Children and Adults Reading Interactively

Abstract

This exploratory Intergenerational Program (IGP) focused on reading to determine whether it affects mood and communication in older adults with mild dementia and neurocognitive deficits, and if it influences school-aged children’s perceptions of older adults over time. Six older adults with cognitive-communication deficits and 12 school-aged children, identified with language and reading concerns, participated for 45 min weekly for 8 weeks in this IGP. The Mini-Mental State Exam, an adult mood and communication questionnaire, and a questionnaire about the children’s perceptions of older adult were administered. No significant findings were obtained from measures of the older adults. Significant findings were obtained for the school-aged children’s perceptions of older adults. Changes in reading behaviors were noted by the teacher and parents. Through observation and comments, the participants indicated mutual enjoyment of this IGP. This IGP is novel because it includes two populations with communication disorders and warrants further investigation.

Keywords

adult age elementary school cognitive impairments exceptionalities language learning disorders reading quantitative designs research speech-language pathologists (SLPs)

The “Profile of Older Americans: 2012” report provides the following statistics. Older adults (65+ years) in the United States numbered 41.4 million in 2011, and this age group is projected to increase to 79.7 million by the year 2040. Currently, approximately one in eight Americans is considered to be an older adult. Of these older adults, approximately 1.3 million live in nursing homes; however, this number increases as the population ages (Administration on Aging, Administration for Community Living, & U.S. Department of Health and Human Services, 2012).

Dementia and Cognitive-Communication Deficits

Brookshire (2007) stated that dementia is the most common diagnosis for residents in nursing homes. Older adults with dementia residing in nursing homes can exhibit mild neurocognitive impairment in areas such as working memory and orientation. The diagnosis of dementia is defined as “a clinical syndrome caused by neurodegeneration and characterized by inexorably progressive deterioration in cognitive ability and capacity for independent living” (Prince et al., 2013, p. 64). Older adults with dementia may require minimal to constant care related to deficits with multiple cognitive processes, communication, physical function, and activities of daily living (Brookshire, 2007). Prince et al. (2013) estimated that worldwide, approximately 65.7 million individuals will be living with dementia by the year 2030. Therefore, it is imperative that health care professionals determine what therapies are most effective and provide the best quality of life for those with dementia.

When an adult undergoes neurocognitive changes, these changes will influence how one is able to communicate. The inability to recall the topic of conversation and shared common knowledge between speakers, difficulty following rapid change of topics in conversation, and problems organizing one’s thoughts are all examples of cognitive-communication deficits that can occur with changes in cognition (Tomoeda & Bayles, 1993). In a 2005 American Speech-Language-Hearing Association (ASHA) Technical Report for the roles of speech-language pathologists (SLPs) working with dementia-based communication disorders, suggestions for intervention of cognitive-communication deficits included “using the less impaired aspects of cognition and communication to facilitate function,” “strengthening knowledge and processes that have the potential to improve,” and “designing therapy that evoke positive responses to increase the likelihood of engagement and learning” (p. 9). In addition to cognitive problems, social isolation can occur if the older adult with dementia resides in a nursing home and has limited interactions or visitations from family members or friends (Holmen, Ericsson, & Winblad, 2000). Krueger et al. (2009) reported that higher levels of social activity and integration have been associated with better cognitive functioning. Therefore, to ensure optimal communication skills, older adults with cognitive deficits can benefit from interactions with other individuals to stimulate and maintain communication abilities for as long as possible.

Intergenerational Programs (IGPs)

ASHA (2005) stated that, based on the needs of the older adult with dementia or cognitive deficits, SLPs can provide either direct cognitive-communication therapy or indirect treatment such as reminiscence and IGPs. Seefeldt (1989) described IGPs as a way to “restore caring and natural connections between the young and old” and “foster positive attitudes” between all group participants (p. 186). Jarrott and Bruno (2003) reported that IGPs have been used successfully to promote interactions between younger and older populations in settings ranging from child care centers, adult day care facilities, nursing homes, and school settings. IGPs can take place in shared sites and unshared sites (American Association of Retired Persons [AARP], 1998; Jarrott & Bruno, 2007; Kuehne & Kaplan, 2001). For instance, IGPs occurring in a shared site include adults and children who populate the same facility. Examples include a building that has an adult day care facility or skilled nursing facility connected to a preschool or school. For the shared-site IGPs, the younger children and older adults can meet multiple times on a daily basis (e.g., greetings during arrival time, farewells, and arts and crafts). Other IGPs have unshared sites where the younger and older populations meet in a designated location.

Much of what is understood about IGPs comes from the fields of sociology and psychology. Many of the IGPs described in the literature incorporate Contact theory for group interactions (Allport, 1954; Pettigrew, 1998). This theory discusses the conditions necessary for positive relationships between groups, including cooperation from all group members to work together on shared activities, use of activities with common relational goals, equal group status with recognition that everyone possesses a talent to share, and opportunities for friendships (Allport, 1954; Gigliotti, Morris, Smock, Jarrott, & Graham, 2005; Jarrott & Bruno, 2007; Pettigrew, 1998). Pettigrew (1998) stated that by instituting the principles of Contact theory, IGPs should increase self-esteem, empathy, and positive affect or mood of all group members.

The basis of Contact theory has been applied by SLPs in community-based group programs in Communication Disorders (Kosky & Schlisselberg, 2011). Typically in speech and/or language group therapy, cooperation between group members and opportunities for friendship are commonly observed. When working with children, the role of the SLP requires constant consideration of the needs of each child in the group therapy setting. Children in group therapy require activities that consider developmental abilities, interests, and educational needs. For older adults with communication disorders, group formats may be used as a process of rehabilitation or to maintain current skills (Brookshire, 2007).

Benefits of IGPs

Some benefits to IGP participants include “fostering positive contact and decreasing social distance between generations” (Jarrott & Bruno, 2003, p. 240). Femia, Zarit, Blair, Jarrott, and Bruno (2008) stated that the main objectives of IGPs are “to encourage meaningful contact,” “promote positive attitudes,” and learn about the aging process (p. 273). Benefits specific to elderly adults participating in IGPs include a sense of well-being, increased self-esteem, and life satisfaction due to interactions with the children (Seefeldt, 1989). For children, many benefits to participating in IGPs have been presented in the literature. Kaplan and Larkin (2004) stated that interactions associated with IGPs may stimulate and educate how children think about aging over the life span. Femia et al. (2008) and Gigliotti et al. (2005) reported that younger children who participated in IGPs had increased social acceptance, greater willingness to help, increased empathy for older adults, increased positive attitude, better ability to self-regulate behaviors, and were less judgmental of others.

IGPs and Older Adults With Cognitive-Communication Impairments

Frequently, IGPs presented in the literature involve healthy older adults interacting with typically developing children, or student clinicians in the health professions (e.g., human development, social work, and speech-language pathology; Jarrott & Bruno, 2003; Kosky & Schlisselberg, 2013). Recently, more IGP studies have been conducted with older adults with dementia (Femia et al., 2008; Gigliotti et al., 2005; Jarrott & Bruno, 2003, 2007; Kosky & Schlisselberg, 2013; Lee, Camp, & Malone, 2007). Many of the activities used in these IGP studies and those with typically aging adults are Montessori-based (AARP, 1998; Femia et al., 2008; Gigliotti et al., 2005; Jarrott & Bruno, 2003, 2007; Kuehne & Kaplan, 2001; Lee et al., 2007). Camp et al. (1997) pioneered the use of Montessori-based activities in IGPs with typically developing children and older adults with dementia. Some examples of Montessori-based activities presented in the classroom include gardening, arts and crafts, music, cooking, and reading aloud to the class or small groups. These activities promote learning by using procedural memory, requiring concrete stimuli to perform the action, and limiting the amount of new information required for working memory (Camp et al., 1997).

Femia et al. (2008) completed an exploratory study evaluating an IGP with children (ages 6–8 years) and older adults with mild to moderate dementia or cognitive impairments. All participants attended a shared-site, day care program. IGP interactions consisted of daily contact with up to seven or more interactions possible during the day with each activity ranging from 30 min to longer in length depending on the activity. Interviews were conducted with 21 parents and/or other family members about the benefits and limitations of the IGP. Due to the interactions in the IGP, the children were more willing to befriend older adults with physical and cognitive impairments (Femia et al., 2008). Based on the positive influences of the older adult on the children, the researchers stated the need for more studies involving multiple generations for interactions. The authors concluded that future IGP studies are necessary as “baby boomers” will soon reach the ages of retirement and disability (Femia et al., 2008, p. 285).

Jarrott and Bruno (2003) conducted an IGP involving 48 older adults with dementia and 82 children (ages 6 weeks to 5 years). All participants attended a shared-site, day care program. The Mini-Mental State Examination (MMSE) was used to assess the older participants’ severity of cognitive abilities. Results from this study found that the severity of dementia, based on MMSE scores, did not prohibit participation in the IGP or have any negative effects on affect or behaviors. Jarrott and Bruno (2003) determined that cognitive impairments were not a deterrent for participation in IGP activities. Based on their findings, the authors suggested that future studies investigate whether the older adults with dementia would continue to exhibit positive mood and affect on other daily tasks following the IGP activities. An additional recommendation was that more IGPs be incorporated in dementia care facilities.

In another study by Jarrott and Bruno (2007), the researchers collected data from a shared-site, community-based day care IGP. This program serves the needs of typically developing children (ages 6 weeks to 6 years) and older adults who require care and/or supervision. The children remain in this IGP program until they are admitted into kindergarten. The majority of older adults in this IGP have mild to severe dementia and/or other cognitive deficits. Survey results from 43 caregivers of the older adults reported that the participants benefited from the IGP, and displayed improved affect and no increase in negative behaviors during interactions with the preschool children. The authors stated that further exploration of IGPs is necessary as both the younger and older populations have a “great deal to offer one another” (Jarrott & Bruno, 2007, p. 254).

Gigliotti et al. (2005) implemented a summer IGP that included multiple groups of children (2–10 years) and older adults with dementia. All participants attended the summer day care program for 4 days a week for 10 weeks. Following interviews with the caregivers of the older adults, the researchers identified several benefits associated with the IGP. The adult participants had an enhanced quality of life, enjoyed the interactions with the children, and developed strong bonds with the children (Gigliotti et al., 2005). Parents of the children and caregivers of the older adults stated that they wanted their family members to continue participation in the summer IGP to maintain the positive intergenerational contact (Gigliotti et al., 2005). Some of the challenges faced in this seasonal IGP were inconsistent attendance by participants and the observation of certain behaviors associated with the adults with more profound disabilities or cognitive deficits. Due to this IGP being conducted in summer, there was a lack of consistent attendance because of families going on vacation in the summer and children attending summer camps. In terms of the behaviors associated with the more impaired adults, some of these participants exhibited signs of impatience and frustration during interactions, and some had difficulty communicating during the activities.

Lee et al. (2007) studied 14 older adults with mild to severe dementia and 15 preschool children (ages 2–5 years) in a shared-site IGP. The severity of the adults’ cognitive abilities was determined using the MMSE. Through observation, the researchers found higher levels of positive engagement and lower levels of negative engagement (e.g., being passive) using Montessori-based activities such as cooking, completing art projects, and storytelling with the older adults. The authors concluded that the “structure, order, meaningful social roles, and the chance to display competence” during activities reduced problematic behaviors of the older adults (Lee et al., 2007, p. 482). Finally, the authors suggested that these findings be implemented in future IGP studies.

Perhaps it is the negative societal perception of dementia that limits the number of IGPs involving this population. Lee et al. (2007) reported that caregivers frequently express anxiety when bringing together children and older adults with dementia to participate in IGPs. The anxiety is often related to behaviors thought to be typical of dementia such as agitation, aggression, anger, use of profanity, and combativeness (Lee et al., 2007). Health care professionals who provide services to adults with dementia have been trained in techniques to redirect the patient if any negative behaviors occur, thereby considerably reducing the risk of negative behaviors while interacting with others. Another problem identified by Lee et al. (2007) is that the older adult with dementia is often a passive participant in the IGP activity, often watching what the children are doing without interacting with them. In these instances, planning is essential for the activities presented in the IGP, and facilitators (if used) need to ensure that the older adult with dementia has the opportunity to participate and communicate. Jarrott and Bruno (2003) concluded that IGPs frequently overlook older adults in dementia care programs, and that more IGP studies should be conducted that include older adults with cognitive impairments and children.

In the speech-language pathology literature, very few IGP studies have been conducted. Kosky and Schlisselberg (2013) described a community-based service model that “promotes transgenerational engagement” (p. 28). This clinical program involved the participation of graduate students in communication disorders and senior citizens with and without dementia. Multiple facility day programs were included in this study. Group size varied from 2 to >20 senior citizens. The program was designed to promote interactions between group members. Through participation in this clinical program, students learned how to facilitate group therapy. Students further established their clinical competencies in areas such as preparing topics for group discussion, demonstrating listening skills, learning how to document the sessions, and so on.

IGPs and School-Aged Children With Language or Reading Concerns

Current research supports the use of IGPs with adults with dementia and typically developing children (Gigliotti et al., 2005; Jarrott & Bruno, 2003; Lee et al., 2007); however, no studies to date have investigated pairing school-aged children with language or reading concerns with older adults with cognitive deficits. Students with identified language deficits have been found to struggle with interpersonal relationships. Specifically, these students are often found to have difficulty engaging successfully in small group activities (Brinton, Fujiki, & Higbee, 1998), establishing relationships (Craig, 1993), sustaining positive interactive relationships (Brinton, Fujiki, Spencer, & Robinson, 1997; Craig, 1993), and being afraid or cautious when interacting with same age peers (Brinton & Fujiki, 2005). Given these concerns, investigating interventions that support these areas is warranted.

As previously discussed, the principles of Contact Theory have been used in other IGP projects to support positive interactions between children and adults (Allport, 1954; Gigliotti et al., 2005; Jarrott & Bruno, 2007). One potential activity that may support the establishment of positive relationships and encourage engagement between two diverse groups is shared storybook reading with paired story retell. These approaches have been identified as effective means of supporting the language and reading skills of preschool and school-aged children with varying language abilities (Isbell, Sobol, Lindauer, & Lowrance, 2004; Justice & Kaderavek, 2002; Petersen, Gillam, Spencer, & Gillam, 2010). For purposes of the Children and Adults Reading Interactively (CARI) IGP, this approach was used to give the school-aged children the opportunity to practice their reading skills in a safe environment with nonjudgmental communication partners.

The current exploratory study was conducted to determine the feasibility of using an IGP for two populations with communication disorders: school-aged children with language or reading concerns and older adults identified with mild dementia or neurocognitive impairment. The CARI program was developed to support the needs of the children using the activity of reading a book aloud to others, and because the ability to read text is unimpaired in older adults with mild dementia and/or mild neurocognitive deficits. The population of older adults with mild cognitive deficits was selected because they served as friendly and engaged communication partners. In addition, the older adults in this study had limited opportunities for interaction with others. The children had been previously educated about dementia in their classrooms, and they perceived their interactions to be helpful to the older adult with cognitive deficits. Based on the CARI IGP, the following research questions were addressed:

Research Question 1: What is the impact of a reading-focused IGP on mood and communication skills of older adults with cognitive impairments?

Research Question 2: What is the impact of a reading-focused IGP on school-aged children’s perceptions of older adults over time?

Research Question 3: Following the IGP, will the classroom teacher observe any changes in the school-aged children’s willingness to read?

Method

Older Adult Participants

Prior to beginning the study, the director of the assisted living facility identified potential participants who had infrequent visitors, little chance for interaction, and a diagnosis of mild dementia or exhibited mild neurocognitive disorder (due to no formal diagnosis of dementia, but questionable working memory abilities that required caregiver assistance). The diagnosis of mild neurocognitive disorder is suggested by the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) for cognitive decline when a formal diagnosis of dementia is not provided. Two female Caucasian older adults with mild dementia, and two male Caucasian and two female Caucasian older adults with mild neurocognitive disorder participated in this study. The older adults had a mean age of 81 years (age range = 72–88 years). Two of the older adults required a wheelchair for mobility, and three required the use of a walker. All participants resided at a local assisted living facility for ≥2 years. All were able to communicate verbally, to display humor in conversation, to produce nonverbal facial expressions, and to read written text. No inappropriate social behaviors were noted during interactions.

All individuals were asked whether they would like to volunteer to participate in a reading program with school-aged children. If they responded favorably, then consent was obtained from the older adults and their guardians. The Blessed Dementia Scale (BDS; Blessed, Tomlinson, & Roth, 1968) was completed to determine the severity of cognitive impairment. The BDS uses information obtained from caregivers and observation to estimate an individual’s ability to complete activities of daily living. The scale has two sections. Section 1 includes statements related to daily living (e.g., “unable to perform household tasks” or “unable to remember short lists of items, for example, in shopping”). Section 2 includes statements that are behavioral in nature (e.g., “coarsening of affect” or “diminished emotional responsiveness”). Individuals who score between 4 and 9 points present with mild impairment (Eastwood, Lautenschlaeger, & Corbin, 1983). The participants in the current study had a mean score of 7.5 on the BDS. Participants were also administered the MMSE (Folstein, Folstein, & McHugh, 1975) to ensure that no change of cognitive status occurred over time. The areas of most difficulty on the MMSE included items that pertained to orientation and working memory. Individuals who score between 19 and 24 points present with mild cognitive deficits (Mungas, 1991). The participants in the current study had a mean score of 22.5 on the MMSE.

School-Aged Children Participants

A total of 12 school-aged children participated in this study. Five females and 7 males between the ages of 8 and 11 years (M = 9 years) were identified by their classroom teacher, as students who, through observation, were not demonstrating language or reading performance at expected grade levels. No participant had received or was receiving special education supports. All students were recruited from the same multigrade classroom for third to sixth graders. No formal reading assessments were administered to students attending this Montessori program; thus, teacher concerns were limited to subjective considerations. Some students were described as hesitant communicators or readers, while others had restricted reading fluency skills. Other students were identified by the classroom teacher due to an aversion for reading aloud, difficulty retelling portions of a story, or difficulty answering questions related to what they had read. Once identified by the teachers and upon receiving parental consent to participate in the study, the children were asked whether they would like to volunteer in a reading program with older adults with dementia. All the children provided verbal assent prior to beginning the IGP. Prior to beginning the study, teachers at the Montessori school presented information about aging and dementia to all the students.

Groups

The older adults and school-aged participants were assigned to one of three groups in which they remained for an entire semester. Each group was comprised of one older adult, two children, and one graduate student clinician in speech-language pathology. The graduate student clinicians who participated in this study obtained practical skills in working with small groups (with a diverse age range), and cognitive-communication disorders related to mild dementia or mild neurocognitive deficits in older adults. In addition, the clinicians obtained skills to work with children with language and reading concerns. The groups met for 45 min weekly for 8 weeks at a local assisted living facility. During the second semester of the CARI IGP, one of the older adults did not complete the entire 8 weeks of the study due to health issues, and another adult who had participated in the previous semester served as a substitute for the final 3 weeks.

Materials

The BDS (Blessed et al., 1968) was completed for each participant. Next, the MMSE was administered (Folstein et al., 1975). This test was completed pre- and post-CARI program to ensure that the mild cognitive impairments remained stable during the course of the study.

A 10-item adult mood and communication questionnaire, developed by the researchers, was completed pre- and post-every IGP session (see Appendix A). This questionnaire was designed based on feedback provided by the staff at the assisted living facility. The staff subjectively reported that the residents who interacted with graduate student clinicians for reminiscence therapy in previous semesters had reduced behavioral issues and improved mood for the rest of the evening. In addition, Jarrott and Bruno (2003) had suggested further research to determine if changes in positive mood lasted throughout the day following IGP participation. Therefore, to assess the possibility that interactions with the student clinicians, researchers, and children could promote these changes, a questionnaire was developed for the older adults using a 5-point Likert-type scale. Responses ranged from all of the time to never to describe the older adults’ moods and communication abilities. Some questions pertained to feelings and mood (e.g., “I feel happy.”), and other questions pertained to communication abilities (e.g., “I attempt to communicate with other people” and “I consider myself to be a good listener.”).

All of the children were administered a pre and posttest measure of their perception of older adults using selected questions from Section III of the Children’s Views on Aging (CVoA; Newman & Marks, 1997; see Appendix B). The perception questions used in this study were identified by Newman, Faux, and Larimer (1997) as showing statistically significant change over time when typically developing children interacted with healthy adult volunteers. Items in Section III use selected bipolar adjective pairs of characteristics as descriptors of older adults. A 5-point Likert-type scale was used to determine the children’s changes in perception. For each question, the child was asked to report how he or she thought about elderly people. The choices ranged from “very” (positive adjective) to “very” (negative adjective) using paired terms such as good/bad and mean/kind.

Eight narrative storybooks were selected by the researchers. The books were chosen for their engaging content, temporal sequencing, and high frequency words (i.e., words that occur across a variety of contexts). In addition, given that these students were identified with reading concerns, and to facilitate an interest in reading, the books were judged to be below grade level for all students. Furthermore, the books chosen related to topics of interest to school-aged children (i.e., animals, fantasy, and humor). All the groups used the same books each week. In addition to the storybooks, approximately eight pictures from each book were selected, laminated, and attached to a flannel board to facilitate temporal sequencing abilities in story retell. Finally, a craft activity related to the story or an upcoming holiday was introduced weekly to promote natural conversation and interaction among the children, graduate student clinician, and older adult.

A new storybook was introduced every week for the first 4 weeks each semester of the CARI program. These books were then reread in the same order during the second 4 weeks of the program to ensure familiarity with the written text and promote enthusiasm for reading the story.

Procedures

Prior to the arrival of the children, the mood and communication questionnaire was administered to the older adult participants. Every week, the children traveled to and from the assisted living facility via private transportation provided by a designated, school-appointed driver. When the children arrived, a graduate student clinician immediately read the storybook identified for the reading program that week. The purpose of this first reading of the storybook was to reduce any possible anxiety the children could have when it came time to read the book with the adult participant.The children and their previously paired graduate student clinician then met with the older adult in a quiet predetermined location. Each week, using counterbalancing, a child in each group read the now familiar, same story to the other child, older adult, and student clinician in their group. In the event the child did not feel comfortable reading that week, the other child in the group was permitted to read. Although this procedure was added with the expectations that some of the children would not want to read, the researchers noted that at least one child per group was always willing to read the storybook. After reading the story, the other child in the group was asked to sequence the pictures related to the story using the flannel board and to retell the story in his or her own words. This nonconfrontational story-retell task, using pictures, was implemented to support the language abilities of the students and to promote interaction between the groups. Throughout the storybook reading and story-retell task, the older adult provided spontaneous, unassisted guidance with reading, made comments, or asked questions related to the story or pictures to the children. The graduate student clinician facilitated the interaction, discussed new vocabulary words with group members, repeated the comments and questions posed by the older adult, and asked questions that required responses from all group members. All of the sessions were supervised by the researchers. After the children left the assisted living facility each week, the older adults were again asked to complete the adult mood and communication questionnaire.

Statistical Analyses

Two-tailed t tests were completed for the MMSE scores obtained pre- and post-CARI program, the adult mood and communication questionnaire scores pre- and post-each reading session, and selected questions from Section III of the CVoA scores pre- and post-CARI program. In addition, teacher reports were gathered at the end of the IGP to determine whether any changes were noted in the children’s reading behaviors in the classroom. In addition, observations and selected comments produced by the children and older adults during the IGP were collected.

Results

No significant findings (p > .05) were obtained for either the MMSE scores or the adult mood and communication questionnaire scores pre- and post-CARI sessions. The MMSE findings indicated that for the older adult participants, there was no change in cognitive status during their participation in the study. In addition, the older adults did not feel that their personal mood and communication skills changed because of participation in the reading program with the children and graduate student clinicians.

The second research question addressed the impact of the CARI IGP on school-aged children’s perceptions of older adults over time. The responses from selected questions from Section III of the CVoA were converted to scores of 1 for “very negative” descriptors through 5 for “very positive” descriptors. A two-tailed t test indicated significant findings for the CVoA scores pre and postreading program, t(11) = 3.150, p = .009.

Postintervention feedback received from the classroom teacher several months after the completion of the CARI IGP project revealed that the children who participated in the intervention group became more confident readers from the experience. In addition, several parents reported positive feelings about their children’s experience with the CARI IGP. The parents stated that their children were less hesitant when expected to read.

Some observations noted during the CARI IGP included increased eye contact between the older adults and children in their small groups, increased questions asked by the children to the older adults over time, children holding the hands of the older adults during conversations, and hugs between the participants at the end of various sessions. Although initially the children were hesitant to read to and interact with the older adults, as the program progressed, the children became more comfortable with the older adult group participants. Several positive comments were made during the course of this study. Comments produced by the older adults included, “I really enjoy the kids,” and “They are so precious.” Examples of comments made by children include, “I wish XXX was here,” when one of the older adults could not continue with the study due to health issues. Another child commented, “I will miss you” to an older adult when the study was completed. One child stated that he did not want the reading program to end. No negative comments were made by any of the participants regarding the CARI IGP.

Trends in the data for this exploratory study suggest that the use of an IGP is feasible for therapy involving two populations with communication disorders. Older adults with mild cognitive deficits and children with learning and reading concerns can successfully engage with one another in the activity of reading. This speech-language pathology focused IGP for older adults with mild dementia or mild neurocognitive deficits provides an opportunity to maintain communication skills associated with reading written text and asking questions about the text or pictures from the story. For children with learning and reading concerns, this IGP provided an opportunity for students to practice their reading and story retell in a nonthreatening and nonjudgmental environment, which resulted in a change in how these children view elderly adults with cognitive deficits. For both populations, the IGP gives participants the opportunity to interact socially with one another. The interactions are especially important when some of the participants have very few opportunities to talk to others. While no data were collected to measure the impact of the IGP on individual student’s actual reading or language performance, clinicians and supervisors noted increased confidence in reading aloud and story retell.

Discussion

SLPs provide services to diverse populations for communication disorders. For older adults, the role of the SLP for intervention will change according to the diagnosed disorder and needs of the client. Indirect treatment such as the implementation of IGPs is recommended to maintain cognitive-communication skills in older adults with dementia (ASHA, 2005). The current exploratory IGP which focused on a reading program is a practical approach to group speech-language therapy. The program implemented the Montessori-based activity of reading aloud to others which incorporated concrete stimulus items and required reading abilities from both populations. The CARI program included two populations with communication disorders: adults with cognitive-communication deficits and school-aged children with language or reading concerns. The older adults with cognitive deficits in the CARI IGP served multiple roles in the group. They assisted the children if they had difficulty reading specific words, discussed vocabulary, and provided positive feedback. In addition, they served as conversational partners by asking questions and responding to the children’s questions. Similar to the findings of Gigliotti et al. (2005), the comments obtained from the older adults in the CARI IGP described enhanced quality of life and enjoyment from the interactions with the children. Moreover, observations of friendships were evident during the study.

Subjectively, the authors noted that positive changes in mood and affect emerged during the CARI IGP. However, there were no significant findings on the older participants’ pre- and post-session mood and communication questionnaire results. Gigliotti et al. (2005), Jarrott and Bruno (2003), and Lee et al. (2007) noted improved affect with older adults with dementia and/or cognitive impairment who interacted with young children during IGP activities. Perhaps the questionnaire developed for the current research study did not capture the residual effects of positive emotions observed during participation in the CARI IGP. To better capture these changes of mood and emotion in the future, qualitative measures for nonverbal and verbal communication will need to be implemented.

However, participation in the CARI IGP changed the perceptions of how school-aged children identified with language or reading concerns view older adults with mild dementia and/or cognitive deficits over time. The children’s perceptions became more positive even though many of the older adults exhibited physical impairments (i.e., requiring a walker or wheelchair for mobility). At the beginning of the study, the children selected descriptors that were either negative or in the middle of the scale on selected questions from Section III of the CVoA (Newman & Marks, 1997). However, with 8 weeks of consistent interactions with the older adults, the adjectives selected post-CARI program became more positive in nature. This finding is similar to those of Newman et al. (1997) who found changes over time in school-aged children’s perceptions of older adults when older adults volunteered in their classrooms. Our findings indicate that even with older adults with cognitive deficits, school-aged children’s perceptions can move toward more positive descriptors.

Based on teacher and parent feedback, the CARI IGP resulted in an overall increase in confidence when reading. A reading activity paired with a story retell appeared to reduce some of the hesitancy and aversion to reading experienced by several of the children involved in the CARI IGP. Further projects should investigate whether using this paired reading approach could also result in quantitative changes to the language and/or reading fluency performance of school-aged children with language or reading concerns.

Several limitations are evident in the current exploratory IGP. First, the sample size of older adults participants (n = 6) with cognitive deficits and school-aged children with reading and language concerns (n = 12) was small. However, this small sample size allowed the researchers to follow the guidelines of amount of time required for supervision of graduate student clinicians specified by the Council for Clinical Certification in Audiology and Speech-Language Pathology of the American Speech-Language-Hearing Association (2013). In addition, the small number of participants allowed the researchers to analyze critically the methods used in the CARI program and consider changes for future studies. Due to the limited sample size, the authors were unable to analyze the qualitative data more critically; however, given a larger sample size, alternative means of analyzing qualitative data will be feasible. Another limitation was that one of the older adult participants discontinued the study 3 weeks prior to study completion due to health issues. However, a previous participant was willing to assist so that the study could be completed. The school-aged children did not demonstrate difficulty interacting with this new participant. Next, the CARI IGP met once a week at the assisted living facility rather than at a shared site which would have provided more interaction opportunities between the children and the older adults. Although the benefits of shared-site IGPs are well documented in the literature (AARP, 1998; Jarrott & Bruno, 2007; Kuehne & Kaplan, 2001), the weekly unshared-site CARI IGP produced positive feedback from both children and older adults. Finally, Gigliotti et al. (2005), Jarrott and Bruno (2003), and Lee et al. (2007) all stressed the need of sustainability for IGPs. As this project was funded by community grants, other sources of funding will be required to continue the CARI IGP. This would be extremely valuable because the school-aged children and older adults with dementia and/or cognitive deficits all stated that they would miss the interactions and friendships that had developed. The staff at the assisted living facility and Montessori school wanted to continue the established relationship.

Future studies should include a greater number of participants in the CARI IGP. Perhaps a wider age range of children identified with language or reading concerns could be recruited based on quantitative reading and language data rather than subjective teacher selection. To increase the number of older adult participants, a wider range of severity levels of dementia and/or neurocognitive impairments could be included in future studies. Also, new questionnaires may need to be developed for the caregivers at the assisted living facility instead of the older adult participants. The caregivers could complete the questionnaires in the evening to determine if positive mood and communication skills remain constant after the older adults participate in the CARI IGP. In addition, if the sample size was increased, in-depth qualitative and quantitative analyses of mood, behaviors, and nonverbal and verbal language could be conducted. Finally, a longitudinal investigation would be beneficial to determine if the children’s positive perceptions of older adults with dementia remain stable over time.

In conclusion, with the expected increase in the number of individuals with dementia worldwide, more evidence-based studies are needed to evaluate the effectiveness of therapies that are currently used to serve this population. IGPs can be used to enhance and maintain cognitive-communication skills by building long-lasting relationships between generations. The use of IGPs by SLPs may assist in improving the quality of life of older adults with cognitive deficits and social interactions of children.

Footnotes

Appendix A

Appendix B

Selected portions of Section III of the Children’s Views on Aging Questionnaire developed by Newman and Marks (1997).

Instructions: Ask, “What are some ways you would describe OLD PEOPLE?”

“Below are 8 pairs of words. For each pair place an X on one of the five lines that tells what you think about old people.”

“Look at the first pair. If you think that Old People are Very Good place an X on the first line under Very. If you think that Old People are A Little Good, place an X on the second line under A Little. If you are not sure, place an X on the middle line under Not Sure. If you think that Old People are A Little Bad, place an X on the fourth line under A Little, and if you think Old People are Very Bad, place an X on the last line under Very.”

“Now do this for all the questions. Read each item carefully before responding. You may put down only one X for each word pair.”

Added instructions for the CARI project: “If you have any trouble reading the words, I will help you read them.”

Acknowledgements

The authors would like to thank Chelsea Hafley, Michelle Harvey, Danielle Moffett, Elise Platz, Lisa Roye, and Bethany Wamboldt for their assistance with this project. They would also like to acknowledge Emeritus at Flagstaff Senior Residential and Assisted Living and Haven Montessori for their long-term partnerships with the NAU Communication Sciences and Disorders program. Finally, the authors would like to thank all the participants who volunteered to take part in this study.

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 research was supported by grants from the Flagstaff Community Foundation.

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