Systematic Review of Naturalistic Language Interventions in Schools: Child- and Adult-Level Outcomes for Verbal Communication

Abstract

Naturalistic language interventions are commonly recommended to educators when teaching children to reliably share their wants, interests, and feelings with others. Recommendations include providing focused attention on a child and embedding multiple instructional opportunities within and across activities. Although such practices are commonly recommended, educators have multiple responsibilities throughout the day and need practical guidelines for implementing these relatively complex procedures in practice. The purpose of this review was to identify experimental studies where educators were trained to conduct naturalistic language interventions in schools for the purposes of improving verbal social communication in children with or at risk for disabilities. We identified a total of 38 experimental studies published in 19 articles. Most studies were conducted by classroom teachers with children with autism spectrum disorder. Inadequate methodological rigor limited the applicability of findings for guiding educators in practice. Practical implications for evaluating naturalistic language interventions in schools are discussed.

Keywords

naturalistic language interventions children preschool elementary school teachers educators autism spectrum disorder disabilities

Children learn how to communicate their wants, interests, and feelings during age-appropriate activities with others, such as toy play with family, games with same-age peers, and at play-based centers with educators. Learning in typical contexts increases the salience of knowing when and how to reliably communicate with others and, in turn, increases the likelihood of a child maintaining and generalizing skills (Brown & Woods, 2015; Hampton & Kaiser, 2016; Hemmeter & Kaiser, 1990; Ledford et al., 2019; Woods et al., 2004; Yoder & Lieberman, 2010; Yoder et al., 1995). During these interactions, young children receive feedback from communication partners and practice using increasingly complex communication, such as combining known words into two- or three-word phrases and adding early morphological markers to words (e.g., play to play-ing, horse to horse-s) (Paul & Norbury, 2012). In contrast, young children with or at-risk of disabilities may display difficulties meaningfully communicating with others, potentially relying on idiosyncratic gestures or challenging behaviors to express needs and frustrations (Kasari et al., 2014; Lane & Brown, 2016; Prizant & Wetherby, 1987). Communication delays have short- and long-term implications for children. For example, children may display challenging behaviors that could persist into adolescence and adulthood (e.g., Qi & Kaiser, 2004; Shevell et al., 2005), potentially negatively impacting successful social interactions with family and peers. In addition, such delays could hinder future academic success and employment in adulthood (U.S. Department of Education Office for Civil Rights, 2014). To ameliorate delays and narrow the developmental trajectory between children with or at risk for disabilities and their same-age peers with typical development, naturalistic supports and interventions are commonly recommended (Schreibman et al., 2015; Snyder et al., 2015). As described by Kaiser and Grimm (2005), naturalistic supports and interventions are “grounded in social communication” and “teaching occurs when two persons have a shared goal of exchanging information within a social interaction” (p. 449). Thus, successful instruction is rooted in the relationship between the child and the adult.

Broadly, naturalistic supports and interventions are designed to capitalize on a child’s interest and motivation to communicate, whether the adult arranges the environment to promote an independent response, or the child spontaneously initiates an interaction (Kaiser et al., 2010; Ledford et al., 2019). The term naturalistic language intervention is an umbrella term used to represent communication-focused instruction that occurs during typical activities and includes age-appropriate materials and corresponding communication targets. In addition, adults engage in responsive behaviors, such as taking turns during play and conversation, to affirm the social nature of communication and create predictable routines and expectations for a child (Lane et al., 2016a). After establishing routines and expectations, interventions, such as individual milieu teaching procedures or manualized interventions (e.g., enhanced milieu teaching, pivotal response training) are introduced to promote increased social communication and help the child use a reliable mode of communication to share their voice (e.g., vocal speech, manual signs, and speech generating device) (Hoff, 2009; Romski et al., 2015; Snyder et al., 2015). Examples of milieu teaching procedures, including modeling (immediately providing a verbal model of an instructional target), mand-model (providing an open-ended question or statement and, if needed, providing a verbal model), time delay (waiting for a child to communicate wants, interests, and feelings, which is typically followed by a verbal model prompt as necessary), and incidental teaching procedures (promoting elaborated requests, with varied levels of support provided to promote growth in communication); each procedure involves the child first being motivated to communicate and then the adult providing support (e.g., Ledford et al., 2019). Also, a number of manualized naturalistic language interventions are available in the literature, each with specific purposes and guidelines for implementing procedures with fidelity. Many of the manualized interventions include some form of milieu teaching procedures; detailed descriptions are outside the scope of this review (see sources, such as Lane & Brown, 2016 for additional details).

Contemporary recommendations for promoting communication indicate the importance of providing naturalistic instruction in typical contexts and arrangements (Division for Early Childhood, 2014). Children typically spend a large portion of their day in schools, which makes educational settings, like classrooms, ideal settings to target social communication. Educators can capitalize on a child’s interests and motivations to communicate by creating a language-rich environment—(a) modeling age-appropriate communication, (b) encouraging children to share wants, interests, and feelings, and (c) embedding opportunities for advancing a child’s communication throughout the day (Kaiser et al., 1993; Koegel et al., 1999; Lane et al., 2020). Relatedly, early childhood is a critical period for children to learn how to share their voices with others. Learning a variety of skills across domains is critical, but such skills are less effective or ineffective if a child cannot share their ideas, wants, interests, feelings, and so on with others (Paul & Norbury, 2012). That being said, classrooms are dynamic settings, requiring educators to plan for and accommodate each child’s developmental and instructional needs. In addition, ensuring children have an adequate number of learning opportunities requires careful planning and consideration, especially for children with more complex communication needs (e.g., children with autism spectrum disorder [ASD] or significant developmental delays) who typically require multiple opportunities to learn to reliably communicate with others (Kasari et al., 2010; Ledford et al., 2019). Educators, specifically teachers and related staff (i.e., classroom aides, educational assistants, and paraprofessionals), are ideal individuals to implement such practices in the classroom because they typically have an established relationship with children and are in the instructional setting throughout the day. Although ideal implementers, the increasing number of responsibilities for educators likely necessitates training and coaching on recommended naturalistic strategies and interventions. A number of adult-learning strategies are recommended in the literature, including performance-based feedback, modeling, role-play, and practice, among others, to support educators’ fidelity of implementation of naturalistic instruction (Artman-Meeker et al., 2015; Barton et al., 2019).

Given the recommendations of targeting early social communication in typical contexts using naturalistic strategies, as well as the potential long-term implications of supporting educators, a review of the literature is warranted. A number of reviews have evaluated aspects of promoting communication in young children, including use of augmentative and alternative communication (AAC) as a form of expressive communication (e.g., Sennott et al., 2016 indicated the importance of aided language modeling during play-based activities), parents as implementers (e.g., Biel et al., 2020 reported that parents displayed success when strategies, such as modeling and performance feedback were provided), and naturalistic instruction with specific populations of children (ASD; e.g., Lane et al., 2016a found that rigorous and successful interventions included model prompts followed by time delay during play-based activities), but we were unable to identify a review that (a) specifically evaluated educators’ use of naturalistic language interventions at school during play-based activities and (b) associated improvements in verbal social communication in children with or at risk for disabilities, as well as (c) considered how adults were trained. Young children communicate using multiple modes of communication, such as gestures, facial expressions, and speech, but over time, children typically begin to use speech to communicate, with behaviors, such as pointing or body orientation functioning as supports for emphasis and further clarification for a communication partner. Thus, we chose to focus on verbal social communication in children in the form of speech; this focus does not minimize the importance of AAC as a standalone voice or support in improving verbal social communication. The overarching purpose of this review was to identify and review experimental studies that evaluated the effects of naturalistic language interventions conducted by educators in classrooms to promote verbal social communication in children with disabilities.

Research Questions

Research Questions 1: With whom and under what conditions were naturalistic language interventions implemented during play-based activities to promote verbal social communication in children with disabilities in the classroom?

Research Questions 2: To what extent were studies that evaluated child outcomes methodologically rigorous? Of those studies, which led to improvements in the child-related dependent variables?

Research Questions 3: How were educators trained to implement naturalistic language interventions? To what extent were studies that evaluated adult implementation methodologically rigorous? Of those studies, which led to improvements in the adult-related dependent variables?

Research Questions 4: What variables moderated the effects of naturalistic intervention on children’s verbal communication outcomes in classrooms? What variables moderated the effects of training educators to provide naturalistic language interventions?

Method

Search

An electronic search of Academic Search Complete, ERIC, PsycINFO, and Medline databases were used to identify articles published through 2020 in academic journals and in English. In addition, we conducted a hand search of relevant journals and an ancestral search of references for each article meeting inclusion criteria (Wolery et al., 2018). We initially conducted an abstract review of potential articles using inclusion and exclusion criteria; if an article’s abstract was unclear, then a full review of the article was conducted. Keywords were divided into four categories: (a) educators, (b) dependent variable, (c) child eligibility or disability status, and (d) intervention (Refer to the online supplemental materials for keywords). Two teams of graduate students independently searched for potential articles. The electronic search initially returned 349 results (100% agreement between teams) and, after duplicates were removed, 258 articles were further reviewed against the inclusion and exclusion criteria.

Studies were selected for review if (a) an educator, defined as a classroom teacher or other classroom staff (i.e., classroom aide, educational assistant, or paraprofessional), implemented a naturalistic language intervention (sessions occurred during typical activities, materials/toys were selected by the child or based on the child’s interests, the adult introduced an intervention during the play-based activity) in a classroom or in a setting within a school; (b) the intervention was designed to improve verbal social communication (independent, prompted, or spontaneous initiations and responses during an exchange) in children 3–12 years of age with disabilities, who had a provisional diagnosis (e.g., suspected ASD), were considered at risk for a disability (3–5 years of age), or were eligible for special education services; (c) the intervention was evaluated within the context of an experimental design (e.g., controlled group design, single-case design); and (d) verbal social communication was measured and reported separately from other variables.

Studies were excluded if (a) a parent, member of a research team, or a related-service provider (e.g., speech-language pathologist; behavior analyst) served as the primary interventionist (speech-language pathologists were omitted because, similar to other related-service providers, they are most likely to serve in a consultative role in classrooms) (Green et al., 2019; McKenna et al., 2021); (b) the primary dependent variable involved use of augmentative and alternative communication; (c) the study used a qualitative design or was observational or descriptive in nature; (d) the target behavior was early literacy/shared reading, such as having children name specific items in a book to promote increased use of vocabulary words, or academic behaviors, like responding to questions after reading a story; or (e) sessions involved removing the child from classroom-based activities or occurred during academic-related instructional activities.

The same two teams of graduate students independently reviewed 100% of the 258 articles. The initial level of agreement for including and excluding articles identified through the electronic search yielded 90.5% agreement; the research team, including the first author, convened and consensus for inclusion was established. It should be noted that one study was identified through the electronic search in which a naturalistic language intervention was compared with another social communication intervention (i.e., Yoder et al., 1995). Given our developed research questions, we added a criterion at this point in the search to indicate that a study needed to evaluate the effects of a naturalistic language intervention against a baseline condition. The teams then conducted a hand search of journals (refer to the online supplemental materials for journal titles), followed by an ancestral search. The level of agreement between the teams was 83%, indicating that of all articles identified as meeting inclusion criteria, 83% of those articles were identified by both research teams. Consensus for final inclusion was established.

The first author repeated the electronic search to identify any recently published articles (2021, February; 2021, April); two additional articles were identified. The search was conducted again to identify peer-reviewed articles published through October 2021, as well as identify relevant theses and dissertations (ProQuest Dissertations and Theses Global database). The follow-up search included the keyword disorder in relation to child eligibility or disability status. Two teams of graduate students independently conducted searches for peer-reviewed articles (n = 85) (100% initial agreement) and theses and dissertations (n = 70) (85.7% initial agreement, with 100% agreement after reviewing articles). One additional article was identified. A total of 19 articles were included in the review (Refer to the online supplemental reference list for the full list of articles) (see Figure 1 for the PRISMA flowchart). Although eligible, no group comparison studies met inclusion criteria.

Figure 1.

PRISMA flowchart for the systematic review of studies that evaluated naturalistic language interventions in schools.

Coding

Data from each included article were extracted and coded across three categories: (a) descriptive information (Wolery et al., 2018), (b) methodological rigor (Ledford et al., 2018a; What Works Clearinghouse [WWC], 2017a, 2017b), and (c) outcomes (visual inspection of data; Barton et al., 2018a).

Descriptive information

These data described the adult-, child-, and contextual-variables included in each article. To obtain this information, we reviewed each article’s Method and Results sections. Interobserver agreement was calculated across coders for approximately 31.6% (n = 6) of articles and yielded 92% agreement across articles (82%–100%).

Methodological rigor

Methodological rigor was assessed to evaluate the internal validity of studies within an article. For purposes of this review, the term article referred to the published article as a whole, while study referred to each experimental design within an article (e.g., four single-case multiple baseline design studies within the same article). We assessed methodological rigor using a combination of design standards provided in the WWC guidelines for single-case studies (WWC, 2017a, 2017b), as well as other contemporary guidelines, such as procedural fidelity data (Barton et al., 2018b; Ledford & Gast, 2018; Ledford et al., 2018a). Given the inclusion and exclusion criteria, the code related to systematic manipulation of an independent variable was not included. The following criteria were used to review methodological rigor by study: (a) there was an opportunity to assess presence or absence of a functional relation in the data (i.e., at least three opportunities to demonstrate the effectiveness of the intervention at three different points in time); (b) a pattern of responding was established in each condition of a study (e.g., stable zero-celerating trend in the baseline condition), with at least three data points in each condition, but preferably five; and (c) reliability of the dependent variable was assessed in the form of interobserver (IOA) or inter-rater agreement and (d) reliability of implementation of procedures in the form of procedural fidelity at least 20% of sessions in each condition and the mean agreement was at least 80% in each condition.

In addition, if a study evaluated an intervention using a multiple probe design, adherence to contemporary guidelines were reviewed: (a) at least one overlapping initial pre-intervention session was conducted across all tiers prior to introducing the intervention in Tier 1, (b) at least one session was conducted prior to introducing an intervention in an untreated tier, (c) at least one probe session was conducted every eight sessions in each untreated tier, and (d) in previous tiers (participant learned the target behavior and the intervention was then introduced to another tier), at least one data point collected in the mastered tier. Also, potential confounds that could negatively influence confidence in findings were reviewed and considered after reviewing the minimal criteria for rigor and adherence to contemporary guidelines for multiple probe designs. This portion of coding focused on potential confounds, such as covariation in untreated tiers of time-lagged designs or an accelerating data path in a pre-intervention condition moving in a therapeutic direction.

Outcomes

Studies that met minimal criteria for rigor and adhered to guidelines for multiple probe designs (if applicable), with no additional confounds present, were visually analyzed to assess outcomes, that is, the presence or absence of a functional relation (Barton et al., 2018a; Ledford et al., 2018b). A within- and between-condition analysis of data occurred with consideration of (a) level-value of each data point on the ordinate, (b) trend-directionality of the data path, (c) stability-degree of movement of the data path on the ordinate, (d) immediacy of effect-extent to which therapeutic or contra-therapeutic improvements were observed after introducing or removing an intervention, (e) overlap-extent to which data paths were similar or dissimilar across conditions of a study, and (f) consistency of effect-extent to which data paths were similar or dissimilar in identical conditions of a study. Finally, interobserver agreement was calculated across coders for methodological rigor and outcomes—(a) at the child-level IOA data were collected for 81.2% of identified studies and yielded an initial agreement of 93.5% across studies (83.3%–100%) and (b) at the adult-level, collected for 80% of identified studies and yielded an initial agreement of 90.3% (83.3%–100%). Any disagreements were related to coding the presence of confounds in a study. The final consensus on codes was established by the first author. Analyses to assess moderating variables, as specified in Research Question #4, were not conducted (see Results section).

Results

A total of 38 single-case studies published in 19 articles were identified and reviewed. At the article level, (a) 8 of 19 articles included child-outcome data only and (b) 11 of 19 included child- and adult-outcome data. Regarding articles that included child- and adult-outcome data, three articles did not report child data within a graph to allow for visual analysis. At the study level, (a) 23 of 38 studies evaluated child-outcome data and (b) 15 studies evaluated adult-outcome data. Refer to online supplemental Table S1 for the variables and codes used to obtain descriptive information data.

Research Question 1

Child characteristics

Across the 19 identified articles, 106 children received a naturalistic language intervention at school, with all sessions conducted by educators. In 3 of 19 articles, child-level data were presented for groups of children (n = 48 children; 45.3%). Race and ethnicity were not reported in most studies. ASD was most commonly reported as the primary diagnosis of some or all participants within and across articles (n = 11; 57.9%), with one of those articles specifically reporting that children displayed comorbid intellectual disability. Relatedly, six articles reported that some participants had developmental delays, with two of those articles indicating children had significant developmental delays. Two articles did not provide specific diagnoses or eligibilities, but rather provided indications that children required specialized services to promote early communication. Regarding relevant pre-intervention characteristics of children, 12 articles (63.2%) reported on social skills and 17 on social communication (89.5%). When social skills were reported, authors indicated that children displayed delayed play skills, oftentimes engaging in solitary play (n = 6), lacked age-appropriate social skills (n = 6), and engaged in challenging behavior (n = 6). When social communication descriptions were reported, authors reported a wide range of communication skills. All children were at least using some vocalizations to communicate (e.g., did not reliably use words; commonly used non-speech sounds or non-functional words to share wants, interests, and feelings), with some studies reporting that gestures typically accompanied vocalizations. In 14 articles, authors reported that at least some of the participants were displaying emerging early speech, with some children beginning to or reliably using sentences to communicate. Due to varied reporting practices, we were unable to ascertain information regarding the complexity of early speech/sentences. Additional descriptive information related to pre-intervention communication, such as relative strengths with receptive language and challenges, such as echolalia, were limited.

Instructional targets

Within seven articles, authors indicated the goal of instruction was promoting use of 1–3 word phrases during age-appropriate activities. In contrast, instead of the length of utterance, four articles included a focus on the social functions of verbal communication—requests (n = 2), initiations (n = 1), and making choices (n = 1). In five articles, the instructional target or function was not specified beyond improving verbal communication in children, in general. For the remaining articles, the authors reported targeting compound sentences (n = 1), preposition use (n = 1), and intelligibility and increased speech (n = 1). In 7 articles (36.8%), the authors focused on independent verbal communication or monitored both independent and prompted verbal communication. Multiple articles collapsed each of the three categories into one or, to some extent, combined them into independent and prompted correct responses for some or all participants (n = 9; 47.4%). In two articles (10.5%), prompted verbal communication was the only target behavior in the study, while the other focused exclusively on spontaneous verbal communication.

Intervention conditions

Across all articles, sessions were conducted in the classroom, with some authors reporting that additional sessions occurred on the playground or in other areas of the school. Within the classroom, sessions occurred during routine and/or play-based activities (n = 12), free play alone (n = 4), free play and small group activities (n = 1), small group activities alone (n = 1), or play portions of circle time (n = 1). In addition, studies were conducted in publicly funded schools (n = 9), private schools/university-based preschools (n = 6), other settings (n = 3), or was not specifically reported (n = 1; e.g., described as “preschool” with no additional clarification). Three articles specifically reported using milieu teaching procedures (e.g., modeling, mand-model procedure, time delay), and eight articles utilized interventions oftentimes categorized as milieu teaching procedures, such as the mand-model procedure (n = 2), time delay (n = 2), and incidental teaching (n = 4) (11 articles; 61%). In four articles, authors reported using a combination of naturalistic strategies (e.g., arrange environment, a variation in time delay) to promote early verbal communication. These strategies oftentimes include responsive interaction strategies, which are typically considered foundational practices for implementing more involved teaching procedures. In the remaining articles, authors reported that pivotal response training (n = 2), naturalistic language paradigm (n = 2; considered an early variation of pivotal response training), or a naturalistic language intervention (based on commonly used practices in the literature for arranging naturalistic instructional trials; cf. Lane et al., 2016a) were used to promote early verbal communication (n = 1). Refer to online supplemental Table S2 for child-level information.

Research Question 2

Methodological rigor

Rigor was evaluated in a total of 23 studies across 16 articles (see Table 1). Of the 23 studies, one study met all criteria for rigor with no additional confounds identified. Two or more threats to internal validity were identified in 78.3% of studies (n = 18), with only one threat identified in four studies. The most common threats to internal validity were missing, inadequate collection, or unclear reporting of procedural fidelity data (91.3% of studies; n = 21) and IOA (65.2%; n = 15). A total of 13% of studies (n = 3) had fewer than three attempts to demonstrate the effectiveness of the intervention at three different points in time. In contrast, all studies (N = 23) had at least three data points in each condition. Also, contemporary guidelines for multiple probe designs were reviewed in nine studies, with 44% of those studies (n = 4) meeting the criteria outlined for such designs. Finally, additional confounds were considered and reviewed (e.g., potential covariation in an untreated tier), with one or more confounds identified in 43.5% of studies (n = 10).

Table 1.

Methodological Rigor in Identified Studies.

First author (design)	IOA	PF	3+ attempts	3+ data points	MPD criteria	Confounds	Criteria met	FR
Rigor Data at the Child Level
Christensen-Sandfort-1 (MB)	N^a	N^a	Y	Y
Christensen-Sandfort-2 (MB)	N^a	N^a	Y	Y
Coogle (MP)	Y	N^a	Y	Y	Y
D’Agostino-1 (MP)	Y	N^a	Y	Y	Y	Y
D’Agostino-2 (MP)	Y	N^a	Y	Y	Y	Y
Gianoumis (MB)	Y	N^a	Y	Y
Halle-1 (MB)	—	—	Y	Y
Halle-2 (MB)	—	—	Y	Y
Hart (WD) (Group)	—	—	N	Y
Hemmeter-1 (MP)	N^a	N^a	Y	Y	N
Hemmeter-2 (MP)	N^a	N^a	Y	Y	N
Kaczmarek (MP)	Y	N	Y	Y	N	Y
Lane (MP)	Y	Y	Y	Y	Y		Y	Y
McGee (MB)	N^a	—	Y	Y
Rogers-Warren (MB)	—	—	Y	Y		Y
McNerney (NCMB)	Y	N	Y	Y		Y
Seiverling (MB)	Y	Y	Y	Y		Y
Sigafoos-1 (MP) (Group)	N^a	—	N	Y	N
Sigafoos-2 (MP) (Group)	N^a	—	N	Y	N
Smith-1 (MB)	N^a	—	Y	Y		Y
Smith-2 (MB)	N^a	—	Y	Y		Y
Warren-1 (MB)	N^a	—	Y	Y		Y
Warren-2 (MB)	N^a	—	Y	Y		Y
Rigor Data at the Adult Level
Coogle (MP)	Y	N^a	Y	Y	Y
D’Agostino-1 (MP)	Y	N^a	Y	Y	Y	Y
D’Agostino-2 (MP)	Y	N^a	Y	Y	Y	Y
Gianomous (MB)	Y	N^a	Y	Y
Halle-1 (MB)	—	—	Y	Y
Halle-2 (MB)	—	—	Y	Y
Haring (MB)	—	—	Y	Y		Y
Harjusola-Webb (MB)	Y	—	Y	Y		Y
Schwartz (MB)	N^a	—	Y	Y
McNerney (NCMB)	Y	N	Y	Y		Y
Seiverling (MB)	Y	Y	Y	Y			Y	Y
Sigafoos (MP)	N^a	—	N	Y	N	Y
Warren-1 (MB)	N^a	—	Y	Y		Y
Warren-2 (MB)	N^a	—	Y	Y		Y
Warren-3 (MB)	N^a	—	Y	Y		Y

Note. Articles that included multiple designs are designated using the first author’s surname followed by a number. Dashes indicate that IOA and PF data were not collected. The experimental design is recorded in parentheses. The term Group indicates the case was a group of children. IOA = interobserver agreement; PF = procedural fidelity; 3+ attempts = at least three attempts to demonstrate the effectiveness of the intervention at three different points in time; 3+ data points = at least three data points were collected in each condition; MB = multiple baseline design; MP = multiple probe design; NCMB = non-concurrent multiple baseline design; FR = functional relation; Y = Yes; N = No.

Designates inadequate collection of IOA or PF data across each condition and participant (extent to which PF data were collected was unclear or did not meet the designated threshold).

Child-outcome data

A functional relation was evaluated in 1 of 23 studies. A functional relation was not evaluated in other studies due to recommendations that indicate a gating system be used in which reviewers first evaluate the internal validity of a study to ensure appropriate standards are met, then evaluate a study’s outcomes (e.g., Barton et al., 2018a). Lane et al. (2016b) evaluated a naturalistic language intervention in a public preschool classroom with children with disabilities, including children with ASD or those with a disability and comorbid social communication delays. Each child was taught five individualized targets in a one-to-one arrangement consisting of the classroom teacher and a child during play-based activities at centers; child-preferred materials were rotated during sessions with two opportunities per instructional target planned per session. Three children were taught action words (e.g., drive), and one child was taught two-word phrases (e.g., race cars). The focus of this study was promoting independent communication, meaning the adult arranged the environment during play (e.g., during turn-taking with a toy, the teacher paused) and provided children an opportunity to independently communicate requests. Following each independent or prompted response, the teacher expanded on the child’s word or phrase by modeling an expanded form of communication (e.g., drive car; give me race cars). In addition, some children began to use expanded requests independently during sessions, as well as spontaneously use words and phrases during play. Three children also displayed increased levels of commenting, which was not directly targeted during the intervention. Visual inspection of the data indicated the presence of a functional relation.

Research Question 3

Adult characteristics

Across the 19 articles, at least 57 adults were trained to implement a naturalistic language intervention with children. Two articles did not specifically report the number of adults who participated in the studies. In 18 articles, lead teachers, assistant teachers, or related classroom support staff (e.g., school employees who supported children in the classroom a few days per week) implemented the intervention. Similar to the description of children in studies, race and ethnicity were reported in a few studies. The age range of adult implementers was 21 to 51 years of age, with the majority of implementers in their 20’s; 12 articles did not report this information. The highest-level of education was reported in 10 articles, with at least six adults receiving training at the bachelor’s level and four at the master’s level. Years of teaching experience were reported in 12 articles and ranged from less than 1 year to 30 years. If this information was reported, it was oftentimes reported as a range of experience across the adults.

Adult training

At the article level, 14 of 19 articles specifically reported how adults were trained to implement interventions. In 13 articles, the content was introduced by having the implementers review content independently prior to a meeting (n = 2), an asynchronous online training (n = 2), or included as part of live trainings covering specific interventions (n = 9). Multiple articles included reports that during these initial trainings that modeling, practice/role-playing, and feedback were utilized. Once the intervention started, a variety of strategies were utilized to promote continued use of interventions, including prompting and immediate feedback by a researcher using bug-in-ear technology or live in the classroom, daily written feedback, post-session feedback, or delayed feedback provided at a later date during meetings. Across articles, authors reported more details regarding pre-intervention training practices and less information after the intervention condition had begun. In one article, all training and related content focused on self-instruction, with no prompts or feedback. The remaining articles indicated the adults were trained by the research team (n = 2; 11%) or did not specify, other than indicating teachers implemented the intervention (n = 3; 17%). Refer to online supplemental Table S3 for adult-level information.

Methodological rigor

Educators’ fidelity of implementation was evaluated in 15 identified studies (within 11 articles), with one study meeting all criteria with no confounds present (see Table 1). Again, the most common threats to internal validity were missing, inadequate collection, or unclear reporting of procedural fidelity data (93.3% of studies; n = 14) and IOA (53.3%; n = 8). One of 15 studies (6.7%) had less than three attempts to demonstrate the effectiveness of the intervention at three different points in time. All studies (N = 15) had at least three data points in each condition of the study. Three of four studies (75%) that used a multiple probe design met the additional guidelines for rigor. Finally, additional confounds were present in 60% of studies that evaluated training teachers to implement a language intervention in typical contexts (n = 9).

Adult outcome data

A functional relation was evaluated in 1 of 15 studies. As noted previously, a functional relation was not evaluated in other studies due to limited confidence in findings due to one or more threats to internal validity being present in a study or the presence of additional confounding factors. Seiverling et al. (2010) trained assistant teachers and other classroom staff to implement the naturalistic language paradigm with 3- to 4-year-old children with ASD. The training consisted of a general overview of procedures, initial feedback of each adult’s baseline-level of performance with the intervention, multiple sessions that included modeling, role-playing with the research team, and specific performance feedback provided at the next practice session (after each session, the research team reviewed a video and incorporated that feedback into the next session). The primary dependent variable in this study was each educator’s correct implementation of setting up the room for instruction (e.g., material arrangement, positioning) and the task analysis for implementing the natural language paradigm, which consisted of 14 potential steps during an instructional opportunity, or trial. Variations in the behavior chain were based on the child’s response (e.g., requiring a verbal prompt). Visual inspection of the data indicated the presence of a functional relation.

Research Question 4

We were unable to answer this research question due to the limited number of studies meeting all criteria to be evaluated for a functional relation. Only one study in our review met all criteria with no additional confounds to be evaluated for a functional relation between (a) a naturalistic language intervention and children’s communication outcomes and (b) training practices and educators’ fidelity with a naturalistic language intervention.

Discussion

The purpose of this review was to identify and evaluate experimental studies that focused on educators’ use of naturalistic language interventions during play-based activities at school to promote verbal social communication in preschool and elementary-age children with or at risk for disabilities. We identified 38 single-case demonstration designs within 19 peer-reviewed articles that were published in English. Our findings offer a much-needed perspective when viewed alongside prior reviews examining naturalistic language interventions for addressing children’s social communication needs. Kong and Carta (2011) conducted a review of responsive interaction strategies for children with developmental delays and identified only one article conducted in school classrooms (Yoder et al., 1995). Lane et al. (2016a) conducted a review to identify common components of naturalistic language interventions in studies that included children with ASD, and similar to Kong and Carta, the authors identified only one study conducted in schools while all others were conducted in clinical settings or children’s homes (Christensen-Sandfort & Whinnery, 2013). These prior reviews suggest that minimal research on naturalistic language interventions has been conducted in school-based settings; however, our findings suggest that there is a developing body of research.

Implications

Given the methodological limitations of nearly all the studies we identified, we are cautious in making any broad claims about the effectiveness or ineffectiveness of using naturalistic language interventions in school settings. After comparing studies against contemporary guidelines for methodological rigor, we identified only one study that reported improvements in child-outcome data (Lane et al., 2016b) and only one study that demonstrated improvements in an educator’s implementation of a naturalistic language intervention (Seiverling et al., 2010). We revisit the issues surrounding rigor in the Methodological Challenges section. In addition to issues with rigor, the variation in conditions under which naturalistic language interventions were implemented further complicates the implications of this body of research. Although we identified 19 articles conducted in school settings, only nine of these were conducted in what we could reliably determine to be publicly funded schools. While similar in some respects, the resources available in publicly funded classrooms may be less than those in tuition-based laboratory preschool environments or related idealized settings (e.g., specialized schools). Given that naturalistic language interventions, as evaluated in the studies we identified, were generally implemented in a 1:1 arrangement for a sustained duration (e.g., 10 min) over multiple days, further consideration is needed regarding the feasibility of providing these interventions with the resources typical of publicly funded classrooms. Furthermore, we identified no articles describing a study conducted in a publicly funded elementary classroom. Given that communication underlies all aspects of successful learning in schools, ideally, an interdisciplinary team would first focus their efforts on ensuring children have a reliable communication system before introducing other instructional goals and objectives. The lack of studies we identified specifically for elementary educators suggests that special education teams may have minimal guidance in their efforts to address elementary-age children’s foundational communication needs.

Methodological Challenges

In terms of how to use this body of research to inform practice, we are unsure given the persistent issues with rigor that we identified. Ultimately, through a methodological lens, our recommendations stress the critical need for researchers to better understand the level of resources required to conduct rigorous single-case studies in school settings with educators providing naturalistic language interventions. In examining the reported rigor of each study as presented in Table 1, dropping the procedural fidelity requirement (which is not part of the WWC guidelines) would only increase the number of studies meeting all other design standards to three of the 23 studies examining child-outcomes and three of the 15 studies examining adult-outcomes. Going further and calculating the percentage of standards that were met by each study reveals that 31 of the 38 studies (81.6%) did not meet at least one third of our proposed standards. At face-value, these findings suggest that there is a critical need to conduct further evaluation studies that adhere to rigorous design standards. However, we think it logical to first consider potential challenges and barriers to conducting experimentally rigorous studies on naturalistic language interventions in school settings with educators. In using the phrase experimentally rigorous, we should note that all studies in our review used single-case designs. Considering that our identified body of research is comprised solely of single-case studies, there are various practices and inherent policies within school settings that may conflict with conducting a rigorous single-case study (see also Locke et al., 2015).

Planning and adaptability in applied research

Perhaps most impactful is the scheduling of resources that permit the occurrence of a study session. Given that the naturalistic language interventions reported in our identified articles were typically implemented in a 1:1 instructional arrangement, it may be necessary for an educator uninvolved with providing the intervention to supervise children during a study session. If this educator is not available, then a study session may not occur on a given day. Even if the educator is present and available, the occurrence of a study session will need to occur during a time in which the implementor can devote their attention to the session. Generally, these times will need to be outside of whole class instruction and mealtimes, and instead, will likely coincide with free-play activities (e.g., centers-based playtimes) to capitalize on the naturalistic aspect of naturalistic language instruction. Unplanned changes to a class’s daily schedule may impact the duration or sequence of daily activities, potentially affecting the occurrence of a study session. Another challenge to conducting school-based research with educators is an implementor’s responsibilities to their job. If an implementor has employer-delegated tasks that need to be completed, then this may take precedence over running a study session.

The impact of these various obstacles to conducting study sessions within a single-case design are compounded when considering that the number of required sessions to conduct a rigorous single-case experiment are generally unknown to the researcher. Rather, iterative decisions are made by a researcher throughout baseline and intervention conditions. Within a baseline condition, sessions should be conducted until data reflects stability or a contra-therapeutic trend. In an intervention condition, sessions should be conducted to permit appropriate determinations about when to terminate or modify an intervention. Throughout both baseline and intervention conditions, it is necessary that adequate reliability data be collected on both the dependent and independent variables; of the 38 studies in our review, 35 did not meet either or both of the reliability design standards. Generally, adequate reliability is considered to be at least 20% of sessions in each condition for each participant, or tier, of a single-case design. Without being able to determine how many sessions need to be conducted, researchers may not be able to allocate resources appropriately to collecting reliability data throughout all conditions of a study. Furthermore, because of unplanned changes in the schedules of school classrooms and responsibilities of educators, it is likely that resources needed by researchers on a daily basis will unexpectedly change. Finally, the methodological limitations of these studies prevented us from answering our fourth research question, as having only two studies meeting our proposed design standards precluded a sufficient sample size to conduct any type of moderator analysis. Although rigor can be modeled through meta-analytic techniques (Gage & Lewis, 2014), our data still lack sufficient variation at the study level to conduct any such analysis.

Future Research

Although methodological challenges were persistent across most studies identified in this review and, as such, necessitate a conservative approach to making recommendations for practice, researchers can and should address such challenges in future studies. Regarding areas for future research, our findings are consistent with those from recent reviews that examined more broadly focused language interventions (Biel et al., 2020; Greenwood et al., 2020). First, more rigorous research is needed in which educators provide interventions to target children’s communication. Relatedly, more implementation data are needed to understand educators’ fidelity in providing communication interventions. Finally, more research is needed to understand how to effectively and efficiently prepare educators to engage in the sustained implementation of communication interventions.

Given the dynamic nature of classrooms and educators’ limited resources related to time and availability, technology-related supports, such as video-based, virtual meeting platforms (e.g., Zoom, Microsoft Teams), or video records of sessions, may be critical for training and coaching educators and monitoring fidelity of implementation. This is especially important if sessions are relatively brief and occur across the day. Utilizing technology as part of a study may address challenges with adequately measuring reliability and fidelity data, which was a common issue in identified studies. Regarding naturalistic language interventions, many of the studies identified in this review and related reviews (e.g., Lane et al., 2016a) involved training families and researchers to use a blend of responsive interaction strategies (e.g., responding to all attempts to communicate by the child; Ledford et al., 2019) and milieu teaching procedures. These strategies and interventions have a long-standing history of promoting early language development in young children in homes and clinical settings. Relatedly, multiple researchers have reported positive outcomes with manualized interventions, like enhanced milieu teaching and pivotal response training, among others (Dawson et al., 2010; Girolametto & Weitzman, 2006; Kaiser & Roberts, 2013; Kasari et al., 2010; Koegel et al., 2002; Wetherby & Woods, 2006). Future studies should consider focusing on translating strategies and interventions implemented in homes and clinical settings into classrooms, with attention to measuring ecological validity (e.g., conducting sessions with multiple children present) and assessing the extent to which outcome data yields positive results for adults and children. Feasibility for researchers and educators is necessary to better understand how we support all children who require naturalistic language interventions.

Limitations

The limitations of this review warrant attention. First, we focused on identifying and evaluating articles published in English; studies not translated to English could have impacted the outcomes of this review. Second, IOA was not collected for 100% of studies when reviewing descriptive information and methodological rigor. Third, our inclusion and exclusion criteria for this review could be considered relatively strict given the focus was on educators in school settings and providing instruction during play-based activities (e.g., with toys or during activities like dramatic play). As discussed previously, our specific setting and implementor focus were intentional and served to fill a gap in the literature that has not been addressed in prior reviews. Similarly, solely examining outcomes targeting verbal social communication in young children with disabilities excludes studies in which AAC may have been targeted. We strongly support encouraging multiple modes of communication, including AAC use; the focus of this review was to better understand a particular aspect of communication in young children (cf., Biggs et al., 2018). Finally, we utilized contemporary guidelines for evaluating rigor, which included WWC guidelines (2017a, 2017b) and rigor recommendations from Ledford et al. (2018b). Traditionally, when used in isolation, WWC guidelines do not include a direct evaluation of procedural fidelity. Thus, we increased the stringency of expectations regarding methodological rigor.

Conclusion

Naturalistic language interventions represent a collection of interventions and strategies designed to help children with or at risk of disabilities reliably learn when and how to meaningfully communicate with others in typical contexts. These interventions and strategies are commonly recommended because when instruction occurs during play and routines, children are more likely to be motivated to communicate about items and activities of interest as well as display generalized improvements in target behaviors. Educators are commonly encouraged to utilize naturalistic language interventions with young children. The findings of this review indicate a need to further develop and refine guidelines for educators by conducting additional rigorous experimental studies to determine how educators can possibly promote verbal social communication in children with more significant needs in school.

Supplemental Material

sj-docx-1-rse-10.1177_07419325221125887 – Supplemental material for Systematic Review of Naturalistic Language Interventions in Schools: Child- and Adult-Level Outcomes for Verbal Communication

Supplemental material, sj-docx-1-rse-10.1177_07419325221125887 for Systematic Review of Naturalistic Language Interventions in Schools: Child- and Adult-Level Outcomes for Verbal Communication by Justin D. Lane, Devin Graley, Collin Shepley and Katherine M. Lynch in Remedial and Special Education

Footnotes

Acknowledgements

The authors thank Kailee Matthews, Amanda Chavez, Rachel Fosnaught, Kaitlin Haggard, Katherine Jordan, Gabrielle Lonnemann, and Elaine Murner for their assistance with this systematic review.

Associate Editor: Eric Common

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Collin Shepley

Supplemental Material

Supplemental material for this article is available on the Remedial and Special Education website with the online version of this article.

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