OBJECTIVE:This study describes recruitment approaches and costs of engaging Spanish-speaking and Latino families and their young children with language delays in a randomized clinical trial of a naturalistic language intervention approach. METHOD:A total of 214 families were initially screened, and ultimately, 81 families were determined to be eligible and were enrolled in a randomized clinical trial. Families found out about the study via passive recruitment strategies (social media or word of mouth) and active recruitment strategies (referral by experts in early bilingual language development or referral by nonexperts in early bilingual language development). Differences in eligibility based on recruitment strategy type were examined, and a participant acquisition cost for each recruitment source was estimated. RESULTS:There were significant differences in eligibility based on how families were referred. Families who were referred to the study by experts were significantly more likely to qualify and enroll. Referrals from an early intervention provider were the most cost-effective way to recruit families. CONCLUSION:Active recruitment strategies were essential to recruiting Spanish-speaking and Latino families into a randomized clinical trial. Studies that use primarily or exclusively passive recruitment approaches may result in biased samples. Establishing relationships with community experts may be especially important for research targeting children with disabilities.

This study examines moderators of the communication outcomes for young preverbal children with autism who participated in a randomized control trial of a multicomponent communication intervention. Sixty-eight children (mean age 43.06 months) with autism were randomly assigned to either a 36-session blended intervention combining a naturalistic communication intervention with a discrete trial intervention or a business-as-usual control group. Object interest and the frequency of disengaging behaviors moderated the effects of intervention on initiating joint attention, such that children with lower frequency play behaviors and higher frequency disengaging behaviors who were randomly assigned to the intervention group demonstrated significantly more initiations of joint attention at posttest compared to those in the control group.

Autism is a prevalent neurodevelopmental disability among children in the United States. Enhanced Milieu Teaching (EMT) en Español Para Autismo is a caregiver-implemented language-focused naturalistic developmental behavioral intervention specifically for young children on the autism spectrum whose families are Latino and Spanish-speaking. The current study tested a reduced intensity adaptation of EMT en Español Para Autismo using a single-case experimental design study with four caregiver-child dyads. All children demonstrated characteristics of autism and lived in low-income Spanish-speaking households. Caregivers were taught to use EMT en Español Para Autismo strategies during play with their child using a cyclical teach-model-coach-review approach. Home visits occurred once each week. Three out of four dyads completed the study. None of the caregivers demonstrated functional relations between the cyclical teach-model-coach-review approach and their use of strategies; however, caregivers did increase their use of contingent language models and time delays when intervention began. Caregiver impressions of the intervention were positive, but they varied in their perceptions of some of the strategies (e.g., limiting instructions), consistent with participants in prior studies. Overall, the reduced intensity of the intervention and long gaps between visits may have limited the effectiveness of this intervention compared to findings in prior studies. More research is needed to tailor language interventions for Latino Spanish-speaking families with autistic children, especially those with limited resources.

OBJECTIVE:The goal of this study is to construct a 16-week, 2-stage, adaptive intervention consisting of DTT (Discrete Trials Training, largely considered usual care for children with autism), JASP-EMT (a blended, naturalistic, developmental behavioral intervention involving JASPER [Joint Attention, Symbolic Play, Engagement and Regulation] and EMT [Enhanced Milieu Teaching]), and parent training (P) for improving spontaneous communicative utterances in school-aged, minimally verbal autistic children. Intervention was delivered both at school (DTT, JASP-EMT) and at home (P). This article reports results for the study's primary aim and a closely related secondary aim. METHOD:The study used a 2-stage, sequential, multiple-assignment randomized trial design. In stage 1 (weeks 1-6), 194 minimally verbal (<20 functional words), 5- to 8-year-old autistic children were randomized initially to DTT vs JASP-EMT (stage 1, weeks 0-6). Early vs slower response status was determined at the end of stage 1. In stage 2 (weeks 7-16), early responders were re-randomized to stay the course vs P, whereas slower responders were re-randomized to stay the course vs combined DTT+JASP-EMT). The primary aim was to test whether there was a difference between starting with DTT vs starting with JASP-EMT on average change in socially communicative utterances (SCU; primary outcome) from baseline to week 16. A secondary aim was to estimate which of the 8 prespecified interventions was most favorable (ie, the largest average SCU at week 16). The secondary outcomes were total number of novel words, joint engagement, play diversity, requesting, and joint attention gestures from independent blinded assessments. RESULTS:There was no evidence to reject the null hypothesis of no difference between starting with DTT or JASP-EMT on primary outcome (p = .41). The most favorable of the 8 interventions was the adaptive intervention, which starts with DTT, augments with P for early responders, and augments with JASP-EMT for slower responders. For this adaptive intervention, average change on SCU from baseline to week 16 for this intervention was estimated to be 7.68 (95% CI = 2.13-13.24). CONCLUSION:The results showed no difference in treatment starting with JASP-EMT or DTT, and the differences among the 8 adaptive interventions of the secondary aim were modest. Based on these results, reflections on next steps are discussed. PLAIN LANGUAGE SUMMARY:There is limited research about the optimal strategy for interventions to improve spoken language outcomes among minimally verbal 5- to 8-year-old children with autism. The goal of this sequentially randomized trial of 194 children was to compare starting intervention with either a highly structured intervention (discrete trial training [DTT], considered usual care) or a blended, naturalistic, developmental and behavioral intervention (Joint Attention, Symbolic Play, Engagement and Regulation [JASPER] and Enhanced Milieu Teaching [EMT], JASP-EMT) and then changing the intervention depending on how the child responded to the initial intervention. Results at 16 weeks found that there was no difference in improvement in spoken language outcomes for children who began with either intervention first. However, an adaptive intervention was modestly better for having the greatest spoken language at the end of the study: begin with DTT, then add parent training in the home for early responders, and combine DTT and JASP-EMT for slow responders. CLINICAL TRIAL REGISTRATION INFORMATION:Adaptive Interventions for Minimally Verbal Children With ASD in the Community (AIM-ASD); https://clinicaltrials.gov/study/NCT01751698.

Purpose: We investigated effects of an adaptive telehealth coaching model on caregiver implementation of enhanced milieu teaching (EMT) with newly diagnosed toddlers with autism. Method: Three caregiver–child dyads participated in a multiple-baseline-across-behaviors, single-case design. Caregivers were taught EMT via telehealth using the teach–model–coach–review approach. EMT strategies were taught sequentially in four components corresponding to design tiers. Caregivers reported their needs for support and adaptation via weekly surveys. Primary outcomes were measures of caregiver's implementation, including (a) a fidelity checklist for wholistic use of EMT and (b) a percentage of correct use of a subset of key EMT strategies (e.g., matched turns, target talk, expansions, play actions, milieu episodes). Generalization and maintenance of caregiver strategy use in uncoached home activities were measured. The number of different words used by children was measured as a secondary, descriptive outcome. Social validity data were collected through ratings and interviews at the end of the study. Results: There was a functional relation between the intervention and caregiver's implementation of EMT for all dyads. Caregiver's use of EMT strategies often generalized and maintained post-intervention. Child response to intervention was variable. Social validity data indicated that the model was beneficial to caregivers and children. Conclusions: An adaptive telehealth coaching model is effective for teaching caregivers of toddlers with autism to implement EMT and potentially helps to bridge the gap between diagnosis and comprehensive intervention. Further exploration of the relation between caregiver fidelity and dosage of active ingredients and child spoken language outcomes is needed. Supplemental Material: https://doi.org/10.23641/asha.25156223

Purpose: This pilot study investigated delivering enhanced milieu teaching tailored for children with Down Syndrome (EMT-DS) through hybrid telepractice. Method: In this multiple-baseline design across behaviors study, a speech-language pathologist (SLP) taught EMT-DS to three caregivers and their children with DS (22–40 months) using a hybrid service delivery model. Sessions were conducted in person and via telepractice. The SLP taught caregivers EMT-DS, emphasizing the use of (a) four target EMT strategies: matched turns, expansions, time delays, and milieu teaching episodes; (b) augmentative and alternative communication (AAC; manual signs, speech-generating device); and (c) aided AAC modeling. The SLP provided caregiver instruction following the teach–model–coach–review approach. Caregiver outcomes were the accuracy (primary) and frequency (secondary) of EMT strategy use. Child outcomes were exploratory and included the rate of symbolic communication acts, weighted number of communication acts, and number of different words (NDW). Results: There was a functional relation between the intervention and the accuracy and frequency of EMT strategy use for all three caregivers. All caregivers showed an increase in the accuracy for all four target strategies. Caregivers also increased the frequency of the three EMT strategies: expansions, time delays, and milieu teaching episodes. There were no changes in the frequency of matched turns. Caregiver use of EMT strategies maintained for 6 weeks post-intervention. After caregivers learned EMT strategies, gradual increases in the rate of symbolic communication acts and NDW occurred for all three children. Conclusion: Results demonstrate the preliminary efficacy of using a hybrid service delivery model to teach caregivers EMT-DS. Supplemental Material: https://doi.org/10.23641/asha.27115252

The primary purpose of the current pilot study was to test the effects of an adapted and collaborative intervention model with a systematic teaching approach on Latina Spanish-speaking caregivers’ use of EMT en Español Para Autismo strategies with their young children on the autism spectrum. A multiple baseline across behaviors single case design was replicated across two dyads. A series of family interviews and a direct therapist-child intervention phase supported individualization of the intervention. Families were provided speech generating devices as part of their children’s intervention protocol. Caregivers were taught to use EMT en Español Para Autismo strategies with aided language input. Strategies included contingent target-level and proximal target-level language modeling, linguistic expansions, and communication elicitations. Secondary variables measured included generalization of strategy use to unsupported interactions and at a 2-month follow-up, child communication outcomes, and social validity. There was a strong functional relation for one dyad between the adapted and collaborative intervention and caregiver use of EMT strategies. The functional relation was weakened by behavioral covariation for the other dyad. Children increased the quantity and diversity of their communication during the study. Caregivers generalized their use of most EMT strategies and reported most aspects of the approach to be socially valid. The current study provides an initial demonstration of an effective model for adaptation and individualization of naturalistic developmental behavioral interventions for Latino Spanish-speaking families with children on the autism spectrum.

PurposeThe purpose of this study was to compare the speech and language outcomes of children with cleft palate with or without cleft lip (CP+/-L) in the USA to children with CP+/-L in Brazil who underwent intervention with enhanced Milieu teaching with phonological emphasis (EMT + PE), as there are few cross-country intervention comparisons for children with CP+/-L.MethodThis is a retrospective analysis of 29 participants from the USA and 24 participants from Brazil who were matched on age. The US participants were between the ages of 13-35 months (M = 23.76), spoke Standard American English in the home, and were recruited from East Tennessee State University and Vanderbilt University. The Brazilian participants were between the ages of 20-34 months (M = 25.04), spoke Brazilian Portuguese in the home, and were recruited from the Hospital de Reabilita & ccedil;& atilde;o de Anomalias Craniofaciais-Universidade de S & atilde;o Paulo. All treatment participants received EMT + PE from trained speech-language pathologists in hospital-university clinics.ResultThe treatment groups demonstrated greater gains than comparison groups in percent consonants correct, number of different words, and expressive/receptive vocabulary. There was no main effect nor interaction by country.ConclusionThe application of EMT + PE in a second culture and language is a viable early intervention option for participants with CP+/-L.

US Preventive Services Task Force; Michael J. Barry, MD; Wanda K. Nicholson, MD, MPH, MBA; Michael Silverstein, MD, MPH; David Chelmow, MD; Tumaini Rucker Coker, MD, MBA; Esa M. Davis, MD, MPH; Katrina E. Donahue, MD, MPH; Carlos Roberto Jaén, MD, PhD, MS; Li Li, MD, PhD, MPH; Carol M. Mangione, MD, MSPH; Gbenga Ogedegbe, MD, MPH; Goutham Rao, MD; John M. Ruiz, PhD; James Stevermer, MD, MSPH; Joel Tsevat, MD, MPH; Sandra Millon Underwood, PhD, RN; John B. Wong, MD

BACKGROUND Language acquisition strongly predicts executive functioning (EF) in early childhood in typical development and in children with Down syndrome (DS). Both language and EF are critical contributors to later positive social and academic outcomes yet are often areas of concern in children with DS. Despite the wider availability of interventions targeting language development in DS, no efforts have been made to understand how these interventions may influence the development of EF in this population. METHODS This study examined secondary data from 76 preschoolers with DS collected as part of a randomised waitlist control trial of an early social communication intervention (JASPER-EMT). Children's EF skills were measured using the BRIEF-P, at three timepoints over 6 months. Linear regression was used to examine the baseline relationship between child characteristics and the three indices of the BRIEF-P: Emergent Metacognition, Flexibility and Inhibitory Self-Control. Linear mixed effects models were used to estimate change across the three indices of the BRIEF-P and whether that change was moderated by treatment. RESULTS Children in this sample exhibited an uneven profile of EF at baseline, with relative strengths in the Flexibility Index and the Inhibitory Self-Control Index, and relative weaknesses in the Emerging Metacognition Index. Chronological age was associated with all indices at baseline (all P < 0.05). Children in the intervention group exhibited improvements in the Flexibility Index from entry to exit (3 months later) compared with the control, although this treatment effect did not maintain at the follow up at 6 months. CONCLUSIONS Baseline EF profiles of children were consistent with findings of other studies with children with DS. Longitudinal findings suggest that behavioural interventions targeting language may have positive collateral effects on certain EF skills, however these effects may be transitory without ongoing support. These findings illustrate both the need for further exploration of the impact of early language interventions on EF abilities and the malleability of certain EF domains in young children with DS.

The use of speech-generating devices (SGD) in early interventions for children with autism spectrum disorder (ASD) can improve communication and spoken language outcomes. The purpose of this study was to describe children's responsiveness to SGD input modeled by a social partner during adult-child play interactions over a 24-week intervention trial and explore the effect of that responsiveness on spoken language growth. This secondary analysis consisted of 31 children with less than 20 functional words at study entry who received a blended behavioral intervention (JASPER + EMT) as part of a randomized controlled trial. Significant improvements were seen in rate of responsiveness to both adult SGD models and adult natural speech models; only rate of responsiveness to SGD models at entry was a significant predictor of frequency of commenting and was a more robust predictor of number of different words post-intervention. Lastly, at entry, children with more joint attention and language responded to SGD models at significantly higher rates. Attention and responsiveness to SGD output may be important mechanisms of language growth and children who have more joint attention skills may particularly benefit from use of an SGD.

Purpose: Optimal augmentative and alternative communication (AAC) systems for children with complex communication needs depend in part on child charac-teristics, child preferences, and features of the systems themselves. The pur -pose of this meta-analysis was to describe and synthesize single case design studies comparing young children's acquisition of communication skills with speech-generating devices (SGDs) and other AAC modes. Method: A systematic search of published and gray literature was conducted. Data related to study details, rigor, participant characteristics, design informa-tion, and outcomes were coded for each study. A random effects multilevel meta-analysis was performed using log response ratios as effect sizes. Results: Nineteen single case experimental design studies with 66 participants (Mage = 4.9 years) met inclusion criteria. All but one study featured requesting as the primary dependent variable. Visual analysis and meta-analysis indicated no differ-ences between use of SGDs and picture exchange for children learning to request. Children demonstrated preferences for and learned to request more successfully with SGDs than with manual sign. Children who preferred picture exchange also learned to request more easily with picture exchange than with SGDs. Conclusions: Young children with disabilities may be able to request equally well with SGDs and picture exchange systems in structured contexts. More research is needed comparing AAC modes with diverse participants, communi-cation functions, linguistic complexity, and learning contexts. Supplemental Material: https://doi.org/10.23641/asha.22111181

PURPOSE:Early language and communication interventions for children with language impairments have been shown to be effective in assessments administered immediately after treatment. The purpose of the current systematic review and meta-analysis was to assess the overall durability of those effects over time and whether durability was related to outcome type, etiology of child language impairments, implementer of intervention, magnitude of posttest effects, time between intervention and follow-up, and study risk of bias.METHOD:We conducted a systematic search of online databases and reference lists to identify experimental and quasi-experimental group design studies. All studies tested the effects of early communication interventions at least 3 months post-intervention. Participants were children 0-5 years old with language impairments. Coders identified study features and rated methodological quality indicators for all studies. Effect sizes at long-term timepoints and associations with potential moderators were estimated using multilevel meta-analysis with robust variance estimation.RESULTS:Twenty studies with 129 long-term outcome effect sizes met inclusion criteria. Studies included children with developmental language disorders or language impairment associated with autism. The overall average effect size was small and significant (g = .22, p = .002). Effect size estimates were larger for prelinguistic outcomes (g = .36, p < .001) than for linguistic outcomes (g = .14, p = .101). Significant factors were the posttest effect sizes, the risk of bias for randomized trials, and etiology of language impairment for linguistic outcomes. Time post-intervention did not significantly predict long-term effect sizes.CONCLUSIONS:Outcomes of early language and communication interventions appear to persist for at least several months post-intervention. More research is needed with collection and evaluation of long-term outcomes, a focus on measurement, and consistency of primary study reporting.SUPPLEMENTAL MATERIAL:https://doi.org/10.23641/asha.23589648.

Purpose: This study examined the effectiveness of Caregivers Optimizing Achievement of Children With Hearing Loss (COACH), an intervention in which parents were taught naturalistic interaction strategies that addressed the unique linguistic input needs of their young children with hearing loss. Method: A single-subject multiple-baseline across-behaviors design was used with four caregiver–child dyads to determine the effects of COACH training on caregivers' use of the COACH language facilitation strategies and on their children's language abilities. Results: A functional relation was demonstrated between teaching of strategies and caregivers' use of the strategies across three dyads with slower, consistent changes observed in a fourth dyad. Improvements in children's use of target-level language were observed for children in three dyads. Conclusions: Caregivers were able to implement COACH language facilitation strategies, although the pace of caregivers' learning differed across dyads. Caregivers reported high satisfaction with participating in the intervention. Future research using a randomized design and a longer intervention condition is needed for a more complete assessment of the effects of the intervention on children's language abilities. Supplemental Material: https://doi.org/10.23641/asha.22290082

Background: Studies of early caregiver-mediated interventions targeting social communication of young autistic children have yielded variable child outcomes. This study examined the effects of combining two caregiver-mediated interventions on caregiver strategy use and child social communication and language outcomes. Method: This was a multisite parallel randomized controlled trial. Participants included 120 caregivers and their autistic children between 24 and 36 months of age. Dyads were randomly assigned to receive a hybrid intervention that combined Enhanced Milieu Teaching (EMT) and Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER) or to a behavior management control condition, each delivered over 6 months. Caregivers in the JASP-EMT group received twice-weekly, in-home, and hour-long sessions. Outcomes were measured at baseline, the end of intervention (T1), and 6 months later (T2) and included a naturalistic language sample procedure, standardized measures, and caregiver report measures. This trial was registered at clinicaltrials.gov (NCT02595697). Results: Child outcomes did not differ between conditions at T1 or T2 for child primary (social communication) or secondary (language, play, and autism symptoms) outcomes. Relative to control group caregivers, intervention group caregivers demonstrated significantly higher use of JASP-EMT strategies at T1 and T2, with the exception of two strategies (Responsiveness and Matched Responsiveness), which were used significantly more by control group caregivers. Neither autism severity nor baseline caregiver responsiveness moderated outcomes. Post hoc analyses revealed significant correlations between specific strategies and all child outcomes. Conclusions: Twice-weekly caregiver-mediated intervention that taught caregivers of autistic children to use social communication support strategies did not yield significant child outcomes. Future studies should examine possible sources for the lack of main effects including unexpected differences in linguistic features of caregiver input, changes in control group caregiver behavior, and insufficient intervention dosage. Supplemental Material: https://doi.org/10.23641/asha.21714278

The purpose of this article is to present a theory-driven blended intervention model that integrates evidence-based interventions to support language and social development of young children. We (1) provide an overview of practices that are designed to support language and social-emotional development, (2) present a theory of change model that outlines the theoretical basis for our proposed approach, and (3) provide an example of the conceptual model via the blending of Tier 1 interventions that provide class-wide language and behavioral support for young children. We conclude by arguing for the parsimony that a proactive synergy between social and language interventions blended into a single professional development approach will provide.

The primary purpose of this study was to examine the effects of using the Teach-Model-Coach-Review approach to teach Spanish-speaking caregivers from low-income households to implement EMT en Español with their young children with language delays. A secondary purpose was to explore the effects of the caregiver-implemented intervention on children's vocabulary. A final and more exploratory goal was to gain insight into caregivers' perceptions of the intervention.21 caregiver-child dyads participated in the intent-to-treat randomized control trial. Their children were 30-43 months old with language delays. Dyads were randomly assigned to receive 24 caregiver training sessions delivered at home in Spanish or a wait list control group. Pre, post and 3-month follow assessments included observational measures of caregiver-child interactions and child standardized vocabulary assessments. Caregivers completed surveys rating their perception of the intervention.Caregivers in the intervention group had significantly higher percentages of matched turns, expansions, and targets at post-assessment and of expansions and targets at follow-up compared to the control group. Overall, children in the intervention condition had significantly higher receptive vocabulary scores and performed better than children in the control condition on observational measure of their lexical diversity, with moderate effect sizes for most outcomes. Caregivers perceived the intervention as effective and culturally appropriate.Teach-Model-Coach-Review is effective in increasing Spanish-speaking caregivers' use of EMT en Español strategies with their young children with language delays. The intervention also appears to be effective for child vocabulary outcomes and acceptable to caregivers.

Early language skills and prosocial behavior contribute to positive outcomes across the lifespan. Screening has improved the identification and early intervention (EI) for children with hearing loss, autism spectrum disorders, and genetically based disabilities. However, many children with significant functional impairments in language and behavior are not identified before school entry. These children have missed a critical window for EI that might have prevented or mitigated persistent developmental language impairment and challenging behaviors. The critical need for early identification of children with delays in both language and social-emotional development by proposing a preventive, universal screening approach. This approach to early screening aims to reduce the number of children on a trajectory of academic failure and social difficulties as a result of these early developmental delays.

191 Vol. 24, No. 4, December 2021 YOUNG EXCEPTIONAL CHILDREN https://doi.org/10.1177/1096250620928335 DOI: 10.1177/1096250620928335 journals.sagepub.com/home/yec Article reuse guidelines: sagepub.com/journals-permissions © 2020 Division for Early Childhood José, a 3-year-old boy with a diagnosis of autism spectrum disorder (ASD), attends an early childhood inclusive classroom. He uses gestures and single words to communicate his wants and needs. He spends much of his time engaged in solitary and stereotypic play with his favorite toys, trains and trucks. José’s teacher, Ms. Baca, is concerned about his social communication skills because he does not have an independent means of communicating with his peers, teachers, or other adults in the classroom. When Ms. Baca asks José to put his toys away during clean up, he often cries. He pushes his peers out of his space when they approach him to play. José receives an hour of speech and language therapy in his classroom each week. Ms. Chavez, his speech-language pathologist (SLP), notes that although José is able to use single words to request, he only requests routines that include his favorite toys. José’s parents also report that they have difficulty understanding what he is trying to communicate when he cries or screams and that he only uses single words for requesting. Together, the teacher and SLP examine current evidence-based 928335 YECXXX10.1177/1096250620928335Young Exceptional ChildrenEnhanced Milieu Teaching Strategies / Davison et al. research-article2020

Very little is known about the 30% of children with Autism Spectrum Disorder (ASD) who remain minimally verbal when they enter school. Restricted and repetitive behaviors (RRBs) are well-characterized in younger, preschool, and toddler samples. However, the prevalence and impact of RRBs has not been characterized in older, minimally verbal children. The goal of this study was to characterize this core diagnostic feature in minimally verbal children with ASD ages 5-8 years over a 9-month period to better understand how these behaviors manifest in this crucially understudied population. RRBs were coded from caregiver-child interactions (CCX) at four timepoints. Upon entry into the study, children demonstrated an average of 17 RRBs during a 10-min CCX. The most common category was Verbal. RRBs remained constant over 6 months; however, a slight reduction was observed at the final timepoint. Compared to prior literature on younger samples, minimally verbal children with ASD demonstrated higher rates of RRBs and higher rates of verbal RRBs. Further work is required to understand the function and impact of RRBs in minimally verbal children. LAY ABSTRACT: Approximately one-third of children with autism spectrum disorder (ASD) remain minimally verbal at the time of school entry. In this study, we sought to characterize the presence of restricted and repetitive behaviors (RRBs) in school-aged children (5-8) who were minimally verbal. Compared to prior studies, minimally verbal children with ASD had higher frequencies of RRBs and demonstrated a different profile of behaviors, including more verbal RRBs.