INT J LANG COMMUN DISORD, MAYJUNE 2013,VOL. 48, NO. 3, 265282

Research Report

Effective intervention for expressive grammar in children with specificlanguage impairment

Karen M. Smith-Lock, Suze Leitao, Lara Lambert and Lyndsey NickelsARC Centre of Excellence in Cognition and its Disorders, Macquarie University, North Ryde, NSW, AustraliaCurtin University, Perth, WA, AustraliaDepartment of Education, Perth, Western Australia

(Received January 2012; accepted November 2012)

Abstract

Background: Children with specific language impairment are known to struggle with expressive grammar. Whilesome studies have shown successful intervention under laboratory conditions, there is a paucity of evidence for theeffectiveness of grammar treatment in young children in community settings.Aim: To evaluate the effectiveness of a school-based intervention programme for expressive grammar in 5-year-oldswith specific language impairment.Method & Procedures: Thirty-four 5-year-old children attending a specialized school for children with languageimpairment participated in the study. Nineteen children received treatment for expressive grammar (experimentalgroup) and 15 children received a control treatment. Treatment consisted of weekly 1-h sessions of small groupactivities in a classroom setting for 8 weeks. Techniques included direct instruction, focused stimulation, recastingand imitation.Outcomes & Results: Results were analysed at the group level and as a case series with each child as their own controlin a single-subject design. There was a significant difference in grammatical performance pre- and post-treatmentfor children who received grammar treatment (Cohens d = 1.24), but not for a group of children who receiveda control treatment. Further, no difference in performance was found in the equivalent time period prior totreatment, nor for an untreated target. Treatment success was more pronounced in children without articulationdifficulties which interfered with their ability to produce the grammatical targets (Cohens d = 1.66). Individualanalyses indicated the treatment effect was significant for the majority of children.Conclusions & Implications: Individually targeted intervention delivered in small groups in a classroom setting waseffective in improving production of expressive grammatical targets in 5-year-old children with specific languageimpairment.

Keywords: specific language impairment, intervention, grammar, efficacy.

What this paper addsWhat is already known on this subject?Children with specific language impairment have difficulty with expressive grammar. Intervention has been successfulwith young children in laboratory settings. The effectiveness of intervention in a community setting has yet to beestablished.

What this study addsThis study demonstrates that eight weekly sessions of classroom-based expressive grammar intervention can beeffective when delivered in small groups, goals are individually selected for each child and a defined cuing hierarchyis used to correct errors.

Address correspondence to: Karen M. Smith-Lock, ARC Centre of Excellence in Cognition and its Disorders, Macquarie University, NorthRyde NSW 2109, Australia; e-mail: karen.smith-lock@mq.edu.au

International Journal of Language & Communication DisordersISSN 1368-2822 print/ISSN 1460-6984 online C 2013 Royal College of Speech and Language Therapists

DOI: 10.1111/1460-6984.12003

266 Karen M. Smith-Lock et al.

Introduction

One of the most identifiable characteristics of specificlanguage impairment (SLI) is a deficit in grammar. Chil-dren with SLI typically begin to talk later than nor-mally developing peers and have a lower mean lengthof utterance (MLU) for their age. Children with SLIdemonstrate a delay in the acquisition of grammaticalmorphemes (word endings which carry meaning, suchas plural s and past tense ed) that is greater than theirgeneral language delay (as measured in MLU) (Gopnikand Crago 1991, Johnson and Schery 1976, Leonard2000, Rice et al. 1995, Smith-Lock 1995). Childrenwith SLI have also been shown to have difficulties in thedevelopment of syntax (sentence structure) and seman-tics (meaning) (e.g. Friedmann 2012, Friedmann andNovogrodsky 2004,Van der Lely 1993).Comparedwithtypically developing children, children with SLI show adelay in the attainment of consistent grammatical per-formance (Smith-Lock 1995).

This delay in consistent grammatical performancemanifests differently at different ages along a de-velopmental continuum. Thus, preschool childrenwith SLI present with difficulties with morphology,whereas older school-aged children might demonstratedifficulties with complex syntax. A difficulty in theacquisition of grammar can interfere with the abilityto communicate successfully and may flow onto othergrammar and language-based tasks. For example, itis difficult to construct a coherent narrative withoutcompetent use of tense to indicate the timing of eventsand pronominal reference to link the characters in thenarrative.

Given the negative implications of language impair-ment, it follows that effective intervention is a highpriority. The need for treatment, combined with in-creased demands for accountability in medical and ed-ucation service delivery has resulted in high demand forevidence-based practice in speech pathology interven-tion. Clearly, evidence-based practice requires a founda-tion of solid evidence (Dollaghan 2007). This evidenceis drawn from studies of treatment efficacy and effective-ness. Efficacy is demonstrated when an intervention isshown to have beneficial results under ideal and tightlycontrolled conditions. Efficacy research requires opti-mally selected and trained clinicians, optimally selectedpatients, optimally delivered treatment and optimallystructured conditions for delivering treatment (Robeyand Schultz 1998, p. 790). In practice, this means thatresearchers control and provide the treatment, often byadvertising for a specific patient profile, often at a uni-versity clinic or laboratory. The implication in efficacyresearch is that the outcome demonstrates themaximumpotential of the treatment, where as many variables aspossible are controlled. Efficacy research is an important

step in establishing an evidence base for speech pathol-ogy practice.

Evidence of efficacy of expressive grammaticalinterventions in SLI

Anumber of studies have shown that language treatmentis efficacious, although individual studies vary substan-tially in their results (Cirrin and Gillam 2008, Law et al.2004). Law et al.s (2004) meta-analysis of interventionsfor children with speech and language delays/disordersfound a significant effect of intervention for childrenwith phonological or expressive vocabulary difficultiesbut mixed evidence for the effects of intervention forexpressive syntax difficulties. The results for childrenwith receptive difficulties were inconclusive. The au-thors commented on the heterogeneity in the resultsand that the meta-analysis identified many gaps in theevidence base for treatment of this population.

A number of techniques have been shown to be effi-cacious in the treatment of language impairment. Whileimitation techniques have been found effective, whetheror not modelling is also required is not clear. Connelland Addison-Stone (1992) taught the comprehensionand production of novel morphemes to children withSLI and both age and language-matched groups usingtwo techniques: one which involved modelling only andone which asked the child to imitate the morpheme af-ter modelling. The children received four teaching ses-sions over 2 weeks, two for each experimental technique(modelling only versus modelling plus imitation). Thechildren with SLI showed significant improvements inthe condition which required imitation but little effectafter modelling only. In contrast, the age and language-matched controls responded similarly to both meth-ods of instruction. Weismer andMurray-Branch (1989)studied four children, aged 5 and 6 years of age, usinga single-subject experimental design, alternating treat-ment with baselines, designed to treat expressive, reallanguage syntax and morphology. They compared atechnique in which models of the target form were pro-vided by the clinician but no responses were requiredby the child with a second technique involving mod-elling plus evoked production, in which target struc-tures were modelled and the child was encouraged toproduce the target and receive feedback. Results var-ied, with three out of the four children demonstratingtreatment effects ranging from mildly to very highly ef-fective and the one child with a delay in both receptiveand expressive language showing no treatment effect.Weismer and Murray-Branch concluded there was nosignificant difference in the success of the two treatmenttechniques and that the treatment effect was shown toincrease the use of the grammar target in three of the fourparticipants.

Expressive grammar treatment 267

One study found significant treatment effects whenmodelling was used intensively and frequently (the fo-cused stimulation technique). Fey et al. (1993) found asignificant treatment effect using focused stimulationand a cyclical goal attack strategy with 30 childrenaged 35 years with delayed grammatical development.The treatment programme involved 3 h per week over4.5 months. Focused stimulation has also been foundto be successful when combined with conversational re-casts. Leonard et al. (2006) found significant treatmenteffects using focused stimulation and conversational re-casts in the treatment of present tense and auxiliary verbsin a group of twenty-five 3- and 4-year-old children.These participants showed a significant improvement intreated targets compared with control forms.

Using novel treatment techniques with older chil-dren in a randomized control trial, Ebbels et al. (2007)demonstrated successful treatment of verb argumentstructure errors in children with persistent SLI aged1116 years. They compared a syntacticsemantic treat-ment (shape coding), a semantic treatment designed toimprove verb argument structure and a control treat-ment. They found a significant effect of their theoret-ically driven treatments, and no difference in successbetween the two treatment techniques. Progress wasmaintained after 3 months and was also found to gen-eralize to untreated verb targets. Thus, it seems thatolder children can still benefit from language treatmentdirected at expressive syntax.

In the majority of treatment studies, treatment isprovided by speech pathologists. However, Fey et al.(1993) compared a programme delivered by a speechpathologist with a parent-run treatment programme andto a waiting list control. Both treatment groups showeda significant improvement in expressive grammar, incontrast to the untreated group. The treatment effectsfor the clinician treatment were more consistent overall.It was noted that the parent intervention programmewas comprehensive, with a substantial time commit-ment and training for both parents and the researcherclinician. This study suggests that successful treatmentdelivery can be carried out by non-speech pathologists,with extensive direct training.

Thus, treatment technique, treatment agent and po-tentially a childs age may affect treatment outcome.Co-occurring speech and/or phonological impairment(Haskill and Tyler 2007, Leonard 2000, Shriberg et al.1999)may also affect a childs success in treatment. Somestudies have taken into account the speech productionabilities of participants, but this has been inconsistent.Clearly, the ability to produce final consonant clusters inEnglish affects the production of grammatical markersinvolving consonant clusters, such as possessive s andpast tense ed. It cannot be assumed that interventiontargeted to grammar will improve speech or phonolog-

ical impairment. As Haskill and Tyler (2007) pointedout, participant screening should include a measure ofthe ability to produce the consonant clusters requiredfor the grammatical targets in question in monomor-phemic contexts. This would allow the examination ofthe potential role speech skills have in language treat-ment success.

While the results of such efficacy studies are en-couraging, at this point evidence for the positive effectsof treatment of expressive grammar remains equivocal.There appears to be some evidence for treatments thathave used one or more techniques such as modelling,modelling plus evoked production, focused stimulation,recasting and shape-coding. Intervention agents havevaried but have usually involved speech pathologists.Intensity has varied from four sessions over a 2-week pe-riod (Connell and Addison-Stone 1992) to 96 sessionsat a rate of four times per week (Leonard et al. 2006).Whilst many of the studies (in particular the earlierstudies) do not make a clear distinction between effi-cacy and effectiveness, they all appear to be have beenconducted under controlled experimental conditions(Connell and Addison-Stone 1992: 844), with treat-ment provided by researchers (either directly or consul-tatively). These studies were research conducted underoptimal circumstances to index the potential value of atreatment, that is, efficacy research (Robey and Schultz1998, p. 791).

Evidence of effectiveness of expressive grammaticalinterventions in SLI

In contrast to efficacy, effectiveness is shown when anintervention does what it was intended to under rou-tine conditions. Thus, treatment effectiveness evidenceis drawn from research into the impact of a treatmentin the less controlled real world of clinical practice(Dollaghan 2007). To date, there have been no reportedstudies of treatment effectiveness specifically evaluat-ing intervention for expressive syntax and morphology.However, there have been two studies of the effective-ness of community speech therapy services in general,with conflicting results. In a randomized controlled trial,Glogowska et al. (2000) compared pre- and post-treatment results of pre-schoolers attending communityspeech pathology clinics in the UK. Children received,on average, eight 45-min sessions over 8 months. Theyfound little effect of speech and language treatment. Incontrast, Broomfield and Dodd (2011) carried out arandomized controlled trial of an entire cohort of 730children up to 16 years of age who were referred toone service over a 14-month period. They evaluated theoutcomes of treatment in general compared with notreatment, using a waiting list control method. Theyfound that the children who received treatment made

268 Karen M. Smith-Lock et al.

significantly more progress than those who were un-treated (i.e. more progress than maturation alone) eventhough the study included childrenwith significant diffi-culties in all three primary categories of comprehension,expressive language and speech.

One study has examined the effectiveness of a lan-guage intervention programme which included expres-sive grammar as one of several language goals, in place inthe community. Gallagher and Chiat (2009) comparedthree groups. One group received an intensive languagetreatment programme delivered by a speech pathologist;a second group received a nursery-based programme inwhich a speech pathologist consulted to nursery teach-ers who provided treatment; and a third group was ano intervention waiting list control. Participants were4- and 5-year-old children with severe expressive and/orreceptive language impairment. Treatment was deliveredby community-based speech pathologists and nurseryteachers (not researchers) and targeted a variety of lan-guage goals. They found that children in the intensivetreatment group improved significantly more than thechildren in the nursery and the no intervention groupson comprehension of grammar, comprehension of vo-cabulary, expressive vocabulary and expressive informa-tion, but not expressive grammar. The progress of thenursery group did not differ from the no interventiongroup on most measures. These findings suggest thattreatment provided by nursery teachers via consultationwith speech pathologists may be less effective than treat-ment provided directly by speech pathologists. However,the intervention groups in this study differed in manyways in addition to the treatment agent. These includedosage, the range of techniques employed and the expe-rience of the clinicians providing treatment. Such fac-tors would have been controlled in an efficacy study.However, the significance of this study is that it exam-ined effectiveness of two programmes delivered in thecommunity, and importantly, evaluated the outcome ofa change made in the provision of community speechpathology services.

In summary, while there is some evidence for theefficacy of interventions targeted specifically at expres-sive grammar, there is limited evidence to date for theeffectiveness of such interventions delivered in real-lifesituations, such as school classrooms. Available effec-tiveness research has typically examined entire commu-nity services, rather than the effectiveness of specific,targeted grammar intervention. While Gallagher andChiat (2009) provided evidence for effective languageintervention when provided directly by speech patholo-gists, the results were less successful when a consultativemodel was applied in a nursery. As they acknowledge,many variables were not controlled in their study. Itis possible that the investigation of specific treatmentsfor specific impairments, with as many controls as pos-

sible within the context of effectiveness research, maylead to more consistent effectiveness findings. The effi-cacy research discussed above suggests that techniques ofmodelling, focused stimulation, recasting and imitationmay be effective treatments for grammatical targets. It isnow necessary to build on this research and establish theeffectiveness of grammar intervention in children withlanguage impairment.

In moving from efficacy to effectiveness research,several additional challenges arise. Because effectivenessresearch examines clinical outcomes obtained under or-dinary circumstances by average practitioners for typicalpatients (Lohr 1988), the treatment programme mustbe not only efficacious, but also practical enough thatit will actually be implemented so that it can be mea-sured. This includes the development of a treatmentprogramme consistent with the beliefs of the commu-nity practitioners (Armstrong et al. 2006), and manual-ization of the treatment programme (Craig et al. 2006).This practicality must also consider the service deliverymodel and administrative constraints of the commu-nities involved (Craig et al. 2006). These constraintswill affect, among other things, dosage and intensity oftreatment, skill level of professionals delivering the in-tervention, individual versus group treatment, and eventhe treatment techniques employed. Appropriate con-sideration of these factors, preferably with end-user in-volvement, will affect the eventual implementation ofthe programme as evidence-based practice (Craig et al.2006). Once this practical treatment programme is de-signed, effectiveness research must also consider the par-ticipant drop out in community-based research, and po-tential lack of adherence to treatment protocols due tothe administration of treatment by non-research per-sonnel (Craig et al. 2006). Clearly, these considerationsmust be directly addressed in the treatment programmeand research design.

While children with language impairment are seenin a variety of clinical settings, school is one of themost logical places for school-aged children to receiveservices. Western Australia has schools for children withSLI, known as Language Development Centres (LDCs).These schools provide specialised language and aca-demic intervention (Fremantle Language DevelopmentCentre 2012: 4) for children with SLI. They have ahigher staff-student ratio than typical schools (12 stu-dents, with one teacher and one education assistant),with a focus on the language needs of the pupils. In ad-dition to a regular classroom program, language supportis provided via intensive small group language inter-vention in collaboration with the specialist teacher, thespeech pathologist and the classroom teacher (Freman-tle Language Development Centre 2012: 6). Such anenvironment provides an excellent opportunity to eval-uate the effectiveness of specifically targeted grammar

Expressive grammar treatment 269

intervention and measure whether changes in grammarperformance can be attributed to grammar treatment orto the general effects of small group intervention, withina classroom setting.

With this in mind, we wished to measure the effec-tiveness of an expressive grammar treatment programmein use in a real-life clinical setting. Specifically, wewishedto test whether changes in grammatical outcomes werespecific to grammatical interventions or the result ofgeneral therapy effects. The intervention was designedto be delivered by the usual teaching team of speechpathologists, teachers and teaching assistants within thetypical classroom practice of weekly small group ses-sions, at a realistic level of intensity and drawing on es-tablished techniques of modelling, elicited productionand feedback.

Method

Participants and baseline data

All 49 children in their first year of full time schoolingin one LDC were invited to participate in the study.Forty-five out of 49 students agreed to participate. Fiveof the children who agreed to participate were deemedineligible due to diagnoses other than SLI. All of the49 children were assigned to treatment conditions, astreatment was part of their regular classroom program.Of the 40 children tested for the study, 22 received treat-ment targeted at grammatical goals. Eighteen childrenreceived their usual treatment which focused on com-prehension. This sample size gave us the ability to detectan effect size of 0.47, with power of 0.8. Participant flowis illustrated in figure 1.

Diagnosis of language impairment

Entry to the school required diagnosis as specificallylanguage-impaired by a speech pathologist. Childrenwere assessed either with the Preschool Language Scale(PLS) (Zimmerman et al. 2002) or the Clinical Evalua-tion of Language Function (CELF) (Wiig et al. 2006) asone part of an extensive assessment process for referralto the school. Referral information also included evi-dence that children had non-verbal skills in the normalrange, as attested by a psychologist or paediatrician. Forthis purpose, referring clinicians used a variety of tests,including the Wechsler Preschool and Primary Scaleof Intelligence (WPPSI-III) (Wechsler 2002), Cogni-tive Adaptive Test (Accardo and Capute 2005), Den-ver Developmental Screening Test (Frankenburg et al.1992), and Griffiths Mental Development Scales (Grif-fiths 1970).We reviewed the schools intake data and in-cluded only those childrenwhowere clearly diagnosed asSLI. We also confirmed the diagnosis of each child with

staff speech pathologists at the time of testing. Thus,diagnosis as SLI was made by two clinicians indepen-dently: the referring clinician and the school clinician.All children (1) had at least moderately impaired recep-tive and/or expressive language; (2) documentation ofnormal non-verbal IQ; and (3) no hearing loss, neu-rological impairment or other diagnosis that would ac-count for their language impairment. Intake test datacan be found in table 1. It should be noted that, as tobe expected in such a heterogeneous population, therewas substantial variance in the intake measures in bothexpressive and receptive language. The children had amean age of 5;1 (SD = 4.02 months).

Baseline equivalence

Each group contained four girls. Age and pre-test ex-pressive language scores can be found in table 2. Theexperimental and control groups did not differ signifi-cantly in age (t(32)= 0.68, p= 0.5) or in expressive lan-guage score on the Renfrew Action Picture Test (RAPT)(Renfrew 1997), which the school administered priorto the study (grammar: (t(32) = 0.49, p = 0.63; infor-mation: (t(32) = 0.211, p = 0.84). They also did notdiffer significantly on their intake assessment scores (ex-pressive language: PLS t(15) = 1.92, p> 0.05; CELF-Pt(6) = 0.39, p> 0.05; CELF-P2 t(6) = 2, p> 0.05; re-ceptive language: PLS t(16) = 0.77, p > 0.05; CELF-Pt(6)= 0.42, p> 0.05; CELF-P2 t(6)= 0.94, p> 0.05).

Pre- and post-intervention tests

A series of tests were devised for the research in order tohave specific measures of the treatment goals: GrammarScreening Test, Articulation Screening Test and Gram-mar Elicitation Test. The grammatical items possessives, past tense ed and the subject pronouns he, shewere identified as potential treatment targets for these5-year-olds and were therefore included in the tests. Foreach testing session, children were shown a series of pic-tures. For each picture, the child was asked a questiondesigned to elicit a specific grammatical structure. Vo-cabulary items used in tests were not used in treatmentactivities.

The purpose of the Grammar Screening Test was toidentify potential treatment targets for each child. Thetest consisted of six possessive s, six past tense and foursubject pronouns (two he, two she). For each of thepossessive and past tense, two items were included foreach allomorph ([s], [z] and [z]; [t], [d] and [d]).

The purpose of the Articulation Screening Test wasto establish if the children had the articulation skills toproduce the targeted grammatical goals. The childrenwere asked to repeat 26 single-syllable non-words which

270 Karen M. Smith-Lock et al.

Figure 1. Participant flow.

contained the final consonant clusters in the grammati-cal items tested (e.g. pept, avz).

The purpose of the Grammar Elicitation Test wasto obtain multiple instances of a particular grammaticaltarget to act as a pre- and post-intervention measure oftreatment effectiveness. The tests consisted of 30 itemsfor each grammatical construction, spread evenly acrossdifferent allomorphs, where relevant. Pronoun tests con-tained 15 items for each pronoun (he and she). Itemswere presented in a different random order for eachround of testing. Test items and instructions can befound in appendix A.

All test items were pilot tested with a group of 17typically developing 5-year-old children who scored at

ceiling on all tests. Any item produced incorrectly bythe typically developing children was replaced.

Each child first completed the Grammar and Artic-ulation Screening Tests. Following the screening tests,a potential treatment target was selected for each child,according to the procedure outlined below. In addition,a second grammatical target was selected for each childin the experimental group, to act as an untreated con-trol. Based on the results of the screening, the GrammarElicitation Test was then carried out, in order to collectfurther data on each childs selected grammatical tar-gets (treated and untreated). The Grammar ElicitationTests were administered three times, at nine week inter-vals. Tests 1 and 2 provided a pre-treatment baseline.

Expressive grammar treatment 271

Table 1. Participant characteristics on referral to the language development centre

Age at assessment (months) Expressive language Receptive language

Control Experimental Control Experimental Control ExperimentalTest group group group group group group

PLSa 43.78 (2.68) 40.55 (2.68) 86.75 (37.69) 75.33 (11.9) 85.44 (38.99) 78.67 (16.89)(n = 9) (n = 9)

CELF Preschoolb 49 (0) 53.17 (1.94) 72 (4.24) 68.8 (10.7) 76 (9.9) 73.7 (6.02)(n = 2) (n = 6)

CELF Preschool 2c 50.75 (0.5) 50.25 (5.38) 64.5 (11.4) 79.5 (9.81) 65.5 (16.5) 75 (11.5)(n = 4) (n = 4)

Notes: Values are mean standard score (standard deviation).aPreschool Language Scale.bClinical Evaluation of Language Fundamentals Preschool.cClinical Evaluation of Language Fundamentals Preschool 2.

Table 2. Age and Renfrew Action Picture Test (RAPT)

RAPT information RAPT grammar

Group Mean age (months) Raw score z-score Raw score z-score

Experimental 61.68 (4.0) 24.95 (6.07) 0.92 (1.08) 13.42 (6.27) 1.57 (1.08)Control 60.73 (4.13) 24.47 (7.24) 0.99 (1.33) 12.40 (5.75) 1.76 (0.96)

Note: Values are mean standard score (standard deviation).

Treatment occurred between Tests 2 and 3. Test 3 mea-sured post-treatment skills.

A grammatical construction was considered a po-tential treatment target if the child made at least sixerrors on the Grammar Elicitation Test. If a child madeerrors on several target constructions, the constructionwhich occurred first on the developmental continuumwas chosen.

Group allocation

Treatment conditions were allocated on the basis of site.The LDC was located on three sites, all under the direc-tion of one school principal and senior speech pathol-ogist. Three classes on one site were allocated to theexpressive grammar programme and two classes at twodifferent sites were assigned to the control program. Asthe three sites were under the same administration, classsizes, access to professional development and adminis-trative procedures were the same. There is no reasonto believe that the general level of teaching expertise orlanguage environment differed between the sites. Thesites drew on the same socio-economic population. Alltesting and intervention was carried out at the childrensschool. The study was approved by the Macquarie Uni-versity Human Ethics Committee.

Interventions

Each child received one of two interventions; eitheran expressive grammar programme (experimental in-tervention) or one of the schools regular programmeswhich focused on following directions and comprehen-

sion of prepositions (control intervention). Treatmenttook place as part of the regular classroom program,within the established treatment model of the school.Groups differed in that the experimental group receivedfocused grammar treatment for individually identifiedtargets (as detailed below) and the control group receivedtheir usual program, in this case, focused on compre-hension. Thus, both groups received small group inter-vention within a language-enriched classroom, with thecritical difference being the language targets.

Experimental intervention: expressive grammarprogramme

As detailed above, children who participated in theexpressive grammar programme completed grammartests and had two grammatical targets identified forthem. One target was treated and one target remaineduntreated.

The treatment programme consisted of the regularmodel employed by the LDC, manualized and moni-tored for research purposes. As per usual practice, onceweekly, for 8 weeks, the staff speech pathologist visitedeach classroom. She first delivered a whole group lessonfocused on one of three treatment goals (subject pro-nouns he and she, possessive s or past tense ed).Children were then divided into three groups, based ontheir identified treatment target. All the children in eachgroup were learning the same target. Each small groupcarried out three activities designed to teach them theirspecific grammatical target. The activities were lead bythe speech pathologist, the classroom teacher or a teacher

272 Karen M. Smith-Lock et al.

assistant. Groups rotated such that each child completedactivities with each of the speech pathologist, teacher andteacher assistant. The number of children in each groupranged from three to six. The entire session, includingthe whole class introduction and the three small groupactivities, lasted 1 h.

Treatment used the techniques of focused stimula-tion, recasting and imitation, which have been shownin the literature to be efficacious. In addition, directteaching was used, as it was a technique in use in theLDC. The grammatical target was first introduced us-ing direct teaching. For example, the speech pathologistexplained that when we talk about boys, we say heand when we talk about girls, we say she. Activitieswere designed which demonstrated the meaning of thetarget and allowed for frequent modelling of the struc-ture. Modelling included a slight emphasis of the target.Each child was asked a question which would elicit thegrammatical target in question. If the child made an er-ror, the teacher/clinician was instructed to offer the childthe opportunity to repeat himself and potentially correctthe error. If that did not result in a correct answer, theteacher would model the correct answer (recast), withslight emphasis on the grammatical target in question,and then give the child another chance to respond. Ifthe child still produced an incorrect answer, the teacherwould model the structure, then instruct the child yousay that. After a correct response, the teacher would sayyes and model the correct response again.

Treatment sessions consisted of play-based activi-ties designed to incorporate the targeted grammaticalitems. Teachers were provided with detailed activityplans, scripts and vocabulary. For example, one activityinvolved playing with Play-Doh. Each child was pro-vided with Play-Doh and given an instruction such asYou roll your Play-Doh. The past tense group thendiscussed what the child did (e.g. he rolled his Play-Doh). The next child was given a different instruction(e.g. you squish your Play-Doh). Each child in thegroup was given an equal number of opportunities touse the past tense in these situations. The activities weredesigned to be naturalistic, fun activities and the teach-ers were encouraged to model and cue grammar targetssystematically, in the context of play.

The key factors that distinguished the treatment pro-gramme from the general classroomprogrammewere (1)the identification of specific targets for each individual,(2) the repeated modelling of grammatical targets, fol-lowed by (3) multiple opportunities for the children toproduce the targets, followed by (4) feedback to thechild, and (5) opportunities for the child to correcthim/herself. An example of a treatment plan can befound in appendix B.

Outside of these treatment sessions, teachers wereasked to carry out their classroom programme as they

normally would. They were provided with a list ofthe items that would be targeted during the treat-ment. Teachers were not discouraged from modellingor reinforcing the targets in whatever fashion they nor-mally would throughout the day, but neither werethey specifically asked to do so. Teachers reported thatthey generally did reinforce the goals between weeklysessions.

Treatment fidelity

Treatment fidelity was facilitated by a number of mea-sures: staff training, manualized therapy activities, de-tailed recording of childrens responses and observationsof interventions.

Staff training: in order to communicate to staffthe treatment principles involved, teachers andteacher aides attended a 3-h education sessionprior to the beginning of the study. In this ses-sion, the design of the study, a sample treatmentactivity and the treatment techniques were pre-sented. The teachers and aides were given op-portunities to role-play treatment and use thetechniques discussed. Feedback was provided bythe researchers. In addition to this formal instruc-tion, the school speech pathologist met with theteachers weekly prior to the treatment sessionto review the treatment goals and the activitiesfor the week. Furthermore, as opportunities aroseinformally (e.g. in playground discussions at re-cess), the speech pathologist reviewed the treat-ment goals and plans with the teachers and teacherassistants. In addition, each session began witha group session lead by the speech pathologist.The purpose of this whole group session was two-fold. First, it provided a teaching session for thechildren. Second, because the teaching staff ob-served this group session, it served as a reviewof the targets and the teaching techniques forthe staff, immediately prior to each interventionsession.

Manualized intervention activities and scoring: inorder tomake sure treatment was consistent acrossteachers and classes, staff were provided detailedtreatment protocols outlining treatment targetsand activities and including scripts for the ses-sions (see appendix B). These were accompaniedby all the materials required to carry out the ther-apy activities. Staff were also provided with scoresheets to record each childs responses. The scoresheets recorded the accuracy of each childs re-sponse to the target items they attempted. Thisallowed weekly monitoring of childrens progress.It also assisted the teacher in confirming during

Expressive grammar treatment 273

the session that each child received an equal num-ber of opportunities to produce the grammaticaltargets in the activity.

Observations of treatment sessions: during the 8weeks of treatment, a researcher visited each classonce and observed each teacher deliver the treat-ment programme. These visits had two purposes:first, to observe the treatment programme in ac-tion to identify strengths and weaknesses of theprogramme; and second, to assess and improvetreatment fidelity by observing teachers and pro-viding them with feedback regarding their use ofthe treatment techniques.

Control intervention: comprehension programme

Children in the control group completed the same gram-mar tests as the treatment group and had a grammaticalgoal identified for them. These children, however, re-ceived eight weekly treatment sessions on language otherthan their selected grammatical goal. This programmeconsisted of the usual intervention carried out in theschool, as determined by the staff speech pathologist.The goals were following instructions containing threeitems plus the understanding and use of in, on, under,top, middle, bottom, next to, behind, in front of, and be-tween. The format of the treatment was the same as theexpressive grammar programme with small group ac-tivities rotating between the speech pathologist, teacherand teacher assistant (i.e. the same staffing levels andorganization as the experimental group). As with theexperimental program, activities were play-based, de-signed to address treatment goals in a naturalistic man-ner. For example, children played with animal figuresand were given instructions to put the sheep behindthe pig. This was in contrast to the Grammar Elicita-tion Test, which elicited expressive grammatical targetsin response to picture stimuli. The teachers in these twoclasses were asked not to design activities focused on thegrammatical targets of the study, but were not preventedfrom addressing the targets incidentally during otherlearning activities. Staff were given no other directionregarding their treatment techniques or programmesby the researchers. Staff training and instruction wereprovided by the speech pathologist as she would inher regular practice. Thus, the professional develop-ment session regarding treatment techniques and themanualized treatment programme were not provided.This group was, effectively, an untreated (for grammar)control group receiving a small group language pro-gramme delivered in a similar manner to the grammartreatment group, consistent with the usual practice ofthe LDC.

Blinding

By necessity, the speech pathologists and teachers werenot blind to the intervention condition they were ad-ministering. The children involved in the study sawthe treatment as a regular part of their classroom ac-tivities and had no contact with children in the othertreatment condition. The children were very used tolanguage instruction and regular testing and thereforecould be considered blind to the entire process.

Three research assistants carried out the outcometesting. Each tester tested the same children in each test-ing phase to reduce the likelihood of test score changesbeing due to different testers. Two of the three testerswere blind to the nature of the study. They were unawarethat the children were participating in a treatment study,and by extension, were unaware of childrens allocationto treatment conditions. The third tester, required dueto last minute staffing issues, was not blind to the treat-ment conditions. This tester tested only eight childrenand was fully aware of the nature of the study and theallocation of children to treatment groups. To test forbias introduced by the fact that one tester was not blind,the non-blinded testers results were compared to thoseof the blind testers.

Results

We used both a standard group comparison approachcomparing the experimental and control groups anda case series approach, in which each child acted ashis own control in a single-subject design (Logan et al.2008, Nickels 2002). Results were analysed at the grouplevel using mixed design Analyses of Variance usingSPSS Statistics software. Individual subject analyses werecarried out using McNemars test, a non-parametrictest for the analysis of single-subject data, again withSPSS Statistics Software. Effect size was calculated us-ing Cohens d, with an online Effect Size Calculator(http://www.cognitiveflexibility.org/effectsize/). In ad-dition to the analysis involving every child in the sample,we performed a further analysis with only those childrenwhose articulation screens indicated that they could pro-duce the consonant clusters required for their grammargoal, in order to determine if articulation skill affectedtreatment outcome.

Six children were excluded from the analysis due tomissing data for one of the testing rounds, three fromthe experimental treatment group and three from thecontrol group, leaving 19 children in the experimen-tal group and 15 children in the control group. Theexcluded children did not discontinue participation inthe study, rather they were absent from school for oneof the three of the testing periods, typically due to ill-ness. All children completed the treatment. These six

274 Karen M. Smith-Lock et al.

children did not differ from the main group on the basisof age (mean age of absent children: 62.67 (SD = 2.97months; mean age of whole group: 61.26months). Theydid not differ in expressive language score on the Ren-frew Action Picture Test (RAPT) (Renfrew 1997), a testgiven as part of the regular school routine. The RAPTrequires a child to tell a story based on a picture. A scoreis calculated for story content (information) and gram-mar (mean grammar z-score for absent children: 1.65(SD = 0.85), mean grammar score for all participants:1.65 (SD= 1.18); mean information z-score for absentchildren: 0.98 (SD = 0.79); mean information z-scorefor all participants: 0.95 (SD = 1.18)).

Outcomes

For each child, the total items correct on the GrammarElicitation Test (out of 30) for the identified grammati-cal target constructions were compared across the threetesting sessions. An item was considered correct if theexpected target construction was produced, with thecorrect allomorph of the target morpheme. Inter-raterreliability was assessed by re-scoring ten percent of theoriginal testers records. This yielded a correlation of0.99.

First, we compared the experimental groups per-formance on their treated grammatical targets with thecontrol groups performance. As can be seen in table 3and figures 2 and 3, the experimental groups grammat-ical performance was stable prior to treatment and im-proved after treatment. In contrast, the control groupsgrammatical performance remained stable over all threetest periods. Group performance did not approach ceil-ing. To confirm this statistically, a mixed analysis ofvariance was conducted. The dependent variable wasgrammatical score, with one between-groups factor (ex-perimental, control) and one within group factor (timeof test). There was a significant main effect for time(F(1,32) = 9.43, p = 0.004), no significant main effectfor group (F(1,32)= 0.14, p = 0.907), and a significantinteraction between group and time (F(1,32) = 7.08,

Figure 2. Grammar Elicitation Test scores over three test times.

p = 0.009). Post hoc testing, with a Bonferroni correc-tion for repeated t-tests, indicated no significant differ-ences between times 1 and 2 for the experimental group(t(18) = 0.07, p = 0.95), but significant differences be-tween times 1 and 3 (t(18)= 4.31, p< 0.001) and times2 and 3 (t(18) = 4.85, p< 0.001). Thus, pre-treatmentperformance was stable and post-treatment testing in-dicated a significant improvement in test scores, on thetreated targets. For the control group, post-hoc testingwith a Bonferroni correction for repeated t-tests, indi-cated no significant differences between any of the tests(time 1 to time 2 (t(14)= 1.0, p= 0.336), times 1 and 3(t(14) = 0.19, p = 0.851), times 2 and 3 (t(14) = 1.17,p = 0.263)). Thus, grammatical performance on thesetargets remained stable in the group that did not receivegrammatical intervention. Effect size (Cohens d), cal-culated using the standard deviations of the pre- andpost-intervention means, corrected for the dependencebetween the means using Morris and DeShons (2002)equation (8), indicated an effect size in the experimentalgroup of 1.24 for the treatment period (time 2 to time3), considered a large treatment effect (Cohen 1988).

In order to determine if improvement in the experi-mental group was specific to the grammatical items tar-geted, the experimental groups performance on theiruntreated grammatical targets was examined (table3). A repeated measures analysis of variance showedno significant difference between the three test times(F(1,18) = 1.49, p > 0.05). Change over time wasalso directly compared for the treated and untreatedtargets. There was no significant difference in gain be-tween tests 1 and 2 for the treated and untreated targets(t(18) = 0.421 p = 0.679). However, there was sig-nificantly greater gain for the treated targets than theuntreated targets between tests 1 and 2 (t(18) = 3.29,p = 0.004) and between tests 2 and 3 (t(18) = 4.01,p = 0.001). Thus, experimental group performanceon untreated grammatical goals did not change overthe three test times. Furthermore, whereas change inthe treated and untreated goals did not differ in the

Figure 3. Grammar Elicitation Test scores over three test times,excluding children with interfering articulation errors.

Expressive grammar treatment 275

Table 3. Grammar Elicitation Test performance across three test times

Time 1: Time 2:Pre-treatment Pre-treatment Time 3:

Articulation Group baseline 1 baseline 2 Post-treatment

All children (n = 34) Experimental (grammar treatment) 6.47 (6.48) 6.53 (5.75) 13.53 (8.75)Experimental (grammar treatment,

untreated goal)7.63 (7.89) 8.26 (8.95) 8.63 (8.94)

Control (comprehension treatment) 9.53 (7.15) 7.93 (7.96) 9.87 (8.7)

Children with articulationerrors excluded (n = 27)

Experimental (grammar treatment) 8.38 (6.96) 8.23 (6.02) 17.62 (7.16)Experimental (grammar treatment,

untreated goal)10.54 (7.97) 11.15 (9.46) 11.69 (9.27)

Control (comprehension treatment) 9.21 (7.31) 8.07 (8.24) 10.36 (8.81)

Note: Values are mean standard score (standard deviation). Maximum score = 30.

pre-intervention period, the treated targets improvedsignificantly more than the untreated targets over theintervention period. This suggests that the treatment ef-fect was specific to the grammatical goals targeted in theintervention programme.

Group analysis excluding children with interferingarticulation difficulties

As there were some children whose Articulation Screen-ing Test indicated that they did not produce the speechsounds required for accurate production of their gram-matical target, an additional analysis excluded these chil-dren (n = 6). This left thirteen1 children in the exper-imental group and 14 children in the control group.Data can be seen in figure 3. A mixed analysis ofvariance was conducted. The dependent variable wasgrammatical score, with one between-groups factor (ex-perimental, control) and one repeated measure (timeof test). There was a significant main effect for gram-matical score (F(1,25) = 16.7, p = 0.001), no signifi-cant main effect for group (F(1,25) = 0.73, p = 0.4),and a significant interaction between group and time(F(1,25) = 10.15, p = 0.004). Post-hoc testing, with aBonferroni correction for repeated t-tests indicated nosignificant differences between times 1 and 2 for theexperimental group (t(12) = 0.15, p > 0.025), but sig-nificant differences between times 1 and 3 (t(12)= 4.75,p< 0.001) and times 2 and 3 (t(12)= 5.87, p< 0.001).Thus, pre-treatment performance was stable and post-treatment testing indicated a significant improvementover time. For the control group, post-hoc testing witha Bonferroni correction for repeated t-tests indicated nosignificant differences between any of the tests (time 1to time 2 (t(13) = 0.69, p > 0.025), times 1 and 3(t(13) = 0.69, p> 0.025), times 2 and 3 (t(13) = 1.31,p > 0.025). Thus, grammatical performance on thesetargets remained stable in the group that did not receive

1One child (#43) was omitted because articulation data was unavail-able for him.

grammatical intervention. Effect size (Cohens d), cal-culated using the standard deviations of the pre- andpost-intervention means, corrected for the dependencebetween the means using Morris and DeShons (2002)equation (8) indicated an effect size for the experimentalgroup of 1.66 for the treatment period (time 2 to time3), a large effect (Cohen 1988).

In order to determine if improvement in the experi-mental group was specific to the grammatical items tar-geted, the experimental groups performance on theiruntreated grammatical targets was examined (table3). A repeated measures analysis of variance showedno significant difference between the three test times(F(1,18) = 1.49, p > 0.05). Change over time wasalso directly compared for the treated and untreatedtargets. There was no significant difference in gain be-tween test 1 and test 2 for the treated and untreatedtargets (t(18) = 0.421 p = 0.679). However, there wassignificantly greater gain for the treated targets than theuntreated targets between tests 1 and 3 (t(18) = 3.29,p = 0.004) and between tests 2 and 3 (t(18) = 4.01,p = 0.001). Thus, experimental group performanceon untreated grammatical targets did not change overthe three test times. Furthermore, whereas change inthe treated and untreated goals did not differ in thepre-intervention period, the treated targets improvedsignificantly more than the untreated targets over theintervention period. This suggests that the treatment ef-fect was specific to the grammatical goals targeted in theintervention program.

Individual analysis

Data for each individual child was analysed using Mc-Nemars test in order to determine which individualsmade significant gains over the treatment period. TheMcNemar is a stringent non-parametric test which con-siders both those items which change from correct toincorrect as well as items which change from incorrectto correct. Thus, in order to show significance, scores

276 Karen M. Smith-Lock et al.

Figure 4. Individual Grammar Elicitation Test scores for the treated group: treated target over three test times. *No significant improvementbetween test times 1 and 2 and significant improvement between test times 2 and 3.

Figure 5. Individual Grammar Elicitation Test scores for the treated group: untreated target over three test times.

must change in a positive direction and not in a negativedirection. A treatment effect was demonstrated if a childshowed no significant change from test 1 to test 2 (a sta-ble pre-treatment baseline) and significant improvementfrom test 2 to test 3 (over treatment period). Data can beseen in figure 4. Ten out of 19 (53%) of the children inthe experimental group showed a significant treatmenteffect. A further three children (16%) showed a suc-cessful treatment profile (no change prior to treatmentand change after treatment), but did not reach signif-icance on the McNemar test. One child (5%) showedsignificant improvement across all three tests, but as heshowed improvement prior to intervention as well asduring intervention, it is not clear that his improvementcan be solely attributed to the intervention. The remain-ing children (26%) showed no significant improvement.Data for the untreated targets can be seen in figure 5. No

children showed significant improvement on untreatedtargets.

Of the five children (26%) in the experimental groupwho failed the articulation screen, four of these (80%)made no significant improvement and one made non-significant positive changes.

Data for the control group can be found infigure 6. Two children (13%) showed no significant im-provement on their grammatical target between tests 1and 2, and a significant improvement from test 2 to test3. Three children (20%) showed significant improve-ment between tests 2 and 3, but not between tests 1and 3. These children each showed a negative changefrom test 1 to test 2 and then an improvement in test 3,approximately back to test 1 levels. The remaining chil-dren showed no improvement (66%), with one showinga significant negative change (7%).

Expressive grammar treatment 277

Figure 6. Individual Grammar Elicitation Test scores for the untreated group over three test times. *No significant improvement between testtimes 1 and 2 and significant improvement between test times 2 and 3.

The one child in the control group who made twoor more errors relevant to her grammatical target on thearticulation screen did not improve significantly on hergrammatical target (number 4).

Assessment of blinding

As noted above, two of the three testers were blind tothe purpose of the study and were responsible for themajority of the testing. The third testerwas aware of boththe purpose and group allocation of the subjects. Post-study interviews confirmed that the blind testers hadremained blind to the purpose of the testing.Of the eightchildren the non-blinded tester tested, all were from theexperimental group. A comparison of the gain scores ofthe children tested by the blind testers versus the childrentested by the non-blind tester found no difference. Themean gain from time 2 to time 3 for children tested bythe blind testers was 7.18 (SD = 5.58) and for non-blind tester 6.75 (SD = 7.57); t(17) = 0.14 (p> 0.05).For time 1 to time 3, the mean gain for children testedby the blind testers was 7.27 (SD = 6.78) and for non-blind tester 6.75 (SD = 8.07); t(17) = 0.15 (p> 0.05).It appears that the scores of the non-blind tester were notaffected by her knowledge of the treatment conditions.

Discussion

The purpose of this study was to measure the effective-ness of an expressive grammar treatment programmein use in a real-life clinical setting. We tested whetherchanges in grammatical outcomes were specific to gram-matical intervention targets or extended to grammaticalmorphemes that were not targeted. We found a signifi-cant difference in performance on treated grammatical

targets, pre- and post-treatment for a group of chil-dren who received grammar treatment. In contrast, nodifference in performance was found in the equivalentperiod prior to treatment or in a group of children whoreceived a control treatment. Furthermore, the treat-ment effect in the experimental group was specific tothe grammatical targets treated and did not carry overto untreated grammatical targets. Treatment success wasless pronounced in children with articulation difficul-ties which interfered with their ability to produce thegrammatical targets. The significant treatment groupdifferences corresponded to a clinically significant, largetreatment effect. Importantly, analysis of each childsperformance in a single-subject design indicated thatthe treatment effect was significant for the majority ofchildren (rather than the results being due to small ef-fects that were significant when accumulated across thegroup but were not for any individual child).

The success of this treatment programme is a clearindication that expressive grammar treatment in school-aged children can be effective in a real-life clinical set-ting. This treatment success cannot be attributed eitherto the school environment or solely to small group in-struction. All of the children in the study attended aspecial school for children with SLI. Classes consist of12 students, with a teacher and teacher assistant in eachclass. Thus, the children were taught by teachers expe-rienced in working with children with language impair-ment, with a ratio of 1 teacher or aide per six students.Nevertheless, the changes in grammatical performancecannot be attributed to this enriched educational set-ting alone, as we found no change in performance onthe grammar tests in the 8 weeks prior to treatment.Of course, the teachers were provided with a list of thegrammatical targets to reinforce throughout the day, as

278 Karen M. Smith-Lock et al.

opportunities arose. Therefore, while the environmentof the school did not affect change on the grammaticaltests alone, conscious inclusion of the grammatical tar-gets in the classroom environment throughout the daymay have contributed to the treatment success. Thechange in grammar scores also cannot be attributed tosmall group language teaching alone. Both the experi-mental and control groups received intensive languageinstruction in groups of four or five children. However,only the group that received grammar instruction im-proved their grammar scores.

In fact, the lack of improvement in the experimen-tal group on untreated grammatical targets emphasizesthe specificity of the treatment effect. Specially designedtreatment focused on a single grammatical target im-proved that performance on that target, and that targetonly. This suggests that general language enrichment orindeed intervention targeted to more global languageareas (e.g. grammar, semantics) may not be sufficientto affect change on specific targets. While the evidencedemonstrates that this specific, focused treatment canbe delivered in group settings, it appears necessary toidentify very specific goals for each individual childand target these goals in order to maximize each childsprogress.

While the treatment did result in improvement inspecific grammatical areas, it is important to note thatthe content and procedures in the test and treatmentwere very different. It is not that case that the chil-dren were simply taught the test. The treatment activ-ities contained none of the vocabulary items used inthe Grammar Elicitation Tests. This is true, by exten-sion, of the list of items that the teachers were given foruse in the classroom (which were the items used in thetreatment sessions). Furthermore, the treatment activi-ties were very different in nature to the Grammar Elic-itation Test. In the one-on-one test situation, childrenwere asked questions designed to elicit the grammaticaltarget in response to a picture, whereas the treatmentsessions consisted of group play activities. Therefore, wecan be confident that the children learned the targetedgrammatical construction, not simply vocabulary itemsor test procedure.

The treatment delivered consistent results acrossmost children. All but one of the childrenwho passed theArticulation Screening Test improved on the GrammarElicitation Test, with ten of 14 of these demonstrating asignificant treatment effect on a stringent single-subjectanalysis. This is a striking outcome, given the knownheterogeneity of population with SLI.

Of the children who did not show improvement onthe Grammar Elicitation test, five (out of six) failed theArticulation Screening Test. That is, they were unableto produce consistently the final consonant clusters re-quired to use their grammatical target. In fact, only one

of the children who failed the Articulation ScreeningTest demonstrated a treatment effect and this did notreach significance on a single-subject analysis. Again,this shows remarkable consistency in a heterogeneouspopulation. It is important to note that the majorityof children in the study had some articulation difficul-ties. However, a child failed the Articulation ScreeningTest only if their articulation errors interfered with pro-duction of their identified grammatical target. Thus,articulation difficulties per se did not impede progress,only articulation difficulties which interfered with theproduction of grammatical targets. Thus, in spite ofthe intensive modelling, options for the production andcorrective feedback, treatment targeted at grammar goalsdid not improve articulation. It appears that articulationneeds to be addressed directly in these children.

After articulation was taken into account, there re-mained only one child who showed no treatment gains.This child was one of the highest functioning children.His errors consisted primarily of the [d] allomorph inhis grammatical target of past tense. It is possible thatbecause treatment included items spread across all threeallomorphs ([t], [d], [d]), this child did not receiveenough exemplars to improve on [d].

There are several factors that are likely to have con-tributed to the overall treatment success. The key fac-tors that distinguished the treatment programme fromthe general classroom programme were: (1) the identi-fication of specific targets for each individual, (2) therepeated modelling of grammatical targets, followed by(3) multiple opportunities for each child to producethe targets, followed by (4) feedback to the child and(5) opportunities for the child to correct him/herself.When children participated in activities which allowedapplication of these treatment techniques to a specificgrammatical goal, test scores on their selected grammat-ical targets improved. The on-going reinforcement ofthe goals throughout the day, in the manner outlinedabove, is also likely to have contributed to the treatmentsuccess.

While the study did not formally assess the accept-ability of the interventions for stakeholders, the schoolinvolved in the research was pleased with the interven-tion on a number of levels. From an administrativepoint of view, having objectively measured and docu-mented treatment success provided administrators withevidence that their school provides an effective servicethat deserves continued financial support. From a teach-ing point of view, staff found the preset activities andmaterials convenient and practical. In addition, stafffound the professional development enlightening anduseful. In fact, it was this ongoing professional support,including communication of goals and hands-on teach-ing of techniques that school staff identified as the mostvaluable outcome of the project. We were told we had

Expressive grammar treatment 279

provided teaching staff with knowledge that would lasta lifetime. Since the study, the school has continued toimplement the programme and has shared it with otherschools.

Limitations

Due to real-world nature of effectiveness over efficacystudies, it is hard to control all experimental variables astightly as we might wish. One limitation of this studyis that random allocation of the subjects to treatmentgroups was not possible in this setting. Random allo-cation of participants to groups is used as an attemptto reduce bias due to differing characteristics of partic-ipants. However, because the groups in this study didnot differ on standardized test performance on intaketo the LDC or on an expressive language measure priorto treatment, it is not likely that results were affected bythe lack of randomization.

Although the groups did not differ on compositelanguage scores on intake to the LDC and they didnot differ in expressive language prior to treatment,oral language comprehension was not assessed directlyprior to treatment. As would be expected, comprehen-sion scores on intake did vary from child to child. Al-though the treatment was for expressive language, it ispossible that success was related, at least in part, to achilds ability to understand the language in the treat-ment tasks. Nevertheless, the fact that all but one childshowed improvement suggests that the treatment wassuccessful across a range of comprehension skill lev-els. It would, however, be interesting to measure com-prehension of the grammatical targets pre- and post-treatment to determine the role comprehension of thetargets plays in treatment success, as well as whether thetreatment improved comprehension of the grammaticaltargets.

The treatment took place in three different loca-tions. However, confounds that this may have causedwere limited due to the fact that the locations werepart of the same school, with the same administra-tion and structure. Class and group sizes were simi-lar. Staff were equally experienced and, with the excep-tion of this project, received the same administrativeand professional support. Treatment within the exper-imental and control groups was consistent, as the onespeech pathologist carried out all of the control groupsessions and one speech pathologist carried out all ofthe experimental group sessions. Finally, the schoolswere in the same geographic area and drew on similarpopulations.

The language intervention programme broughtabout a significant change with a large clinical effectover a relatively short intervention period of 8 weeks.However, it must be noted that the post-test mean was

13.53 out of 30.00 (17.62 if the children with articu-lation errors are excluded). This is far from mastery ofthe grammatical targets. Of course, the possessive andpast tense contained ten items of each allomorph. It ispossible that a child mastered the voiced and voicelessallomorphs, but not the syllabic allomorph (e.g. [s] inPips and [z] in Bobs but not [z] in Trishs), yielding ascore of 20 out of 30. Similarly, a score of 15 out of 30 onpronouns is likely to reflect mastery of he, but not she.Thus, a score less than 30may reflect skill at one, but notall, components of the target construction tested in theoutcome measures. The optimal length of interventionto achieve mastery remains to be determined.

Future research

This study should now be replicated with a large-scalerandomized controlled trial to confirm that the successachieved with the small numbers can be replicated. Suchresearch should attempt to determine exactly which fac-tors contribute to treatment effectiveness. For example,does the provision of a list of treatment targets andspecific vocabulary items to teachers for reinforcementincidentally throughout the day add to the success ofthe targeted small group treatment? Is the identificationof a personal treatment target a necessary componentof treatment success? What is the optimal frequencyof treatment sessions? Does the technique used make adifference to treatment success? Does concurrent artic-ulation treatment improve language intervention out-comes? Generalization of the treatment results beyondtest situations to spontaneous speech should be inves-tigated. Finally, future research should investigate thelong-term success of grammar treatment programmes,through the use of delayed post-testing.

Conclusion

In summary, we have demonstrated a large, significanttreatment effect in a school-based grammar treatmentprogramme for specific grammatical targets in 5-year-old children with SLI. This effect was present both ingroup and single-subject analyses. Small group treat-ment using direct teaching, modelling, opportunities forproduction and feedback targeted specifically to a childsneeds was effective in improving grammar targets. Thebiggest impediment to treatment success was articula-tion impairment which interfered with the realizationof grammatical targets.

Acknowledgements

This work was funded by a Macquarie University Research De-velopment Grant to the first author and supported by the Aus-tralian Research Council Centre of Excellence for Cognition and its

280 Karen M. Smith-Lock et al.

Disorders (CE110001021) (http://www.ccd.edu.au). The authorswould like to thank research assistants Joanne and Caroline Dixonfor their capable testing; and the Fremantle Language DevelopmentCentre staff and students for their enthusiastic commitment to theproject. It was the dedication of the Fremantle Language Develop-ment Staff to demonstrating the effectiveness of their programmesthat made the project possible in the first place, and which enabledits completion. Declaration of interest: The authors report no con-flicts of interest. The authors alone are responsible for the contentand writing of the paper.

Appendix A: Grammar Elicitation Test

Target: Possessive /s/Sample Stimulus: [child is shown a picture of a cat witha ball]

Tester says: This is a cat. The cat has a ball. Whose ballis it?

Correct response: the cats ballIncorrect responses: the cat, the cat ballPrompts: I think the ball belongs to the cat. Whose ballis it?

Test items:Possessive [s]:Hopes, Jacks, Pats, Bretts, Blakes, Kates,Pips, cats, ducks, sheeps

Possessive [z]: Dougs, bees, Mays, Carls, dogs, Ems,Marys, Bobs, boys, mans

Possessive [z]: Joyces, churchs, Joshs, Graces,Blanches, Mitchs, Richs, Trishs, horses, fishs

Target: past tenseSample Stimulus: [child is shown a picture of a boykicking a ball]

Tester says: This happened yesterday. What did the boydo yesterday?

Correct response: the boy kicked the ballIncorrect responses: kick, the boy kick ball, the boyis kicking the ball

Prompts: If a verb other that kick was used:Tester says: Did he kick the ball?Child: (if ) yesTester: You tell me that.What did the boy do yesterday?Child: (if ) noTester: I think he did kick the ball. You tell me that.What did the boy do yesterday?

Past [t]: hopped, skipped, touched, danced, walked,shopped, dropped, licked, jumped

Past [d]: squeezed, paddled, smiled, crawled, combed,cried, stirred, buzzed, watered, climbed

Past [d]: pointed, ended, needed, twisted, added,folded, counted, landed, painted, melted

Target: he/sheSample Stimulus: [child is shown a picture of a girldancing]

Tester says: Tell me about this picture. Whats happen-ing?

Correct response: She is dancing.Incorrect responses: the girl is dancing, her dance, heis dancing

Prompts: If the child used the girl, the tester repliedwhy? The child typically then answered with the pro-noun, as the referent was previously established.

Appendix B: Sample treatment plan

Goal 1: Whole group activity with Speech pathologist(SLP): To identify items that belong to a pirate andintroduce and expose to the possessive (s sounding [s],[z] and [z]).

Procedure: To check students can identify the itemsthat belong to a pirate. Place the items in the centre ofthe circle. SLP points to each item and children takea turn to label it. Model using one item that is puton the pirate, the pirates beard. The beard belongs tothe pirate. Whose beard is it? It is the pirates beard.Explicitly teach We add a possessive s to the endof the word, pirate, to show that the beard belongsto the pirate. Repeat and emphasise. Can you hear,the pirates beard. Children each have an item. Eachchild gets a turn to name 4 student names using thepossessive s for their item as they put it on the pirate,e.g. The hook belongs to Nick. SLP: Whose hook isit? It is Nicks hook. 3 students will be involved inthe items for each dressing of the pirate. After eachdressing students will move items to the left so eachstudent has a different item. Dressing of the pirate willbe repeated 4 times for all students to practise. Pointout when the ending sounds /z/ and /z/. Sometimesinstead of /s/ the possessive sounds like /z/ or /z/(For ref /s/ after k, t, p or /z/ after g, l, m, n, vowel,e.g. bees or /z/ after sh, ch, s, x). Errors are recaston-line.

Targets: Model: the pirates beard. Student targets, oneeach: ___________s earring, eye patch, shirt, pants,hat, sword/cutlass, hook, map, gold, spade, telescope,binoculars (12)

Assessment by the SLP: Anecdotal notes taken of stu-dents who had difficulty using the possessive s on aclass list and also students who had difficulty listeningand following instructions

Task explanation: Sit in a circle. You will each havea turn to name these items that belong to the pirate.Point and say What is this? Yes, it is the piratesbeard. When something belongs to the pirate, we adda possessive s to the word pirate and say, the piratesbeard. Now we will dress up ___________ as a pirate.Here is an item each that belongs to you. Each of youwill get 4 turns to name a friend and what belongs tothem e.g., I want you to say: The hook belongs to

Expressive grammar treatment 281

Nick, its Nicks hook. Then Nick will go up and dressthe pirate. This time __________ will be the pirate. Passyour item to the next person on your left.

Motivation: A pirate stickerMaterials: Class list for assessment, pirate stickers,12 targets earring, eye patch, shirt, pants, hat,sword/cutlass, hook, map, gold, spade, telescope,binoculars and a model beard

Time: 15 minutes

References

ACCARDO, P. J. and CAPUTE, A. J., 2005, Cognitive Adaptive Test(Baltimore, MD: Brookes).

ARMSTRONG, R., WATERS, E., ROBERTS, H., OLIVER, S. and POPAY,J., 2006, The role and theoretical evolution of knowledgetranslation and exchange in public health. Journal of PublicHealth, 28, 384389.

BROOMFIELD, J. and DODD, B., 2011, Is speech and language ther-apy effective for children with primary speech and languageimpairment? Report of a randomised control trial. Interna-tional Journal of Language and Communication Disorders, 46,613675.

CIRRIN, F.M. andGILLAM, R. B., 2008, Language intervention prac-tices for school-age children with spoken language disorders:a systematic review. Language, Speech, and Hearing Services inSchools, 39(Suppl.), S110S137.

COHEN, J., 1988, Statistical Power Analysis for the Behavioral Sciences,2nd edn (Hillsdale, NJ: Lawrence Erlbaum Associates).

CONNELL, P. and ADDISON-STONE, C., 1992, Morpheme learning ofchildren with specific language impairment under controlledinstructional conditions. Journal of Speech and Hearing Re-search, 35, 844852.

CRAIG, P., DIEPPE, P., MACINTYRE, S., MICHIE, S., NAZARETH,I. and PETTICREW, M., 2006, Developing and Evaluat-ing Complex Interventions: New Guidance (available at:http://www.mrc.ac.uk/complexinterventionsguidance) (ac-cessed on 11 October 2012).

DOLLAGHAN, C. A., 2007, The Handbook of Evidence-BasedPractice in Communication Disorders (Baltimore, MD:Brookes).

EBBELS, S., VAN DER LELY, H. K. J. and DOCKRELL, J. E., 2007,Intervention for verb argument structure in children withpersistent SLI: a randomized control trial. Journal of Speech,Language and Hearing Research, 50, 13301329.

FEY, M. E., CLEAVE, P. L. and LONG, S. H., 1993, Two approachesto the facilitation of grammar in children with language im-pairment. Journal of Speech, Language and Hearing Research,36, 141157.

FRANKENBURG, W. K., DODDS, J., ARCHER, P., SHAPIRO, H. andBRESNICK, B., 1992, The Denver II: a major revision andrestandardization of the Denver Developmental ScreeningTest. Pediatrics, 89, 9197.

FREMANTLE LANGUAGE DEVELOPMENT CENTRE, 2012 (available at:http://www.fremantleldc.det.wa.edu.au/annual_report.htm)(accessed on 11 October 2012).

FRIEDMANN, N., 2012, Which questions are most difficult to under-stand? The comprehension ofWh questions in three subtypesof SLI. Lingua, 121, 367382.

FRIEDMANN, N. and NOVOGRODSKY, R., 2004, The acquisition ofrelative clause comprehension in Hebrew: a study of SLI andnormal development. Journal of Child Language, 31, 661681.

GALLAGHER, A. L. and CHIAT, S., 2009, Evaluation of speech andlanguage therapy interventions for preschool children withspecific language impairment: a comparison of outcomes fol-lowing specialist intensive, nursery based and no intervention.International Journal of Language and Communication Disor-ders, 44, 616638.

GLOGOWSKA, M., ROULSTONE, S., ENDERBY, P. and PETERS, T.J., 2000, Randomised controlled trial of community basedspeech and language therapy in preschool children. BritishMedical Journal, 321, 15.

GOPNIK, M. and CRAGO, M. B., 1991, Familial aggrega-tion of a developmental language disorder. Cognition, 39,150.

GRIFFITHS, R., 1970, The Abilities of Young Children (HighWycombe: Cournswood House).

HASKILL, A. M. and TYLER, A. A., 2007, A comparison of linguis-tic profiles in subgroups of children with specific languageimpairment. American Journal of SpeechLanguage Pathology,16, 209221.

JOHNSON, J. R. and SCHERY, T. K., 1976, The use of gram-matical morphemes by children with communication dis-orders. In D. Morehead and A. Morehead (eds), Normal andDeficient Child Language (Baltimore, MD: University ParkPress), pp. 239258.

LAW, J., GARRETT, Z. and NYE, C., 2004, The efficacy of treat-ment for children with developmental speech and languagedelay/disorder: a meta-analysis. Journal of Speech, Languageand Hearing Research, 47, 924943.

LEONARD, L. B., 2000, Children with Specific Language Impairment(Cambridge, MA: MIT Press).

LEONARD, L. B., CAMARATA, S., PAWLOWSKA, M., BROWN, B. andCAMARATA, M. N., 2006, Tense and agreement morphemesin the speech of children with specific language impairmentduring intervention: Phase II. Journal of Speech, Language andHearing Research, 49, 749770.

LOGAN, L. R., HICKMAN, R. R., HARRIS, S. R. and HERIZA, C. B.,2008, Single-subject research design: recommendations forlevels of evidence and quality rating. Developmental Medicineand Child Neurology, 50, 99103.

LOHR, K.N., 1988,Outcomemeasurement: concepts and questions.Inquiry, 25, 3750.

MORRIS, S. B. and DESHON, R. P., 2002, Combining effectsize estimates in meta-analysis with repeated measuresand independent group designs. Psychol Methods, 7, 105125.

NICKELS, L. A., 2002, Theoretical and methodological issues inthe cognitive neuropsychology of spoken word production.Aphasiology, 16, 319.

RENFREW, C., 1997, Action Picture Test (Camberwell, VIC: ACER).RICE, M. L., WEXLER, K. and CLEAVE, P. L., 1995, Specific language

impairment as a period of extended optional infinitive. Journalof Speech and Hearing Research, 38, 850863.

ROBEY, R. R. and SCHULTZ, M. C., 1998, A model for conduct-ing clinical outcome research: an adaptation of the stan-dard protocol for use in aphasiology. Aphasiology, 12, 787810.

SHRIBERG, L. D., TOMBLIN, J. B. andMCSWEENY, J. L., 1999, Preva-lence of speech delay in 6-year-old children and co-morbiditywith language impairment. Journal of Speech, Language andHearing Research, 42, 14611481.

SMITH-LOCK, K. M., 1995, Morphological awareness and oral lan-guage skill in normal and specifically-language-impaired chil-dren. Annals of Dyslexia, 45, 163185.

VAN DER LELY, H. K. J., 1993, Canonical linking rules: forward vs re-verse linking in normally developing and specifically languageimpaired children. Cognition, 51, 2972.

282 Karen M. Smith-Lock et al.

WECHSLER, D., 2002, Wechsler Preschool and Primary Scale ofIntelligenceTM Third Edition (WPPSITM III) (Sydney,NSW: Pearson).

WEISMER, S. andMURRAY-BRANCH, J., 1989, Modeling versus mod-eling plus evoked production training: a comparison of twolanguage intervention methods. Journal of Speech and HearingDisorders, 54, 269281.

WIIG, E., SECORD, W. and SEMEL, E., 2006, Clinical Evaluationof Language Fundamentals Preschool Second Edition, Aus-tralian and New Zealand Standardised Edition (CELF P-2Australian and New Zealand) (Sydney, NSW: Pearson).

ZIMMERMAN, I., STEINER, V. and POND, R., 2002,Preschool LanguageScale, Fourth Edition (PLS-4) Australian Language Adapted(Sydney, NSW: Pearson).