempted
Prompting and Time Delay Strategies
Raw Score: _________
22 – Number of N/A Items = _____________ Total Possible
Sum of Raw Scores ÷ Total Possible = _____________ % Total Fidelity
APPENDIX C
FAMILY AND TEACHER REPORT
Participant Initials: _________________ Circle: Family Teacher
Please complete the following questionnaire to provide feedback about the intervention implemented with the student listed above. Thank you for your participation.
No, not at all
Somewha t
Yes, very 1. Prior to the intervention, was the
participant’s level of communication a concern?
1 2 3 4 5
2. Were the modes of communication targeted in this intervention (speech and sign) appropriate for this child?
1 2 3 4 5
3. Were the target words appropriate for this child?
1 2 3 4 5
4. Were the intervention procedures appropriate for this child?
1 2 3 4 5
5. Did the child’s communication improve after the implementation of this intervention?
1 2 3 4 5
Overall Score:
\
TABLES Table 1
Inclusion Criteria
Criterion Measurement System
Age Between 12-36 months Teacher/Parent report
home speak English
Attendance Absent from school less than 15% of the previous 30 school days
Teacher/Parent report
Sign training No previous sign training of target words
Teacher/Parent report Motor imitation skills Score of 80% or higher Motor Imitation Scale; MIS
(Stone, et. al., 1997) Expressive language skills Score below 50% percentile in
age range
MacArthur-Bates
Communicative Development Inventories; MCDI (Fenson, et. al., 2006)
Expressive language skills Score of 85 or lower Preschool Language Scale;
PLS-4 (Zimmerman, Steiner,
& Pond, 2002) Table 2
Assessment Results
Child MCDI MIS PLS
G 10th Percentile 81% 72
V 30th Percentile 89% 50
Criterion Below 50th Percentile Above 80% Below 85
Table 3
Independence Levels
Response Definition Example
p Participant communicates correct word after prompt
“Say ball.” Child: “Ball”
u Participant spontaneously communicates word
“Say ball.” Child: “Please”
i Participant communicates word after “The ball is rolling.” Child: “Ball”
implementer, but without a prompt Table 4
Hypothetical IOA Data
Condition G V Percent of Sessions
Baseline 83% (75%-100%) 100% (100%) 84% (67%-100%)
Intervention 85% (65%-100%) 95% (90%-100%) 38% (35%-42%) Generalization 86% (63%-100%) 91% (89%-100%) 58% (50%-67%)
Totals 85% 95% 60%
Table 5
EMT Components
Rationale Examples and Specific Steps
Environmenta
l Arrangement Prevent and manage child behavior
Maintain and extend child’s play and interaction with adult
Promote child engagement
Select materials that are preferred
Provide several choices to allow for changing preferences
Designate play space with a physical cue (ex: carpet square);
limit number of toys/materials that are within the child’s reach
Responsive
Interaction Engage children in positive interactions
Include space for child to engage in conversations (ex: pause time)
Reinforce child for all communication attempts (verbal or nonverbal)
Follow child’s play or conversational lead
Mirror child’s actions and verbally map corresponding language which support child in orienting to adult conversation
Pace interactions so child has time to participate as an equal
conversational partner Language
Modeling Provide child with specific models of target language
Prime child to imitate targets spontaneously
Model all of child’s language targets in the context of child interest
Map language onto mirrored actions that are close to the child’s attentional focus
Language
Expansion Scaffold language for more complex
vocabulary, grammar, and syntax
Expand child language attempt by adding 1-3 words to model more complex language at a time when child is motivated to communicate Time Delay Provide supported
practice initiating nonverbally and verbally
Present choices nonverbally and verbally
Adult nonverbal behavior cues child to communicate
promote requesting
Respond to the child’s nonverbal request (point, reach) or
vocalization by modeling the label for the object requested and giving the object or assistance
Milieu Teaching Prompt
Prompts are presented in response to child
nonverbal requests and indicated interests to encourage children to communicate verbally using target language
Prompts follow a least to most support hierarchy to provide the needed level of support (open ended question, choice, say prompt)
Child attempts are always reinforced with positive attention, compliance with child request, and expanding on utterance
Model the specific target language several times in the interaction before using prompting
Prompt only when the child is requesting or highly motivated and you have a reinforcer
Begin with the least supportive prompt unless you know the child needs more support to verbalize (e.g., can only imitate the target so start with the say prompt)
You may repeat the prompt once, or follow up with a more
supportive prompt, but keep the episode brief and positive
Every episode should end with the child accessing the requested material or action and an expansion or restatement of the target utterance
Table 6 PF Data
Condition G V Percent of Sessions
Baseline 12% 28% 33%
Intervention 90% (74%-98%) 89% (86%-92%) 38% (35%-42%)
Table 7
Social Validity Questionnaire
Question G Family V Family V Teacher Average Score
Q1 3 4 4 4
Q2 5 5 5 5
Q3 5 5 5 5
Q4 5 5 5 5
Q5 5 4 4 4
Note: Results for G Teacher are still being collected due to prolonged absence
FIGURES Figure 1
Results
Note: in-session target word usage across word sets for G; the blue arrow indicates the start of prompting procedure done correctly.
Figure 2 Results
Note: in-session target word usage across combined word sets for G
Figure 3 Results
Note: in-session spontaneous word usage for G
Figure 4 Results
Note: in-session target word usage across word sets for V
Figure 5 Results
Note: in-session target word usage across combined word sets for V
Figure 6 Results
Note: in-session spontaneous word usage for V
