Speech-Language Pathologists’ Self-Reported Language Input and Recommendations During Early Intervention

Abstract

This study examined the extent to which early intervention (EI) speech-language pathologists (SLPs) use and recommend language input strategies for caregivers of children with language delays and the child factors associated with these decisions. Participants included 213 SLPs who completed an online survey. Wilcoxon signed-rank tests, Friedman’s analyses of variance, and Spearman correlations were used to determine the extent to which EI SLPs used and recommended language input, child factors that influenced recommendations and input, and relationships between SLPs’ self-reported strategies and recommendations to caregivers. EI SLPs reported recommending expanding on child utterances more than other strategies. EI SLPs reported using grammatical input more than telegraphic input and recommended grammatical phrases as children made gains in spoken language. Language strategies used by SLPs inconsistently aligned with their recommendations to caregivers. Results underscore the importance of evaluating recommendations to caregivers in the context of EI.

Keywords

speech-language pathologist survey caregiver recommendations early intervention

Young children with language delays, defined here as difficulty in the acquisition or use of written or spoken language, are at risk of persistent communication deficits, poor academic outcomes, and differences in social–emotional development into school age and adulthood (American Psychiatric Association, 2013; Aro et al., 2014; Preston et al., 2010; Snowling et al., 2000). Language delays are quite common, with as many as two in five children under the age of 5 years presenting with difficulties in language learning (Roberts et al., 2019). Early intervention (EI) is often provided to young children (age birth to 3) who have language delays, which has been shown to benefit articulation, phonology, expressive and receptive language, social communication, and syntax (see Nelson et al., 2006 for a review). Moreover, children with language delays have higher rates of co-occurring behavior problems, mood dysregulation, motor delays, and deficits in joint attention than children without language delays (Bal et al., 2019; Curtis et al., 2019; Mundy et al., 1995; Salo et al., 2018). EI practitioners, therefore, play an essential role in a child’s overall development, and targeting language in particular can have additional downstream effects beyond this individual domain.

However, outcomes are somewhat inconsistent with regard to which domains of language development are most likely to improve during EI. For instance, randomized control trials among children with diverse expressive and receptive language impairments have documented stronger effects of EI on receptive compared with expressive language (Glogowska et al., 2000); others have found effects for specific aspects of expressive language, such as vocabulary (Fricke et al., 2013; Roberts & Kaiser, 2015). It is unclear what factors contribute to this variability in outcomes. For instance, it is possible that aspects of speech-language pathologists’ (SLPs) language input, as well as their recommendations to caregivers, may underlie some of this variability. Therefore, we sought to determine how EI SLPs approach language input in practice and recommendations, as well as the child factors that are associated with clinical decision-making.

Evidence-based practice in speech-language pathology integrates scientific evidence, clinical expertise, and client perspectives (American Speech-Language-Hearing Association, n.d.). In the context of EI, evidence-based practice is highly synthesized such that clinicians implement scientifically based interventions, adjust their practice based on child and contextual factors, and include caregivers’ perspectives during the intervention and when making recommendations. Accordingly, EI is highly individualized; language input and strategies are adapted to best support a child, and the recommendations to caregivers consider the needs of the family in addition to the child. Nevertheless, there are no clear research-based guidelines regarding what exactly should be recommended to caregivers, which leaves lingering questions about best practices. For instance, how imperative is it that SLPs’ strategies are the same as those recommended to caregivers? What do SLPs perceive as the most important and/or effective strategies to teach caregivers during EI? As a first step toward answering these questions, the present study employed a survey among EI SLPs regarding recommendations to caregivers, adjustments to their own language input, the child factors that influence practice and recommendations, and links between practice and recommendations. Such information is essential for both EI research and clinical practice and may help guide clinicians as they support children in language learning.

Caregiver Inclusion in Early Intervention

Young children learn language in their natural environments through play and in the context of everyday routines (Zwaigenbaum et al., 2009). As such, caregiver inclusion in EI is considered essential (Hampton et al., 2017; Roberts & Kaiser, 2011, 2015). Caregivers are uniquely suited to capitalize on incidental teaching opportunities outside of the therapeutic environment, which maximizes language exposure opportunities for the child and increases the likelihood of skill generalization (Carter et al., 2011; Zwaigenbaum et al., 2015). Caregiver-implemented EI programs (e.g., the Hanen Parent Program) are not only cost-effective (Gibbard et al., 2004) but also support child gains in expressive and receptive language as well as social communication (Cable & Domsch, 2011; Curtis et al., 2019; Roberts & Kaiser, 2011).

Evidence-based EI techniques used by SLPs promote engagement, play, and gesture use (Roberts & Kaiser, 2015; Walker et al., 2020). EI SLPs may employ a range of approaches when working with young children such as adjusting the language input used (e.g., modeling particular words or phrases), quantity-based strategies (i.e., varying the amount of language directed to the child), and engagement-based strategies, which incorporate responsive interactions (i.e., modeling language that reflects the child’s focus of attention) as the basis of the intervention (Walker et al., 2020). Roberts and Kaiser (2011) identified four aspects of parent–child interactions that facilitate language development in children: amount of interactions, responsiveness, amount/quality of linguistic input, and use of language learning support strategies. Of these, we were particularly interested in the types of strategies that are recommended to caregivers in terms of the quality of linguistic input. For instance, the use of utterance expansions—adding semantic or syntactic information to a child’s utterance—among parents has been shown to result in gains in child receptive language and expressive vocabulary (Roberts & Kaiser, 2015). Other modifications include simplifying input by shortening utterances (e.g., using two words per utterance) or using specific word combinations (e.g., noun + verb), which is aligned with early-emerging multiword combinations among children (Brown, 1973) and are commonly employed among SLPs. However, there is minimal research on the kinds of strategies that are recommended to caregivers by SLPs during the course of EI compared with those strategies evaluated in intervention studies.

SLPs’ recommendations to caregivers regarding language modification strategies may influence the effectiveness of EI, although the extent of this influence is not entirely clear. Differences in post-intervention child outcomes may vary by the quantity of caregiver training to maximize the effectiveness of an intervention (Dawson et al., 2010; Rogers et al., 2012) or the inclusion of systematic instruction with accompanying fidelity measurement (Wake et al., 2011). During EI, caregivers benefit primarily from interventionist modeling and coaching (Roberts & Kaiser, 2015). However, it may be quite difficult to implement rigorous, long-term parent training given the need for individualization, appropriate coaching, and monitoring (Roberts & Kaiser, 2015), so it is essential that recommendations provided to parents in short-term contexts be effective.

Language Input Strategies Among SLPs

Adults often simplify their language input when speaking to young children with language impairments. The complexity of such input may take one of two forms, either telegraphic or grammatical. Telegraphic input primarily includes content words, such as nouns and verbs, and removes function words (e.g., articles, prepositions; “Daddy go,” “Doggie hungry”; Brown, 1973; van Kleeck et al., 2010). In contrast, simplified grammatical input maintains the morphosyntactic rules of a language, but the utterances themselves are often shorter than those used in adult interactions (e.g., “Mommy is running”; “I want a toy”).

The extent to which either telegraphic or grammatical input should be used with children who have language delays has been extensively debated (Bredin-Oja & Fey, 2014; van Kleeck et al., 2010), and disagreements remain among experts in the field as to their utility. For example, divergent opinions exist pertaining to how particular language input strategies should be used across contexts (e.g., directives vs. imitation; Bredin-Oja & Fey, 2014; Venker et al., 2019), which diagnostic groups may benefit from either language input strategy (Kaiser & Trent, 2007; Lorang et al., 2020; Venker et al., 2015), and the appropriate use of either strategy as a function of the child’s expressive and receptive language abilities (Kaiser, 1993; van Kleeck et al., 2010; Venker et al., 2020). For instance, the use of telegraphic input for children with particular diagnoses (e.g., ASD) may not be warranted and may even adversely influence child language development (Venker et al., 2015).

Grammatical input is viewed favorably for children with typical development (Hadley et al., 2011, 2018; Hadley, Rispoli, & Holt, 2017; Hsu et al., 2017), and there is evidence to suggest that consistent, repeated examples of grammatically appropriate utterances should be modeled for young children with language delays given their difficulties acquiring and internalizing the “rules” of a language (Eisenberg, 2014; Plante & Gomez, 2018; Sandbank & Yoder, 2016). Importantly, among well-established early interventions (e.g., the Hanen Parent Program and Enhanced Milieu Teaching; Kaiser & Hampton, 2017; Pepper & Weitzman, 2004) clinical recommendations have shifted away from telegraphic input toward grammatical input. In the context of EI, it is not clear whether SLPs tend to use telegraphic or grammatical input, particularly when modeling or coaching caregivers, or whether these choices are dependent on external factors (e.g., child expressive language). No research to date has explored whether SLPs recommend telegraphic or grammatical input to caregivers or the consistency with which particular strategies are recommended. It could be, for example, that inconsistencies between SLPs and caregivers could detract from language learning opportunities for the child. This has potentially far-reaching implications, as 98% of caregivers have reported teaching strategies to their child’s other caregivers (Roberts & Kaiser, 2015). Therefore, documenting the kinds of recommendations SLPs make to caregivers is a first step in understanding the implications of these practices.

Survey data suggest that both telegraphic and grammatical input are endorsed by SLPs who work with children across a diverse age range; however, there is variability in the perceived utility of telegraphic input in particular (Venker et al., 2019, 2020). To investigate the use of and perspectives on telegraphic input among SLPs, Venker and colleagues (2019) surveyed practitioners who worked with a diverse age range of children with language delays. Specifically, most children on the respondents’ caseloads (82%) were school-aged and older. SLPs were asked to respond to questions about their own language input when working with children in the prelinguistic, single-word, or two-word stage of spoken language development, regardless of child age. In response to a question about the extent to which SLPs used telegraphic input, 82% of SLPs reported ever having used telegraphic input when working with a child with language delay, and 62% of SLPs reported using telegraphic input at least “Sometimes.” Of the group of SLPs who had ever used telegraphic input, they were most likely to report using it in the context of prompting for verbal imitation, and also to describe children’s play and facilitate requests. In addition, the survey asked whether it was useful for adults, including parents and clinicians, to use telegraphic input with children with language delays; only 30% of the SLPs who had ever used telegraphic input indicated this strategy was useful. This suggests that there may be certain contexts in which SLPs view simplified, telegraphic language as useful during the intervention, but telegraphic input was not viewed as favorably in the context of teaching caregivers. In addition, SLPs also rated child factors that informed their decision to use particular language input strategies, including receptive and expressive language, cognitive ability, and diagnosis. Of these options, SLPs reported receptive language as most important in decision-making, followed by cognitive ability, and expressive language (Venker et al., 2019). This study reiterated that SLPs believe that language input should be adapted to the child’s needs based on individual factors but should also be consistent with the grammatical structure of the language. However, it was not clear how early interventionists specifically adjust their language input to young children with language delays, as only 18% of respondents included children aged birth to three on their caseloads. Furthermore, previous work focused solely on SLP practices not caregiver recommendations.

Venker and colleagues (2020) evaluated the extent to which SLPs considered telegraphic phrases (e.g., “More cracker”) or grammatical phrases (e.g., “Mommy’s turn”) to sound like something they might say to a child with a language delay at the prelinguistic, single-word, or two-word stage of expressive language development, regardless of child age. As with the prior study, only 18% of respondents worked with children within the birth to three age group. In general, SLPs rated grammatical phrases as more like something they would say to a child with a language delay compared with telegraphic phrases. Among a subgroup of SLPs who felt telegraphic input was useful, respondents rated both telegraphic and grammatical utterances as equally likely to sound like something they would say to a child with a language delay. Furthermore, the subgroup who endorsed telegraphic input as useful was more likely to endorse shorter utterances generally, regardless of whether the utterance was specifically telegraphic or grammatical. This suggests that in some cases, SLPs may attend more to the length of an utterance as opposed to the grammatical quality of the language input. Nonetheless, these practices might differ from those used during EI, as a minority of participants reported working with children in the birth to three age range, and there were no questions about caregiver recommendations.

The Present Study

Prior work has evaluated the use of telegraphic and grammatical input among SLPs generally, without a specific focus on birth to three, EI, or the integration of caregiver recommendations and SLP strategies in this context. It is possible that variability in EI language input, and specifically telegraphic versus grammatical language, may play a role in the success of EI outcomes. To date, however, there is minimal research regarding language input recommendations to caregivers despite the necessity of integrating scientific evidence, clinical expertise, and caregiver input in the provision of evidence-based practice. In this study, we sought to document the language input strategies EI SLPs reported recommending to parents and those used in practice as well as the role of child factors in influencing clinical decision-making.

Research Questions

Building on prior work, our study addressed the following questions regarding clinical practice in the birth to three population:

Research Question 1: What language modification strategies do EI SLPs recommend to caregivers of young children with language delays? Based on prior work on parent-implemented interventions, we predicted that SLPs would be most likely to endorse recommending that caregivers expand on their child’s utterances during play (Roberts & Kaiser, 2015).

Research Question 2: In what ways do EI SLPs report modifying their language input when speaking to children with language delays? Based on prior surveys of telegraphic and grammatical input among SLPs (Venker et al., 2019, 2020), we predicted that SLPs would rate grammatical input more highly than telegraphic input.

Research Question 3: What is the role of child factors in (a) SLPs’ reported recommendations to caregivers and (b) SLPs’ reported language input practices during EI? We predicted that SLPs would report recommending grammatical language to caregivers more often than telegraphic language, particularly for children beyond the prelinguistic stage of expressive language development. We further predicted that receptive language would be rated as the most important child factor in determining language input during EI (Venker et al., 2019).

Research Question 4: To what extent do SLPs’ language input and recommendations to caregivers align? Based on prior work (Venker et al., 2019, 2020), we predicted that reported use of grammatical language input among SLPs would be associated with recommendations that caregivers also use grammatical language when interacting with their young child with a language delay.

Method

Procedures

The present study included an online survey among practicing SLPs regarding their language input strategies and recommendations as well as child factors that influence such decisions. Participants provided informed consent prior to completing the survey. All procedures were reviewed by the Institutional Review Board, and the study was determined to be exempt from full review as no identifying information was collected.

Recruitment

Participants were recruited from five different postings on Facebook groups for SLPs, EI SLPs, medically based SLPs, and by word of mouth. The posts indicated viewers could share the post with other groups or people. Potential respondents were invited to complete the survey if they practiced in the United States and were working with children in the birth to three population. To verify that EI SLPs were respondents, this requirement was listed in the consent form on the first page of the survey; participants had to accept that they consented and met the requirements for participation. In addition, the first question of the survey asked if the participant was an SLP working with children within the birth to three population; if the participant selected “no,” they were routed to the end of the survey. No compensation for participation was provided.

Participants

Three hundred seventy-six SLPs from 47 U.S. states participated in the study. Only SLPs who were actively providing birth to three services (EI SLPs) and completed the survey in its entirety (n =213) were included in the analyses. The average age of SLPs who completed the survey was 35.46 years (SD = 10.32). Respondents reported a range of less than a year to 41 years of experience as an SLP (M = 9.15, SD = 5.00). They reported a median of 4 years as a birth to three provider. Most SLPs (85.0%) reported including parent coaching (i.e., a form of EI where the intervention focuses on helping parents develop their abilities to interact with their child in a way that supports speech and language development) as part of their practice. Hours per week as a birth to three provider ranged considerably from 0.5 to 50 hours (M =23.60, SD = 24.00), with 15 children (aged 0–3 years) as the median caseload. Most providers (65.7%) practiced in a government-funded (e.g., home- or community-based) setting.

Survey

Consistent with best practices in survey development (McCoach et al., 2013; McKenna et al., 2021), content validity was assessed by identifying the purpose of the survey and target group, developing the survey based on prior literature, and consulting with EI SLPs. The purpose of the full survey was to investigate EI SLPs’ language input strategies, recommendations to caregivers, and the use of alternative and augmentative communication (AAC) during EI and was based on previously published studies on telegraphic and grammatical language input among caregivers and SLPs (Venker et al., 2015, 2019, 2020). Prior surveys did not address recommendations provided to caregivers and alignment with self-reported practice among SLPs, and were focused on a broader group of SLPs, not specifically EI SLPs. Previous surveys also included questions specific to the contexts in which grammatical and telegraphic speech were used, as well as opinions among SLPs regarding their use, which were adapted to align with the purpose of the present survey and the target population (EI SLPs).

In the present study, examples of telegraphic and grammatical utterances were based on examples used in prior work, our clinical expertise, and descriptions and examples of telegraphic input used in prior publications (Bredin-Oja & Fey, 2014; Lorang et al., 2020; van Kleeck et al., 2010; Venker et al., 2015, 2019). We also included the same list of child factors that might affect clinical decisions (e.g., cognition and receptive language) as those used in prior work to improve content validity. The novel questions in this survey were designed to elicit responses regarding recommendations to caregivers and augmentative communication (AAC) as well as open-ended responses that could guide future survey development, practice, and research.

The second author generated the initial item pool for inclusion in the survey. The initial survey included 40 items with three primary sections: language input and recommendations, AAC use, and open-ended responses. For the purpose of the present work, the second section regarding AAC is not included although is published elsewhere (Lorang et al., in press). Further drafts of the survey were then developed in conjunction with feedback from five EI SLPs. The final survey consisted of 29 multiple-choice and open-ended questions (see Online Appendix for survey questions). The survey was presented via Qualtrics and took approximately 10 min to complete.

Demographic and background questions

Information was collected regarding participant age, location, years of experience practicing as an SLP, years of experience providing birth to three services, hours per week providing birth to three services, caseload of birth to three clients, and intervention settings. Settings included government-funded home-based programs, clinics, private practice, or others.

Recommended strategies for caregivers

Participants were asked to rate how often they used and recommended that caregivers implement particular strategies to simplify input during play. SLPs were asked to rate how often they recommended the following strategies: expanding on child utterances, modeling specific word combinations, producing utterances with a specific number of words, and simplifying input by shortening utterances. Ratings ranged from Never (1) to Always (5).

Recommended phrases for caregivers

Participants rated the likelihood of recommending a series of phrases to a caregiver during play. Twenty phrases were included that represented both telegraphic and grammatical statements and questions, based on the examples used in the survey by Venker et al. (2020). Only one phrase was duplicated from their survey (i.e., Where is it?), and all others were unique to this study. Examples of telegraphic phrases include “Read book” and “Where it go?” Examples of grammatical phrases include “Put the block on top” and “Where is it?” Participants rated their likelihood of recommending/using these phrases with a child according to the child’s expressive language ability (i.e., not yet saying words, single words, and two-word phrases). The scale was ranked from Extremely Unlikely (1) to Extremely Likely (5).

Use of simplified input among SLPs

Participants rated the extent to which they used particular language input strategies when working with birth to three clients with a language delay. Seven questions were asked pertaining to the use of telegraphic input, shortening and simplifying utterances, and grammatical input. To avoid any misinterpretation of the term “telegraphic input” during survey administration, questions were instead worded to refer to the removal of grammatical markings (e.g., articles). However, for ease of interpretation, further discussion of these particular questions will use the term telegraphic input. Answers were rated on a scale of Never (1) to Always (5).

Importance of child characteristics in determination of language strategy use among SLPs

SLPs were asked to rate the importance of child characteristics in determining the type of language input used. Child characteristics included expressive language ability, receptive language ability, cognitive ability, diagnosis, and chronological age. Response options ranged from Not Important (1) to Very Important (4).

Open-ended questions

The survey included three open-ended questions to allow SLPs to elaborate on the above responses. The first pertained to strategies used by EI SLPs that were not included in the survey and stated, “Are there any strategies you use that are not specified above? If so, please explain.” Second, we asked “Do you think it is important to speak to children using utterances that are grammatically correct? Please explain.” The third question stated, “Please explain what specific child characteristics influence the quality and quantity of input that you use with a child.” Two coders (first and second author) individually identified themes described by SLPs in response to these questions. For strategy use, coders overlapped in thematic identification for 16 (66.7%) of 24 categories. For the importance of grammar, similar thematic identification emerged for 7 (53.8%) of 13 categories. Regarding child factors, overlap was 11 (68.8%) of 16 categories. All categories that did not overlap were then consensus coded to establish the final themes used for descriptive analyses. Importantly, SLPs could report more than one answer for each open-ended question. For example, regarding child characteristics, a respondent could state that both child language ability and motor skills influenced their decisions.

Analyses

All statistics were performed in IBM SPSS statistics, version 26 (IBM Corp., 2019). We conducted nonparametric statistics given that answers to the survey were ranked and thus categorical in nature. Research Questions 1, 2, and 3 were analyzed using Friedman’s analyses of variance (ANOVAs), with post hoc analyses of within-participant scores using Wilcoxon signed-rank tests. Qualitative analyses were used to assess themes identified by SLPs in response to open-ended questions. To address Research Question 4, we conducted Spearman correlations to examine associations between the strategies used by SLPs and the phrases they recommended to caregivers based on the child’s expressive language ability.

To correct for multiple comparisons, we adjusted p values consistent with Holm-Bonferroni sequential corrections (Holm, 1979), in which α was set at p < .050, and all p-values from a given analysis were rank-ordered. Adjusted p values were then computed using the Holm-Bonferroni Sequential Correction Excel calculator (Gaetano, 2013) to control for family-wise error rates.

Results

Research Question 1: What Language Modification Strategies Do EI SLPs Recommend to Caregivers?

EI language input strategies that were recommended to caregivers included expanding on the child’s utterances (i.e., if the child says one word, then add another word), modeling specific word combinations (e.g., noun + verb), using a specific number of words per utterance, and shortening utterances. Ninety-four percent of respondents reported recommending expansions “Often” or “Always.” Eighty-five percent of SLPs endorsed modeling specific word combinations “Often” or “Always.” Sixty-one percent of EI SLPs reported recommending using a specific number of words “Often” or “Always,” and only 22% of SLPs recommended shortening utterances “Often” or “Always.”

A Friedman’s test revealed a significant effect of strategy type on SLPs’ ratings, χ²(3) = 318.77, p < .001. Follow-up tests showed that EI SLPs were significantly more likely to report recommending expanding on the child’s utterances than any other strategy (z-values >−4.85, p values < .001). Modeling specific word combinations was significantly more likely to be recommended than using a specific number of words per utterance (z = −6.90, p < .001) or shortening utterances (z = −10.65, p < .001). Using a specific number of words per utterance was rated significantly more highly than shortening utterances (z = −8.53, p < .001). See Table 1 for additional details.

Table 1.

Language Input Strategy Recommendations to Caregivers.

	1	2	3	4	5
How often do you use or recommend the following strategies during play?	Never, % (n)	Rarely, % (n)	Sometimes, % (n)	Often, % (n)	Always, % (n)
(a) If the child says one word, use that word and add another word.^b,c,d	0.00% (0)	0.00% (0)	5.20% (11)	58.00% (123)	36.80% (78)
(b) Model specific word combinations (e.g., noun + verb).^a,c,d	0.00% (0)	3.30% (7)	11.70% (25)	59.60% (127)	25.40% (54)
(c) Use a specific number of words per utterance.^a,b,d	0.50% (1)	7.50% (16)	30.50% (65)	47.90% (102)	13.60% (29)
(d) Rather than using a specific strategy, focus more generally on shortening utterances.^a,b,c	3.30% (7)	27.40% (58)	46.70% (99)	19.30% (41)	3.30% (7)

Note. The options are listed as presented within the survey; however, for the purposes of this study, we use the term “expansions” to denote the first option (i.e., if the child says one word, use that word and add another word). Different superscripts denote significantly different ranked scores (p < .050).

Research Question 2: In What Ways Do SLPs Report Modifying Their Language Input When Speaking to Children With Language Delays?

Regarding language input modifications reported by EI SLPS, 82.1% endorsed shortening their utterances (in general) and 80.2% reported shortening their utterances while retaining grammaticality either “Often” or “Always.” This was followed by 75.6% of SLPs who reported simplifying their input (in general) and 72.7% of SLPs who reported using grammatical utterances (in general) “Often” or “Always.” The use of telegraphic input to help children learn to use more words or to help children process what was being said was endorsed “Often” or “Always” by 31.5% and 33% of SLPs, respectively. See Table 2 for detailed responses.

Table 2.

SLPs’ Reported Use of Telegraphic and Grammatical Input.

When speaking to a young child with a language delay, do you use. . .	1	2	3	4	5
	Never, % (n)	Rarely, % (n)	Sometimes, % (n)	Often, % (n)	Always, % (n)
(a) Simplified input?^c,d,f	0.00% (0)	2.30% (5)	22.10% (47)	50.70% (108)	24.90% (53)
(b) Grammatical utterances?^c,d,e,f	0.00% (0)	2.30% (5)	24.90% (53)	50.20% (107)	22.50% (48)
(c) Remove function words (e.g., articles) to help the child learn to use more words?^{^, a,b,e,f}	6.10% (13)	24.90% (53)	37.60% (80)	28.20% (60)	3.30% (7)
(d) Remove functions words (e.g., articles) to help the child process what is being said?^{^,a,b,e,f}	5.70% (12)	23.10% (49)	38.20% (81)	29.20% (62)	3.80% (8)
(e) Shorten your utterances?^b,c,d	0.00% (0)	1.90% (4)	16.00% (34)	56.30% (120)	25.80% (55)
(f) Make sure that shortened utterances remain grammatical?^a,b,c,d	0.00% (0)	0.90% (2)	18.90% (40)	47.20% (100)	33.00% (70)

Note. Different superscripts denote significantly different ranked scores (p < .050).

In the context of this study, removing function words is interpreted as telegraphic input.

A Friedman’s test revealed a significant effect of language modification type on SLPs’ ratings χ²(5) = 344.23, p < .001. Follow-up tests indicated that shortening utterances while retaining grammaticality was endorsed significantly higher than all other options (z-values > 1.99, p -values < .047) except for generally shortening utterances (z = .97, p=.330). Generally shortening utterances was significantly more highly ranked than grammatical utterances (z = 1.97, p = .049) and telegraphic input (z-values > 10.55, p values <.001). Grammatical utterances did not significantly differ from simplified input (z = −.63, p=.529) but both were rated higher than telegraphic input (z-values > −8.14, p values < .001).

Research Question 3a: What Is the Role of Child Factors in SLPs’ Reported Recommendations to Caregivers?

We examined the likelihood of SLPs’ recommendations of telegraphic and grammatical phrases according to child expressive language (i.e., prelinguistic-, single-, and two-word stages). A significantly higher proportion of SLPs reported recommending telegraphic phrases for children at the prelinguistic stage compared with children who spoke in single words (p < .001) or two-word utterances (p < .001; see Supplementary Materials, Table 1). Conversely, a significantly higher proportion of EI SLPs reported recommending grammatical phrases when the child spoke in two-word utterances, as compared with children speaking with single words (p<.001) or those in the prelinguistic stage (p < .001).

Based on the findings from Research Question 1, which indicate that SLPs report recommending expansions more often than any other strategy, we sought to assess the extent to which expansions were associated with SLPs’ reported recommendations of grammatical and telegraphic phrases. We completed Spearman correlations to examine these relationships. A significant association emerged between expansions and grammatical phrases (r_s = .14, p = .047), indicating that the recommendations of expansions to caregivers are likely to be grammatical in their construction. No significant association emerged between recommendations of expansions and telegraphic phrases (r_s = .003, p =.964).

Research Question 3b: What Is the Role of Child Factors in SLPs’ Language Input Practices During EI?

Child factors included expressive language, receptive language, cognition, chronological age, and diagnosis. Ninety-six percent of respondents endorsed receptive language as either “Moderately Important” or “Very Important.” Cognitive ability and expressive language were rated as either “Moderately Important” or “Very Important” by 89.4% and 86.4% of SLPs, respectively. Chronological age and diagnosis were rated as either “Moderately Important” or “Very Important” by 50.0% and 49.8% of respondents, respectively.

A Friedman’s test revealed a significant effect of child characteristics on SLPs’ ratings χ²(4) = 377.85, p < .001. Consistent with our prediction, follow-up tests showed that receptive language was significantly more important than expressive language, cognitive ability, diagnosis, and chronological age when determining language input (p values <.001). Expressive language and cognitive ability were rated as significantly more important than diagnosis (p values <.001) and chronological age (p values <.001). Diagnosis and chronological age did not significantly differ in their ratings (p = .478). See Table 3 for additional information.

Table 3.

Child Factors That Influence SLP Language Input.

When determining what type of language input to use with a child, in your opinion, how important are the following child characteristics?	1	2	3	4
	Not Important % (n)	Slightly Important % (n)	Moderately Important % (n)	Very Important % (n)
(a) Expressive language ability^b,d,e	1.00% (2)	12.6% (25)	29.80% (59)	56.60% (112)
(b) Receptive language ability^a,c,d,e	0.50% (1)	3.00% (6)	14.60% (29)	81.90% (163)
(c) Cognitive ability or mental age^b,d,e	1.50% (3)	9.10% (18)	23.20% (46)	66.20% (131)
(d) Diagnosis^a,b,c	9.50% (19)	40.70% (81)	35.70% (71)	14.10% (28)
(e) Chronological age^a,b,c	13.60% (27)	36.40% (72)	35.40% (70)	14.60% (29)

Note. Different superscripts denote significantly different ranked scores (p<.050).

Research Question 4: To What Extent Do SLPs’ Language Input Practices and Recommendations Align?

We examined associations between SLPs’ reported language input during EI and their reported caregiver recommendations. Higher ratings for grammatical language input among SLPs were significantly positively associated with their reported recommendations of telegraphic phrases for children at all expressive language stages (i.e., prelinguistic-, single-, and two-word utterances; see Table 4a), with small to medium effects. Contrary to our expectations, as SLPs’ ratings of simplified or telegraphic input decreased, telegraphic phrases were significantly more likely to be recommended to caregivers.

Table 4.

Associations Between SLP Language Input Strategy and Recommendations by (a) Telegraphic and (b) Grammatical Phrases.

When speaking to a child with language delay do you use. . .	Not yet saying words consistently	Single words	Two-word utterances
(a) Ratings for recommending telegraphic phrases
(1) Simplified input?	−.16*	−.17	−.22**
(2) Grammatical utterances?	.28**	.26**	.27**
(3) Remove function words to help the child learn to use more words?^a	−.44**	−.38**	−.46**
(4) Remove functions words to help the child process?^a	−.39**	−.36**	−.43**
(5) Shorten your utterances?	−.11	−.08	−.17*
(6) Make sure that shortened utterances remain grammatical?	.27**	.17*	.27**
(b) Ratings for recommending grammatical input
(1) Simplified input?	−.18*	−.13	−.08
(2) Grammatical utterances?	.17	.09	.07
(3) Remove function words to help the child learn to use more words?^a	−.29**	−.30**	−.19**
(4) Remove functions words to help the child process?^a	−.34**	−.31**	−.13
(5) Shorten your utterances?	−.18*	−.13	−.03
(6) Make sure that shortened utterances remain grammatical?	.13	.12	.17

Note. The table represents Spearman correlations between language input strategies among SLPs and the specific kinds of phrases recommended to caregivers. Values represent r_s coefficients.

In the context of this study, removing function words is interpreted as telegraphic input. See Online Appendix for all telegraphic and grammatical phrases.

Adjusted p < .050. **Represents Holm-Bonferroni-adjusted p values < .010.

Consistent negative associations were observed between recommendations for grammatical phrases and telegraphic language input for children in the prelinguistic and single-word stages of expressive language (see Table 4b). For children not yet saying words consistently or using single words, lower ratings of using telegraphic input to help children process were significantly associated with a greater likelihood of recommending grammatical phrases, but this was not the case for children using two-word utterances. For all children, lower ratings of using telegraphic input to help children learn to use more words were significantly associated with a greater likelihood of recommending grammatical phrases, with small to medium effects. Together, these findings suggest some differences between SLP strategy use and recommendations to caregivers.

Open-Ended Responses

We asked open-ended questions to gain further insight into EI SLPs’ language input strategies and recommendations. Respondents could include a list of more than one theme in response to each open-ended question; percentages reflect those SLPs who reported a given theme out of the total respondents. Seventy-eight SLPs answered an open-ended question regarding other strategies recommended to caregivers (Research Question 1). Of the 15 themes identified, the most prevalent themes that emerged from these responses were gestures and nonverbal cues (28.2%), modeling (23.1%), auditory strategies (e.g., repetition, bombardment; 21.8%), and joint attention/social strategies (17.9%). One hundred forty-seven SLPs answered an open-ended question regarding the importance of grammatical utterances (Research Question 2). For those who indicated that using grammatically correct utterances was important, six themes emerged. The most common reason was that grammatical utterances are better models for language (33.3%), followed by the notion that it is possible to simplify utterances while maintaining grammaticality (23.1%). Four themes emerged among respondents who indicated that it is not important to maintain grammaticality. The most common themes were that grammar does not help imitation (14.2%) and that the use of grammar at that age (birth to three) is not aligned with child development (8.8%). More than a quarter of respondents (27.2%) indicated that whether or not grammatical utterances were used depended on the child and context. One hundred eighteen respondents described child factors that influence language input (Research Question 3), and 10 themes emerged. Consistent with questions from the survey, the most commonly reported child factors were receptive (50%) and expressive (39%) language. However, other themes emerged such as social skills/engagement (27.1%) and developmental considerations (e.g., motor abilities, sensory difficulties; 17.8%). See Supplementary Materials, Table 2 for descriptive information on SLP responses.

Discussion

This study documented EI SLPs’ language input and recommendations to caregivers during EI, child factors that may influence practice, and associations between SLP strategy use and those recommended to caregivers. EI SLPs recommended that caregivers expand on child utterances more than any other strategy, which was associated with reported recommendations of grammatical phrases to caregivers. SLPs were more likely to report recommending grammatical phrases to caregivers compared with telegraphic phrases, particularly as children made gains in expressive language. Consistent with prior work (Venker et al., 2019), EI SLPs were significantly more likely to report using grammatical rather than telegraphic input. Child receptive language was identified as the most important child factor for determining language input among EI SLPs. Furthermore, the type of language input reportedly used by SLPs did not always align with their recommendations to caregivers, specifically with regard to recommendations of telegraphic input, and differed according to child expressive language ability. These findings suggest that some EI SLPs may not frequently include telegraphic input in their own practice but that they may view it as an effective strategy to teach caregivers.

Recommended Language Modification Strategies

Our first question concerned the language input strategies that SLPs reported recommending to caregivers. Consistent with our predictions, SLPs reported recommending expansions more than any other strategy. The use of expansions is an evidence-based strategy employed among well-known intervention programs (e.g., enhanced milieu teaching, Hanen) that has been shown to effectively support expressive language development (Conway et al., 2018; Kaiser, 1993; Levickis et al., 2014; Masur et al., 2005; Pepper & Weitzman, 2004). When an SLP or caregiver expands a child’s utterance, this could entail the construction of either telegraphic or grammatical utterances. For instance, an expansion of a child’s use of “Doggie” could become “Doggie run” (telegraphic), rather than “The doggie runs” (grammatical). Our findings suggest that recommendations of expansions were associated with a greater likelihood of recommending grammatical phrases to all children. Because the strength of this relationship was weak, however, this finding suggests future research is needed to facilitate evidence-based grammatical modeling to caregivers. In particular, further attention should be given to whether SLPs recommend expansions by providing grammatical models or instead simply expand without consideration of grammaticality. Prior work suggests that caregivers’ use of grammatical forms is significantly positively associated with their children’s use of those forms (Rüter, 2011), indicating that this approach may be an effective tool for grammatical language development.

Importantly, other strategies were endorsed by SLPs that were not formally included in the survey. Namely, the use of gestures, modeling, auditory-based strategies (e.g., bombardment, repetition), and joint attention/social engagement were among those tactics utilized by SLPs in addition to the strategies we included in the survey. The wide variety of approaches used by SLPs underscores how important flexible interventions and individualized factors are to guiding EI. Given that all EI providers, including caregivers, communicate with the child, a shared understanding of the factors associated with clinical decision-making could improve practice across disciplines. Moreover, many of the endorsed strategies apply to other EI practices as well (e.g., occupational therapy), so clinicians from multiple disciplines may benefit from sharing common strategies across providers to encourage carryover.

Language Input Modifications Among SLPs

Second, we evaluated the extent to which EI SLPs used particular language input strategies for young children with language delays. Aligned with our predictions, we found that SLPs were most likely to report using shortened, grammatical utterances during EI, as compared with simplified or telegraphic input. The lowest ratings were given to the use of telegraphic input to help children use or process language. These findings indicate alignment with proponents of grammatical input, who argue that optimal language models for children with language impairments are those that maintain grammaticality, which may be of particular importance as very young children are acquiring spoken language (Eisenberg, 2014; Kamhi, 2014). However, just over 30% of SLPs endorsed the use of telegraphic input “Often” or “Always,” suggesting variability in EI practice among SLPs. Responses to open-ended questions indicated that some SLPs use telegraphic input with the intention to meet the child where they are, keep children engaged, or to help a child learn content words more effectively. Using telegraphic input in this way is not empirically well-supported (Bredin-Oja & Fey, 2014; van Kleeck et al., 2010), although some SLPs may believe it is effective in particular clinical circumstances, such as when prompting a child to produce a verbal imitation (Venker et al., 2019). Further research should continue to investigate the effects of telegraphic input to extend evidence-based practice.

Influence of Child Factors on Recommendations and SLP Input

Our third question explored the extent to which certain phrase types (telegraphic vs. grammatical) were recommended to caregivers based on child expressive language ability. We predicted that SLPs would report recommending grammatical language to caregivers more often than telegraphic language, particularly for children beyond the prelinguistic stage of expressive language development. Aligned with our hypothesis, for children speaking in two-word phrases, SLPs were significantly more likely to indicate recommending grammatical phrases compared with telegraphic phrases. Contrary to our prediction, however, the lowest ratings for the likelihood of recommending grammatical phrases was for children at the single-word utterance stage of expressive language development and not the prelinguistic stage. However, SLPs reported recommending telegraphic phrases more highly than grammatical phrases for prelinguistic children. It may be that some SLPs recommend telegraphic phrases to caregivers of children at the single word level to focus on utterance length. Prior work from Venker et al. (2020) suggests that in practice, some SLPs reported focusing more on the length of the utterance rather than the grammaticality of the utterance per se, so it is possible that this applies to recommendations as well. Based on the open-ended responses, more than a quarter of SLPs indicated that the use of grammatical or telegraphic utterances depended on the child. Descriptively, many of these responses indicated considerations specifically about the child’s expressive language level and age. Furthermore, SLPs who endorsed the use of telegraphic language in their open-ended responses did so in an attempt to promote imitation and to be better aligned with child developmental stages. This is consistent with Venker et al.’s (2019) findings that context may determine how likely SLPs are to use telegraphic input. Findings from the present study suggest that recommendations to caregivers may be, in part, dependent on child expressive language and contextual factors, and it will be important for practitioners and researchers to consider how language input is used and recommended as children progress through EI.

Consistent with our prediction, we also found that EI SLPs endorsed child receptive language as the most important factor in determining language input modifications during EI, similar to prior work from diverse age cohorts (Venker et al., 2019). SLPs may report adjusting their language input based on child receptive language given that young children with and without language impairments are likely to understand more words than they can produce (Benedict, 1979; Davidson & Ellis Weismer, 2017; Luyster et al., 2008; McDaniel et al., 2018). Interestingly, however, child expressive language appeared to influence the kinds of recommendations given to caregivers, although it must be noted that the survey questions were not structured to probe child receptive language in the same way. Furthermore, the open-ended responses indicated that other factors, such as social engagement and developmental abilities, also play a role in clinical decision-making. It is essential that SLPs take such other factors (besides language) into account when developing intervention strategies, as there are links between language development and joint attention, motor skills, and behavioral problems (Bal et al., 2019; Curtis et al., 2019; Mundy et al., 1995; Salo et al., 2018; Stone & Yoder, 2001). This has implications for carryover across EI practitioners who may be considering the same factors when developing individualized plans alongside caregivers.

Alignment of Used and Recommended Strategies

Finally, we sought to examine the extent to which language input modifications used by SLPs aligned with their recommendations to caregivers. In contrast with our predictions, we observed significant negative associations between SLPs’ ratings for telegraphic input and their likelihood of recommending telegraphic phrases, regardless of child spoken language ability. That is, for SLPs who had lower ratings for telegraphic input in their own practice, there were higher ratings for recommendations of telegraphic input. In contrast, higher ratings of SLPs’ use of grammatical input were associated with a greater likelihood of recommending telegraphic phrases. For children not yet saying words consistently or using single words, lower ratings of SLPs’ use of telegraphic input were associated with a greater likelihood of recommending grammatical phrases to caregivers. The discrepancies in these findings are somewhat puzzling but may be explained by a few possibilities. First, it is possible that telegraphic and grammatical phrases are somewhat difficult to distinguish, particularly when making a recommendation or when the language is being simplified. For example, if an early interventionist says “Crash blocks” to a child, it could also be modified further to emphasize other aspects of grammaticality, such as “Crash the blocks” or “The blocks crash.” Although these statements are all fairly similar, they may differ in their effectiveness with regards to emphasizing grammatical structures, and could also exemplify different communicative purposes (directive vs. descriptive). Second, it could be that some telegraphic phrases (e.g., Car go) may be easier or simpler to recommend in the context of EI. Indeed, one SLP noted, “I think it’s difficult for parents to simplify language while still keeping utterances grammatically correct. . . even for myself it is difficult.” It may be that reframing recommendations to emphasize “naturalness” (i.e., using language in the same way you would with a typically-developing child) may be an effective approach (Bredin-Oja & Fey, 2014). Finally, evidence from Walker and colleagues (2020) suggests that approximately 75% of early childhood language intervention studies include multiple language input strategies. Indeed, in response to the open-ended questions, EI SLPs endorsed a number of varied strategies that could be recommended to caregivers beyond simply telegraphic or grammatical utterances (e.g., waiting, environmental adjustments, engagement-based approaches, etc.). From an EI perspective more generally, the critical inclusion of caregivers can facilitate more positive interactions, regardless of the strategy used, thus having broader effects than solely on language development (e.g., emotion regulation, reduction in problem behaviors, etc.). For example, Curtis et al. (2019) showed that enhanced milieu training, which entails following the child’s lead during play, had both direct and indirect effects on child problem behaviors. Thus, the importance of including caregivers in the treatment decision-making process (Glogowska & Campbell, 2000) and variability in strategy use may help to explain differences between SLP practice and recommendations and underscores the importance of considering the manner in which language input modifications are recommended to caregivers.

Based on the differences observed between self-reported strategy use and recommendations to caregivers, it is important to reflect on the considerations made by experts in the field concerning telegraphic and grammatical input. van Kleeck and colleagues (2010) presented a synthesis of clinical expertise and a meta-analysis to inform evidence-based practice regarding telegraphic input and to highlight the debate surrounding language input strategies. Among the experts was Jon Miller, who argued in part that a child’s level of comprehension (e.g., receptive language) should motivate adult language input style. This position was contrasted by Ann Kaiser who discussed that child expressive language and cognition should be key factors in determining language input (Kaiser & Trent, 2007; van Kleeck et al., 2010; Willer, 1974). It may be important that SLPs inform caregivers about the debate surrounding the use of grammatical and telegraphic input, even in the context of other strategies, as the manner in which a caregiver models language has ramifications for the child’s development of grammatically complex language (Hadley et al., 2011; Hadley, Rispoli, & Holt, 2017; Hadley, Rispoli, Holt, et al., 2017; Hsu et al., 2017). Such a conversation could provide a fruitful context in which SLPs and parents critically examine how they make joint treatment decisions as well as create a shared understanding of the available evidence for each approach. This will be important to examine in future work to better inform recommendations to caregivers.

Strengths, Limitations, and Future Directions

This study had a number of strengths, including a relatively large sample of SLPs drawn from across the United States and the use of survey questions derived in part from previous work, which enhanced our ability to interpret findings in the context of prior literature. Nonetheless, this study had some limitations. An inherent limitation of survey data is that the reporting may not reflect SLP decision-making in clinical practice. In addition, the inclusion of other factors that could influence clinical decision-making, such as the responses of the child to telegraphic versus grammatical input, might have enhanced the interpretation of these data. Another limitation of this work is that, although we received extensive input from practicing EI SLPs in the development of this survey, we did not include cognitive interviews during survey development, which might have informed survey content (McCoach et al., 2013; McKenna et al., 2021). Furthermore, the phrasing of some of the questions (i.e., “. . .use or recommend”) may have been interpreted differently across providers, which could help explain some of the unexpected findings from this study.

An important next step in this work is to understand why there are some differences between SLP practices and recommendations to caregivers. By understanding these differences, there may be important implications for future research seeking to evaluate the outcomes of EI practices as well as for establishing best-practice guidelines related to caregiver recommendations. Moreover, future work may consider why SLPs choose to use and recommend particular strategies to caregivers. Future studies should also investigate how SLPs use and recommend language input strategies as it relates to child receptive language, as 96% of SLPs considered this child factor to be especially important when determining language input. This study highlights the need to conduct observational studies to evaluate SLP implementation of caregiver recommendations in the context of EI. Delineating the factors that contribute to discrepancies in recommendations is essential for effective parent-mediated EI, and speech and language therapy in general.

Clinical Implications

The findings from this study have implications for clinical use among EI SLPs. First, EI providers should consider whether their beliefs regarding telegraphic versus grammatical input align with the language input they use and recommend to caregivers. Second, EI SLPs should consider how the strategies they use during EI (e.g., expansion and modeling) may lend themselves to telegraphic or grammatical input, and ensure these strategies are used simultaneously with the intended caregiver language models. Third, consistent with the transdisciplinary model of EI (Rapport et al., 2004), it may be useful to have direct conversations with parents about using grammatical or telegraphic input, including the state of research in the field and the pros and cons for each type of input according to SLPs and formal research studies. Finally, findings from the open-ended questions reveal the multitude of possible strategies used by EI providers that may be applicable beyond speech-language intervention. Leveraging these strategies in a transdisciplinary manner could improve carryover and consistency with downstream implications for children.

Conclusion

As a first step toward supporting the scientific evidence base regarding the relationship between EI SLP practice and caregiver recommendations, we focused on the use of telegraphic and grammatical input, and how child factors influence SLPs’ clinical decision-making. Findings from this study demonstrate the importance of including SLPs’ perspectives as a component of evidence-based practice, and the need to continue this line of research to best facilitate language learning in children. We also underscore the necessity of informing caregivers about why SLPs use particular language input techniques, which could guide the development of caregiver-focused strategies in future work.

Supplemental Material

sj-docx-1-jei-10.1177_10538151221086512 – Supplemental material for Speech-Language Pathologists’ Self-Reported Language Input and Recommendations During Early Intervention

Supplemental material, sj-docx-1-jei-10.1177_10538151221086512 for Speech-Language Pathologists’ Self-Reported Language Input and Recommendations During Early Intervention by Nell Maltman, Emily Lorang, Courtney Venker and Audra Sterling in Journal of Early Intervention

Supplemental Material

sj-docx-2-jei-10.1177_10538151221086512 – Supplemental material for Speech-Language Pathologists’ Self-Reported Language Input and Recommendations During Early Intervention

Supplemental material, sj-docx-2-jei-10.1177_10538151221086512 for Speech-Language Pathologists’ Self-Reported Language Input and Recommendations During Early Intervention by Nell Maltman, Emily Lorang, Courtney Venker and Audra Sterling in Journal of Early Intervention

Footnotes

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health under Award Number T32 HD007489 (Hartley) and U54 HD090256 (Chang), and the National Institute on Deafness and Other Communication Disorders under training grant T32 DC005359 (Ellis Weismer). The authors would especially like to thank the participating clinicians. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

ORCID iD

Nell Maltman

Supplemental Material

Supplemental material for this article is available online.

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