Treatment section of the Spoken Language Disorders Evidence Map for pertinent scientific evidence, expert opinion, and client/patient perspective.
Spoken language disorders (SLD) are heterogeneous in nature, and the severity of the disorder can vary considerably. Each individual with language difficulties has a unique profile, based on his or her current level of language functioning, as well as functioning in areas related to language, including hearing, cognitive level, and speech production skills. In addition to having a unique profile of strengths and needs, individuals bring different backgrounds to the treatment setting. For bilingual individuals, it is important that the clinician consider the language or languages used during intervention. See
bilingual service delivery.
The goal of language intervention is to stimulate overall language development and to teach language skills in an integrated fashion and in context, so as to enhance everyday communication and ensure access to academic content. Goals are frequently selected with consideration for developmental appropriateness and the potential for improving the effectiveness of communication and academic and social success.
Roth and Worthington (2015) summarize steps in the selection and programming of treatment targets and provide sample case profiles for early intervention through adolescence. They also identify a number of basic principles of effective intervention regardless of client age or disorder. These include:
- to the extent possible, teach strategies for facilitating communication rather than teaching isolated behaviors
- provide intervention that is dynamic in nature and includes ongoing assessment of the child's progress in relation to his or her goals, modifying them as necessary
- provide intervention that is individualized, based on the nature of a child's deficits and individual learning style
- tailor treatment goals to promote a child's knowledge, one step beyond the current level
Intervention strategies for various age ranges are outlined in the sections below. Older individuals with severely impaired language may be functioning at developing language levels. Rather than being based on developmental sequences, interventions for these individuals may be more functional in nature, focusing on building independence in everyday settings.
In typically developing preschool children, language is developing at a rapid pace; their vocabularies are growing, and they are beginning to master basic sentence structures. For children with language difficulties, this process may be delayed. For children in this population, areas targeted for intervention typically include:
- improving significantly impaired intelligibility—particularly if it results in frustration in communicating and/or masks problems in semantics and syntax—including
- increasing consonant repertoire,
- improving accuracy of sound production,
- decreasing use of phonological processes;
- enhancing phonological awareness skills, such as
- blending and segmenting spoken words at the following levels
- syllable (2 syllables in pancake: pan and cake),
- onset and rime (2 onsets: p and c; 2 rimes: an and ake),
- phoneme (6 phonemes: p+a+n+c+a+ke)
- deletion of whole words, syllables, and phonemes in spoken words, phrases, and/or sentences.
- increasing size of vocabulary, including
- verbs, pronouns, conjunctions;
- basic concept vocabulary;
- increasing understanding and use of a wider range of semantic relationships (e.g., agent-action, agent-object, possessor-possession, attribute-entity, recurrence).
morphology and syntax
- facilitating acquisition and use of age-appropriate morphemes—in particular, auxiliary verbs, articles, pronouns;
- increasing sentence length and complexity;
- increasing use of varied sentence types.
- increasing flexibility of language for various contexts;
- using imaginative play activities to practice newly acquired language skills;
- improving conversational skills, including
- initiating and maintaining communication;
- turn taking, topic maintenance, and topic shifts;
- requesting and making conversational repairs;
- developing narrative skills.
social communication disorder for more information about pragmatics.
- building emergent literacy skills, including
- print awareness,
- book awareness,
- understanding simple story structure,
- letter knowledge,
- matching speech to print.
treatment section of the Written Language Disorders Practice Portal page.
The focus of language intervention for elementary school children with language difficulties is to help the child acquire the language skills needed to learn and succeed in a classroom environment. Interventions are curriculum-based, that is, goals address language needs within the context of the curriculum where these skills are needed.
Interventions may also address literacy skills (e.g., improving decoding, reading comprehension, and narrative and expository writing), as well as metacognitive and metalinguistic skills (e.g., increasing awareness of rules and principles for use of various language forms, improving the ability to self-monitor and self-regulate) that are critical for the development of higher-level language skills. See the
treatment section of the Written Language Disorders Practice Portal page.
For children who speak a language other than English in the home, it may be necessary to use the home language as a mechanism for transitioning the child to using the language of the school. Planning and implementing an effective language intervention program is often a coordinated effort involving the SLP, classroom teacher(s), and other school specialists.
Areas targeted for this population typically include
- enhancing phonological awareness skills,
- eliminating any residual phonological processes.
- improving knowledge of vocabulary, including knowledge of curriculum-related vocabulary,
- improving depth of vocabulary understanding and use, including
- subtle differences in meaning,
- changes in meaning with context,
- abstract vocabulary,
- figures of speech;
- understanding figurative language and recognizing ambiguities in language (e.g., words with multiple meanings and ambiguous sentence structures);
- monitoring comprehension, requesting clarification;
- paraphrasing information.
morphology and syntax
- increasing the use of more advanced morphology (e.g., monster/monstrous, medicine/medical, school/scholastic);
- increasing the ability to analyze morphologically complex words (e.g., prefixes, suffixes);
- improving morphosyntactic skills (e.g., use of morphemes in simple and complex clauses, declarative versus questions, tag questions and relative clauses);
- improving the ability to understand and formulate more complex sentence structures (e.g., compound sentences; complex sentences containing dependent clauses);
- judging the correctness of grammar and morphological word forms and being able to correct errors.
- using language in various contexts to convey politeness, persuasiveness, clarification;
- increasing discourse-level knowledge and skills, including
- academic discourse,
- social interaction discourse,
- narrative discourse,
- expository discourse,
- use of cohesive devices in discourse;
- improving the ability to make relevant contributions to classroom discussions;
- improving the ability to repair conversational breakdowns;
- learning what to say and what not to say;
- learning when to talk and when not to talk.
As students enter their adolescent years, curriculum demands increase. Children with language disabilities may have difficulty meeting increased demands of secondary school. Although basic language skills are still taught, it may not be possible to close the gap between skill level and grade level. At this point, interventions tend to focus on teaching ways to compensate for language deficits. Student involvement is important at this age to foster a feeling of collaboration and responsibility for developing and achieving intervention goals and to learn self-advocacy skills for the classroom (e.g., requesting priority seating in front of classroom).
Instructional strategies approaches that focus on teaching rules, techniques, and principles to facilitate acquisition and use of information across a broad range of situations and settings are often used with older students. Enhancing metalinguistic and metacognitive skills is fundamental to learning new strategies. The emphasis is on how to learn, rather than what to learn. Classroom assignments are often used to teach strategies for learning academic content. Some instructional strategies are discipline-specific, and others are generalizable across disciplines (Faggella-Luby & Deshler, 2008). Examples include strategies for using
- context to deduce meaning and infer and identify main ideas;
- deciphering of morphologically complex words associated with different academic course work (e.g., history, literature, chemistry, algebra);
- checklists and graphic organizers to plan assignments (e.g., book reports, presentations, research papers);
- spell check and grammar check to edit written work composed in an electronic format;
- digital technologies (e.g., Internet, collaboration sites) to access and evaluate information, share and collaborate with classmates, produce shared products, etc.
Also see the
treatment section of the Written Language Disorders Practice Portal page.
Difficulties experienced by children and adolescents with language impairment can continue to impact functioning in post-secondary education and vocational settings. When compared with typically developing peers, fewer individuals with language impairment complete high school or receive an undergraduate degree (Johnson, Beitchman, & Brownlie, 2010). The majority of young adults with specific language impairment who pursue education after high school seek vocational rather than academic qualifications (Conti-Ramsden & Durkin, 2012). In addition, individuals with speech and language impairment tend to be employed in lower-skilled jobs than their typically developing peers (Conti-Ramsden & Durkin, 2012; Johnson, Beitchman, & Brownlie, 2010).
The data on educational and vocational outcomes for individuals with speech and language disorders highlight the need for continued support to facilitate a successful transition to young adulthood. These supports include, but are not limited to, the following:
Transition Planning—the development of a formal transition plan in high school that includes career goals and educational needs; academic counseling (including discussion about requirements for admission to post-secondary schools); career counseling; opportunities for work experience; and community networking
Transition Goals—goals for successful transitioning to post-secondary school or employment that can include preparing a resume; completing a job or college application; effectively presenting skills and limitations during an interview; expressing concerns to authority figures about academic or job performance; stating or restating a position to effectively self-advocate in academic and employment settings
Disability Support Services—individualized support for college-level students that can include accommodations, such as extended time for tests and the use of assistive technology (e.g., to help with reading and writing tasks)
Vocational Support Services—include testing to identify vocational strengths, career counseling, vocational training, job search assistance, and job coaching
Secondary school personnel can assist the student in transition by
- including students and parents in planning,
- being sensitive to culture and values of the student and family,
- educating students about their rights and helping them develop self-advocacy skills,
- helping the student and family in the selection of an appropriate post-secondary school setting and assisting with the application process,
- informing students and families about services in post-secondary settings (e.g., disability support services and academic counseling),
- providing current documentation needed to access services (including academic accommodations) in a post-secondary setting,
- helping students identify the need for supports and any accommodations and assistive technologies.
(National Joint Committee on Learning Disabilities, 1994)
The treatment modes/modalities described below may be used to implement various treatment options.
Augmentative and Alternative Communication (AAC)—supplementing or replacing natural speech and/or writing with aided (e.g., picture communication symbols (PECS), line drawings, Blissymbols, speech generating devices, and tangible objects) and/or unaided (e.g., manual signs, gestures, and finger spelling) symbols. Whereas aided symbols require some type of transmission device, production of unaided symbols only require body movements. See ASHA's Practice Portal page on
Augmentative and Alternative Communication.
Computer Based Instruction—use of computer technology (e.g., iPads) and/or computerized programs for teaching language skills, including vocabulary, social skills, social understanding, and social problem solving.
Video-Based Instruction (also called Video Modeling)—use of video recordings to provide a model of the target behavior or skill. Video recordings of desired behaviors are observed and then imitated by the individual. The learner's self-modeling can be videotaped for later review.
There are a number of different approaches and strategies for individuals with language disorders. Interventions can vary along a continuum of naturalness (Fey, 1986), ranging from contrived or drill-based activities in a therapy room (clinician directed) to activities that model play or other everyday activities in more natural settings (child centered), to those that use activities and settings that combine both approaches (hybrid).
Below are brief descriptions of general and specific treatments for addressing language disorders. Some attempt has been made to organize treatment options into broader categories, recognizing that intervention approaches do not always fit neatly into one particular category. Several of the approaches listed below are most often associated with treatment for social communication disorder and autism spectrum disorder. These approaches are included here, because they are also used with a broader population of children with language disorders. This list is not exhaustive, and the inclusion of any specific treatment approach does not imply endorsement from ASHA.
SLPs and educators determine which methods and strategies are effective for a particular student by taking into consideration the individual's language profile; the severity of the language disorder; factors related to language functioning (e.g., hearing impairment and cognitive functioning); cultural background and values; learning style; and communication needs.
Behavioral interventions and techniques are designed to reduce problem behaviors and teach functional alternative behaviors using the basic principles of behavior change. These methods are based on behavioral/operant principles of learning; they involve examining the antecedents that elicit a certain behavior, along with the consequences that follow that behavior, and then making adjustments in this chain to increase desired behaviors and/or decrease inappropriate ones. Behavioral interventions range from one-to-one, discrete trial instruction to naturalistic approaches.
Discrete Trial Training (DTT)—one-on-one instructional approach utilizing behavioral methods to teach skills in small, incremental steps in a systematic, controlled fashion. The teaching opportunity is a discrete trial with a clearly identified antecedent and consequence (e.g., reinforcement in the form of praise or tangible rewards) for desired behaviors. DTT is most often used for skills that learners are not initiating on their own; have a clear, correct procedure; and can be taught in a one-to-one setting.
Early Intensive Behavioral Interventions—one-on-one comprehensive treatment programs that teach appropriate behaviors using discrete trial training, natural environment teaching, and analysis of verbal behaviors. Treatment typically begins in the young child's home and expands to include early education settings, the community, and other settings as new skills are acquired.
Functional Communication Training (FCT)—a behavioral intervention program that combines the assessment of the communicative functions of maladaptive behavior with behavioral procedures to teach alternative responses. Problem behaviors can be eliminated through extinction and replaced with alternate, more appropriate forms of communicating needs or wants (Carr & Durand, 1985).
Incidental Teaching—a teaching technique that utilizes behavioral procedures; naturally occurring teaching opportunities are provided, based on the child's interests. Following the child's lead, attempts to communicate are reinforced as these attempts get closer to the desired communication behavior.
Lovaas Therapy—a comprehensive, early intensive behavioral intervention program targeting skills that complement and build on one another (Lovaas, 1987). Treatment is based on principles of applied behavioral analysis. The Lovaas treatment model begins with 10–15 hours per week of therapy, gradually increasing to 35–40 hours per week.
Milieu Therapy—a range of methods (including incidental teaching) that are integrated into a child's natural environment. It includes training in everyday environments and during activities that take place throughout the day, rather than only at "therapy time."
Pivotal Response Treatment (PRT)—a play-based, child-initiated behavioral treatment formerly referred to as the Natural Language Paradigm (NLP). The goals of PRT are to teach language, decrease disruptive behaviors, and increase social, communication, and academic skills. Rather than target specific behaviors, PRT targets pivotal areas of development (response to multiple cues, motivation, self-regulation, and initiation of social interactions) that are central to—and result in improvements across—a wide range of skills (Koegel & Koegel, 2006). PRT emphasizes natural reinforcement (e.g., the child is rewarded with an item when a meaningful attempt is made to request that item).
Some language intervention programs target specific language skills (e.g., phonology, semantics, syntax, morphology), while others are more holistic in nature, targeting a broader range of language and communication skills (e.g., expressive language interventions and receptive language interventions). Language intervention approaches can include the following.
Clinician-Oriented—the clinician selects the goals and the treatment setting and determines the stimuli to be used and the type and schedule of reinforcement for accurate responses. These approaches utilize operant procedures and are often used to teach language form (e.g., syntax and morphology).
Child-Oriented—the clinician utilizes indirect language stimulation techniques and follows the child's lead in more natural, everyday settings and activities in an effort to stimulate language growth. These approaches are typically used with young children but can be modified for use with older children. Examples include
- expansions—the child's utterance is repeated in response, while the clinician adds grammatical and semantic detail;
- recasts—in this type of expansion, the child's utterance is recast, changing the mode or voice of the original (e.g., declarative to interrogative or active to passive);
- build-ups and breakdowns—the child's utterance is first expanded (built up) and then broken down into grammatical components (break down) and then built up again to its expanded form.
Hybrid—the clinician develops activities that are very natural, but at the same time, allow opportunities for the child's spontaneous use of utterances containing the targeted language forms. Examples include
- focused stimulation—the clinician produces a high density of the child's target forms in meaningful and functional contexts; these contexts are designed to motivate target production by the child, although the child is at no time asked to respond;
- vertical structuring and expansion—the clinician presents a stimulus (e.g., a picture depicting a semantic relationship), asks the child to respond to the stimulus (e.g., What is this? What's happening), and then expands the child's response into a well-formed sentence;
- incidental teaching—the clinician utilizes operant approaches in natural settings to elicit and reinforce target responses; within the setting, the child selects the topic stimulus that initiates the interaction.
Narrative interventions focus on improving a child's story-telling ability, including the ability to provide context for the listener; use narrative structures (story grammars) to organize events; and utilize microstructure (e.g., syntactic complexity, temporal and causal conjunctions, coordinating conjunctions, elaborated phrases, and adverbs) to enhance the clarity of the narrative. Narratives can provide a naturalistic means of targeting specific language difficulties.
Parent-mediated or implemented interventions consist of parents' using direct, individualized intervention practices with their child to increase positive learning opportunities and acquisition of skills.
Peer-mediated or implemented treatment approaches incorporate peers as communication partners for children with language disorders in an effort to provide effective role models and boost communication competence. Typically developing peers are taught strategies to facilitate play and social interactions; interventions are commonly carried out in inclusive settings where play with typically developing peers naturally occurs (e.g., preschool setting).
Pragmatics/social communication/discourse approaches are designed to increase social skills and promote socially appropriate behaviors and communication, using social group settings and other platforms to teach peer interaction skills.
Relationship-based practices in early intervention are aimed at supporting parent-child relationships. Greenspan/DIR/Floortime is a relationship-based intervention that promotes development by encouraging children to interact with parents and others through play. The model focuses on following the child's lead; challenges the child to be creative and spontaneous; and involves the child's senses, motor skills, and emotions (Greenspan, Weider, & Simons, 1998).
Sensory-based therapies are used to treat dysfunction in sensory processing or integration. Many of these interventions are based on, or derived from, the principles of sensory integration theory and involve providing enriched or specialized sensory input to the child.
Auditory Integration Therapy(e.g., the Berard method)—involves exercising the middle ear muscles and auditory nervous system to treat distortions/dysfunctions of the auditory system (Berard, 1993).
According to ASHA's position statement titled,
Auditory Integration Training, "The 2002 ASHA Work Group on AIT, after reviewing empirical research in the area to date, concludes that AIT has not met scientific standards for efficacy that would justify its practice by audiologists and speech-language pathologists" (ASHA, 2004, para. 1).
Fast ForWord®—a computer-based program designed to strengthen memory, attention, processing rate, and sequencing in children with temporal processing abnormalities. Strengthening these cognitive skills are thought to improve language and reading skills (e.g., phonological awareness, vocabulary, decoding, and comprehension; Tallal, 2004; Institute of Educational Sciences, 2006).
Service Delivery section of the Spoken Language Disorders Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
In addition to determining the type of speech and language treatment that is optimal for children with spoken language disorders, SLPs consider other service delivery variables—including format, provider, dosage, and timing—that may impact treatment outcomes.
- Format: whether a person is seen for treatment one-on-one (i.e., individual) or as part of a group
- Provider: the person providing treatment (e.g., SLP, trained volunteer, caregiver)
- Dosage: the frequency, intensity, and duration of service
- Timing: the timing of intervention relative to the diagnosis
- Setting: the location of treatment (e.g., home, community-based, school)