Culturally consistent treatment for late talkers.
Keywords: cultural/linguistic diversity; communication; language learning disorders; exceptionalities; family-parent issues; intervention strategies; therapy
Toddlers and younger preschool-age children with primary developmental language delay, referred to in the literature as "late talkers," form a core constituency on clinical caseloads for many speech-language pathologists (SLPs). These young children lag behind peers in the attainment of early language milestones for no readily apparent reason. Approximately 10% to 15% of monolingual English-speaking 2- to 3-year-old children in the United States from middle- to upper-income families of the cultural majority are late talkers (Kelly, 1998; Paul, 1991). Typical criteria for late talkers include a failure to use 50 different words or 2-word utterances by 24 months of age, in the absence of other observable cognitive, sensory, or neurological disorders (such as autism, heating impairment, or global developmental delays; Rescorla, 2005). Although some late talkers "catch up" to peers, a significant number have language difficulties that persist into the school years and interfere with learning and social relationships (for reviews, see Kelly, 1998; Leonard, 1998; Thai & Katich, 1996). To date, a single reliable predictor of which late talkers will catch up and which will have persistent delays has not been found. Early language intervention is viewed as a means to improve long-term language and academic outcomes.
As with the general population, late talkers and their families represent a broad range of diversity in terms of cultural, linguistic, economic, and educational experiences. SLPs have a professional mandate to provide timely, effective, and appropriate intervention to late talkers and their families, independent of potential cultural or language mismatches between providers and clients (American Speech-Language-Hearing Association, 2004). For children identified as late talkers, general intervention goals are to increase the production and/or comprehension of words and sentences and to promote the use of newly acquired language within meaningful communicative interactions. To attain these goals, SLPs must determine the contexts of treatment, the procedures to be used in these different contexts, and immediate or long-term treatment objectives (Paul, 2001). In the United States, received wisdom related to planning and implementing intervention programs for late talkers comes from legal mandates, professional experience, theoretical conceptualizations of early language, and a growing body of empirical studies with late talkers from primarily monolingual, English-speaking middle- or upper-income families who are part of the cultural majority. In this article, we examine the cross-cultural validity of different organizational and language stimulation features traditionally used by SLPs when intervening with late talkers.
Culture, as used here, refers to the shared, accumulated, and integrated set of learned beliefs, values, habits, attitudes, and behaviors of a group of people or community (cf. Brislin, 1993; Kohnert, 2008; Westby, 2000). Culture is at once the context in which language is developed and used and the primary vehicle by which it is transmitted. The culturally embedded beliefs and values of individuals affected by language delays, as well as those of the professionals working with them, are essential contributors to the clinical process (Kohnert, 2008). Our goal here is to draw attention to potential cultural influences on clinical interactions when treating late talkers and to suggest alternative approaches, in the case of cultural mismatches, that preserve the long-term goal of improved language and communicative functioning in affected children. In the following section, we describe selected aspects of standard treatments successfully employed with late talkers from the majority cultural community in the United States.
Treatment Strategies Used in Language Intervention Programs With Late Talkers
A number of different language treatments have received empirical support for their effectiveness in promoting language in late talkers whose families are part of the cultural majority in the United States. Some of these empirically validated treatments focus on the use of a particular language stimulation technique and are intended to be combined with other procedures into a comprehensive action plan. These include the focused stimulation approach, which relies on multiple repetitions of preselected target forms (Ellis Weismer & Robertson, 2006), and the conversational recast intervention, which advocates elaboration of a previous child utterance (Camarata & Nelson, 2006). Other treatments combine and promote the use of several different language stimulation techniques into a free-standing program, such as It Takes Two to Talk: The Hanen Program for Parents (Manolson, 1992). All have common roots in social interactive or social constructivist theories of typical language development. From this perspective, children's active engagement in frequent, positive, reciprocal social interactions is essential for language development (e.g., Bruner, 1983; Vygotsky, 1978; for a review, see Tannock & Girolametto, 1992).
Consistent across different treatments is the use of strategies that emphasize frequent, focused, and developmentally appropriate language input to the child while he or she is engaged in meaningful activities with a responsive, sophisticated communication partner. Because a hallmark of late talkers is delays in expressive vocabulary, specific words or word combinations are considered immediate objectives. The sophisticated partner in these language-rich interactions is either the parent, with professional training and support, or the SLP. Parent education and training is the exclusive focus of some treatment programs. For example, It Takes Two to Talk: The Hanen Program consists of extensive parent training in various methods designed to facilitate communication in natural contexts (Manolson, 1992; see for a review, see Girolametto & Weitzman, 2006). The goal is to increase parents' use of techniques that support children's communicative interactions and developing language abilities. As with clinician-implemented treatments, the idea is that enhanced adult language input during meaningful interactions in naturalistic settings will result in gains in the child's language. Parent education and training is provided by an SLP who has expertise in early language development, in general, and the Hanen program in particular. Parents attend small-group training sessions with other parents of young children with language delays, with individual session follow-up during which the SLP provides feedback on parent and child videotaped interactions. In other treatments, parent training and education in specific language facilitation methods is viewed as a complement or alternative to clinician-implemented treatment (e.g., Ellis Weismer & Robertson, 2006).
Whether the clinician or parent is the primary agent of intervention, the nature of interactions fostered in current treatments with late talkers is generally dyadic and child led. Clinician-implemented treatments are play based, employing objects familiar or of interest to the child. During these dyadic interactions, the adult talks to the child about the ongoing activities in developmentally appropriate ways to increase the accessibility of spoken language. Parents may also be encouraged to engage in play-based activities with their child, following the child's lead while talking in specific ways about objects or actions of interest to the child. There are a number of different, specific focused language stimulation techniques employed across a range of current early language intervention programs. Brief descriptions and examples of common techniques are shown in Table 1. These include frequent repetitions or models, narration, recast or expansion, and modeled elicitations (Buteau & Kohnert, 2000; Camarata & Nelson, 2006; Chapman, 2000; Ellis Weismer & Robertson, 2006; Girolametto & Weitzman, 2006).
Looking across different treatment approaches, it seems that the overarching objective is to increase the child's opportunities to hear and respond to language that is tailored to his or her developmental level during meaningful social interactions with a responsive partner. Both legal mandates and professional best practice guidelines for young children with communication delays recognize the need for parents to be included as full partners in-the intervention process (Note 1). When parents learn and use specific language facilitation techniques, children's language-learning opportunities are significantly extended and generalization to other partners or settings is a natural outcome (Buteau & Kohnert, 2000).
Empirical evidence also supports the inclusion of parent education and training in successful early language intervention programs. Law, Garrett, and Nye (2004) conducted a meta-analysis of treatment for young children with developmental speech or language delay. Ten of the 13 studies included in this analysis focused on language treatments to 2- and 3-year-old monolingual English speakers from the majority cultural group. An important outcome of this analysis was the finding of comparable outcomes for parent-provided interventions as compared to clinician-provided treatments. Although these findings may not hold for older children (e.g., Johnston, 2005), it is clear that language facilitation programs that consider the young child's primary social environment and communicative partners should be emphasized over those that attempt to extricate young children from these primary social and cultural units.
Of course, the primary social environment, communication partners, and nature of interactions in the social environments may vary considerably both within and across cultures. The validity of the individual and combined features of language intervention programs for late talkers cannot be determined independent of the population with whom it is used. In the following section, we explore potential challenges to the relevance or effectiveness of core features of early language intervention programs when employed with families whose cultural values and behaviors may differ from those promoted in existing treatment programs.
Potential Cultural Inconsistencies and Alternative Actions
A number of different interactive treatment approaches have proven effective in improving communication outcomes for late talkers who are part of the cultural and linguistic majority of the United States. However, given that cultural variation, rather than homogeneity, is typical of many SLP caseloads, it is important to consider the relevance of standard intervention practices in the context of cultural diversity. As Girolametto and Weitzman (2006) appropriately note, "Our understanding of how the interactive model of language intervention applies to different linguistic and cultural groups is still in its infancy" (p. 95).
There may be occasions when diverse cultural experiences or preferences challenge or collide with standard treatment practices. In this section, we discuss potential cultural variation as it relates to two core aspects of current language intervention programs for late talkers. These two interacting aspects are (a) the nature and context of social interactions in terms of partners, settings, or activities and (b) the language goals and language facilitative techniques used. Although our emphasis here is on cultural rather than linguistic variation, the underlying assumption is that the treatment plan will support the primary language used by other family members in the home, even when this is at odds with the majority language of the community. Supporting the home language is considered best practices for young children with primary language delays (for additional discussion, see Kohnert, 2008; Kohnert, Yim, Nett, Kan, & Duran, 2005).
Nature and Context of Social Interactions
Focused language input during meaningful social interactions with an adult partner, either parent or clinician, is at the heart of treatment for children identified as late talkers. This practice is culturally consistent for some, but not for all. Expectations for child behavior are defined differently across cultures. In some cultures, particularly collectivist or interdependent cultures, children may be expected to play and talk more with siblings or peers, and interactions may involve multiple partners of varying ages (Hammer, 1998; van Kleeck, 1994). Dyadic interactions, particularly between a single child and adult, may be unfamiliar and therefore less "natural" or facilitative. It may be even less natural to engage in child-led play-based interactions, as this is sometimes inconsistent with social roles and expectations.
Family-centered services for late talkers are considered consistent with both legal mandates and best professional practice. Consistent with cultural norms for parental roles characteristic of the majority culture of the United States, family-centered is most often interpreted as parent involvement. Parents are considered necessary partners for providing intense, focused language input to their children. However, the underlying goal of these mandates is to provide a method to increase the frequency of focused language input for the affected child in naturalistic contexts. In some cultures, or for some individuals in larger cultural groups, it may not be either culturally consistent or effective in facilitating child communication for the parent to engage in child-directed play. When this is the case, parent involvement, as conventionally considered, may be expanded to include siblings, cousins, or other peers.
Play-based interactions offer many opportunities for joint attention, heightened interest, and rich and varied language input. If important for treatment, the SLP may facilitate these interactions with older siblings or peers in triadic or group interactions to increase cultural congruency. Vigil and Hwa-Froelich (2004) also suggest that parents may be shown how to "play" with their children in the framework that they are teaching, if it is not customary that they would engage in play together. Structured teaching tasks such as book reading, storytelling, listening to recitation of prose by older siblings, rhyme games, rapping, and singing may be more culturally consistent language-rich activities (for suggestions, see also Cordero & Kohnert, 2006; Kohnert, 2008; Kohnert et al., 2005).
Often, professionals consider the home to be the preferred setting for language intervention for young children with communication delays. This is indeed true for many families. For others, however, most particularly those with traditional collectivist cultural views, the natural home environment may be viewed as the place for caring, nurturing, and acquiring social morals, but it may not be viewed as the natural learning environment for acquiring other skills, particularly with professional mediation. Polmanteer and Turbiville (2000) point out that in any cultural group some families view home-based intervention services as intrusive and inappropriate, and therefore these services will likely be less effective. Options to offer center- or school-based therapy or a combination of center-based and home-based services may better meet the needs of the family and support the family's beliefs about learning and education.
Cultural alternatives for social interactions in early treatment programs with late talkers may include small groups consisting of the affected child and a sibling or peer as well as an adult family member. (See Table 1, "Older sibling as language models" and "Multiparty interactions.") It may also consist of several pairs of children and adults in a small-group instructional setting that takes the focus off adult-child dyads yet provides opportunities for the SLP to provide training and mentoring to interested adults at the same time that late talkers participate in moderately structured language-rich instructional activities with peers. For some late talkers, this small-group instructional environment may be more effective than dyadic interactions between an adult and child, as it presents a better cultural match. One such program that incorporates these elements is Preschoolers Acquiring Language Skills (PALS; Buteau & Kohnert, 2000). Although PALS incorporates group instruction, parent or family partnerships, and center-based instructional opportunities combined with extension activities for other sites, it has yet to be empirically tested with culturally diverse populations.
Language Goals and Language Facilitation Techniques
Western cultures, including the majority culture in the United States, place a high value on language ability in both spoken and written forms. In both the profession of speech-language pathology and the broader community, high language ability is equated with social, academic, and vocational success; low language ability puts one at risk in each of these domains and warrants intervention to improve long-term outcomes. A cultural priority for children, typical or otherwise, is a language-rich environment that will facilitate early communication development and later literacy and academic achievement. Children and adults in Western cultures are first identified as individuals, unique and separate from those around them, whose success and failures in life will be determined by personal actions and achievements. Language ability, in terms of early versus late talking, is one of the most observable signs of skill or need in early childhood.
In some cultures, verbal precociousness takes a back seat to the development of other behaviors. Even when there is a shared goal to increase language abilities, the division of responsibility between parents and professionals may initially differ across cultures and warrants skilled conversation to explore potential points of overlap or divergence. In contrast to the rugged individualism that characterizes the majority culture in the United States, interdependent or collectivist cultural perspectives define individuals first and foremost with respect to family and community membership (Vigil & Hwa-Froelich, 2004). Children are viewed as an integral part of a larger group, and as such, social roles, responsibilities, and interactions are given priority over individual abilities. From the collectivist perspective, the role of the parent is to teach children how to behave and live in social relationships with others. Evidence for this perspective can be found in the Spanish concept of la educacion. Although the literal translation is "education," the term actually encompasses manners, politeness, social appropriateness, and morality as taught by the family (Halgunseth, Ispa, & Rudy, 2006). A similar idea is present in a well-known Vietnamese proverb, Tien hoc le, hau hoc van (Vu, Vu, & Vu, 2000). The proverb is literally translated as "First learn politeness then learn literature" and expresses the importance of courteous and respectful behavior above and beyond scholastic training. Others have translated this proverb as "Education comes before knowledge" (Dang, 1997) to emphasize that being educated equates to polite social behavior rather than academic achievement.
From a collectivist perspective, care providers may focus energy on encouraging qualities of helpfulness, sharing, and harmonious interactions within the family. Quiet observation and listening, as well as imitation of adult behavior, are valued, but verbal skills as separate from social use are not (cf. Hammer & Weiss, 2000; Hwa-Froelich & Vigil, 2004; van Kleeck, 1994; Vigil & Hwa-Froelich, 2004). Parents who have traditional collectivist perspectives may explicitly teach about behavior at home; teaching language may not be considered a priority for very young children and may be viewed as the role of professionals outside of the family (cf. Hwa-Froelich & Westby, 2003; Rodriguez & Olswang, 2003).
To value cultural perspectives while developing an effective intervention plan, the SLP must first and foremost consider the child within his or her primary social environment. Through respectful, responsive, reciprocal conversations, or "skilled dialogue" (Barrera & Corso, 2002), the SLP can gain an understanding of behavioral priorities for the child. During these skillful, ethnographic conversations, the SLP must also carefully make clear to parents the link between early language ability and later academic attainment. Once this link is made explicit and professional motives for treatment recommendations are clearly explained within their theoretical, empirical, legal, and cultural context, it will be more likely that language, broadly conceived, will be a shared goal between the family and SLP. In the absence of such a clear link, the family may not understand the emphasis on verbal skills in a 2- to 3-year-old child.
When possible, language or communication goals may be paired with cultural priorities for social roles and behaviors. (See Table 1, "Social function routine") For example, receptive language, including attentive listening, while an older family member tells a story or reciprocal turn taking during interactions with a sibling or cousin may be reasonable goals. Immediate expressive language targets may include social terms and politeness forms that indicate respect (good morning, thank you, and please and forms of address for elderly family members). Book reading may be replaced with shared time with another family member looking at family pictures to learn about social relationships and appropriate forms of address.
It is also the case that there may be some cultural incongruence in the extent to which responsive rather than directive language input is favored with typical language learners and with late talkers. Language facilitation techniques emphasized in standard treatment with late talkers are responsive, not directive (see Table 1). Repetition or modeling, narration, and expansion provide multiple listening opportunities for the child. Spontaneous productions by the child are welcomed and further elaborated, but there is no obligation to respond. Nondirective language input is consistent with the type of talk used by middle- to upper-income parents from the majority culture in the United States. In the profession of speech-language pathology, directive methods that instruct the 2- to 3-year-old child to do something (tell say, repeat) are generally viewed as negative and less conducive to language development; responsive or nondirective language input is seen as much more desirable and likely to produce positive child outcomes. This is most likely true for children socialized in middle- to upper-income homes who adhere to individualist, cultural perspectives, as this language is congruent with broader family values and parenting behaviors. However, directive language use may not always be negative or run counter to language treatment goals.
Mothers in interdependent cultural groups may produce more directives and imperatives when interacting with young children (Vigil & Hwa-Froelich, 2004). Bhimji (2001) reported that directives did not always elicit a passive response but often resulted in a creative narrative from children. Directives have also been successfully employed with children during triadic interactions in which children were instructed what to say through a third party (Eisenberg, 1982). An example of this dile (tell him or her) strategy involving older siblings is shown in Table 1. Directives may be used effectively by the SLP in simulated multiparty interactions using dolls, puppets, or stuffed animals when working with a young child who is comfortable with this form of interaction.
Even for late talkers from the majority cultural community in the United States, there is some evidence that elicited techniques (rather than modeling only) may be more effective for some children (Ellis Weismer, Murray-Branch, & Miller, 1993; Kouri, 2005). Finding the best match for the styles of parents and children and then shaping and expanding language facilitation techniques based on these core tendencies may prove most effective in meeting communication goals. Because some children are accustomed to a more directive interaction style, they may respond more favorably to a more structured, elicited mode of intervention (Vigil & Hwa-Froelich, 2004).
In this article, we discussed potential cultural influences on clinical interactions when treating children identified as late talkers. Precepts of current treatment programs developed and tested with late talkers from the cultural majority were examined in light of cultural variation. The general resulting recommendation is that when standard practices are inconsistent with the family's cultural values and behaviors, and therefore unnatural for the child socialized in this environment, alternative strategies must be considered. In examining the cultural fit of tried-and-true treatment strategies, the SLP is forced to strip away the cultural layers that naturally govern professional practice to reveal the essence of treatment.
Goals and rationales, once distilled to their most basic form, provide direction for identifying potential alternative treatment strategies that are consistent with both professional mandates and family perspectives. If the short-term goal is to increase the child's receptive and expressive language ability to promote long-term achievements in social development and academic attainment, then multiple ways to facilitate these objectives can be envisioned. In this article, we have introduced a small sample of potential alternatives. The possibilities are countless and perhaps cannot be fully anticipated or articulated independent of the particular partners involved--family, child, and SLP. Cultural adaptations to interventions with late talkers will not be developed successfully in a vacuum but instead through dialogue with families, leading to joint problem solving between the SLP and the family.
Authors' Note: Please address correspondence to Kathryn Kohnert, Speech-Language-Heating Sciences, 115 Shevlin Hall, 164 Pillsbury Drive, SE, University of Minnesota, Minneapolis, MN 55455; e-mail: firstname.lastname@example.org.
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(1.) See Polmanteer and Turbiville (2000) for a review of legislation regarding family-centered services legislation, including the current Individuals With Disabilities Act and its predecessor, Part H of the Education of Handicapped Children Act Amendment of 1986.
Kelly Nett Cordero
Kerry Danahy Ebert
Pui Fong Kan
University of Minnesota, Minneapolis
Christine Wing, MA, MS, CCC-SLP, is currently a doctoral student in the Department of Speech-Language-Hearing Sciences at the University of Minnesota, Minneapolis. Her interests are in program and policy development for at-risk preschool children and their families.
Kathryn Kohnert, PhD, CCC-SLP, is an associate professor in the Department of Speech-Language-Hearing Sciences at
the University of Minnesota, Minneapolis. Her research program investigates relationships between language, cognition, and environment in monolingual and bilingual children and adults with or without language impairments.
Giang Pham, MA, CCC-SLP, is a doctoral student in the Department of Speech-Language-Hearing Sciences at the University of Minnesota, Minneapolis. Her research interests are bilingualism, language acquisition, and language disorders, particularly in Vietnamese- speaking populations.
Kelly Nett Cordero, MA, CCC-SLP, is a doctoral candidate in the Department of Speech-Language-Hearing Sciences at the University of Minnesota, Minneapolis. Her interests are in cleft palate and craniofacial conditions and speech and language disorders in bilingual children.
Kerry Danahy Ebert, MA, CCC-SLP, is a doctoral student in the Department of Speech-Language-Hearing Sciences at the University of Minnesota, Minneapolis. She is interested in the interactions between different cognitive and linguistic factors and how these affect the classification and treatment of developmental language disorders.
Pui Fong Kan, MA, CCC-SLP, is a doctoral candidate in the Department of Speech-Language-Hearing Sciences at the University of Minnesota, Minneapolis. Her primary interests are child language development, bilingualism, language disorders, and research methodology.
Kristina Blaiser, MA, CCC-SLP, is a doctoral candidate in the Department of Speech-Language-Hearing Sciences at University of Minnesota, Minneapolis, and director of Northern Voices. Her interests are in speech and language development in young children with hearing impairments.
Table 1 Conventional and Alternative Language Stimulation Techniques Used by Adults With Late Talkers Technique Description Conventional Example Modeling or Adult models and then Adult: Here's an repetition repeats words or apple. It's a red phrases within a apple. I like apples. meaningful context. Put the apple in the When words or phrases basket, please. are preselected, training targeting this technique is considered "focused stimulation." It may also be used as a general language stimulation technique. Narration Adult describes what Adult: You're jumping. (including the child is doing, You jump high. I'm self-talk, what the adult is combing my hair. It's parallel doing, or items or messy. That's a kitty. talk, and actions that have He has a long tail. description) captured the child's interest. Recast or Adult expands on a Child: Uh oh. expansion previous child Adult: The horsie fell. gesture, vocalization, -- word, or sentence. Child: Baby owie. Adult: Baby has an owie. Her leg hurts. Elicitation Direct request to name Adult [pulling apple or prompt object or produce from picnic basket]: target utterance after What's this? substantial amount of modeled input. Technique Alternative Example Modeling or Social function routine: repetition For cultures such as Vietnamese, it is customary to greet each adult in a room upon arrival. An adult walks with the child to greet each person: Con chao ong. Con chao ba. Con chao chu. Con chao di. [I greet grandpa. I greet grandma. I greet uncle. I greet aunt.] Narration Older siblings as language models: (including An older sister is showing the child self-talk, how to make a sandwich: parallel Sister: First you scoop out the talk, and peanut butter and smear it [while description) she spreads peanut butter on bread]. Then you take both pieces of bread and put them together. See? Now you try. Recast or Multiparty interactions: Mother, expansion aunt, and child are setting the table. Mom models what child would say: Child: Mine [points to a cup]. Mom: This cup is mine. Aunt: No, that cup is mine. Mom: You're right [gives cup to aunt], here's your cup. Elicitation "Dile" [tell him or her] strategy or prompt involving older sibling: Adult to child with sibling in room: Dile a tu hermana que quieres mas jugo ... mas.... Tell your sister that you want more juice ... more. ...] Child to sibling: Mas. More.]