Exploring the outcomes of a novel computer-assisted treatment program

targeting expressive-grammar decits in preschoolers with SLI

Karla N. Washington
a,
*, Genese Warr-Leeper
a
, Nancy Thomas-Stonell
b
a
Child Language Laboratories, School of Communication Sciences and Disorders, The University of Western Ontario, London, Ontario, Canada
b
Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, Ontario, Canada
1. Introduction
During the language acquisition process some children experience delays in producing and/or understanding language at
an expected rate. There is one group of children, those with specic language impairment (SLI), for whomthe language delay
Journal of Communication Disorders xxx (2011) xxxxxx
A R T I C L E I N F O
Article history:
Received 10 February 2010
Received in revised form 22 December 2010
Accepted 1 January 2011
Keywords:
Treatment outcome
Specic language impairment
Children
Computer-assisted treatment
Expressive-grammar
Verbal working memory
Treatment effectiveness
A B S T R A C T
Purpose: The impact of a newly designed computer-assisted treatment (C-AT) program, My
Sentence Builder, for the remediation of expressive-grammar decits in children with
specic language impairment (SLI) was explored. This program was specically designed
with features to directly address expressive-grammar difculties, thought to be associated
with hypothesized decits in verbal working memory (VWM).
Method: Thirty-four preschoolers with decits in expressive-grammar morphology
participated. Using the randomization procedure of consecutive sampling, participants
were recruited. Twenty-two participants were consecutively assigned to one of two
treatment groups, C-AT or non C-AT (nC-AT). The nC-AT utilized conventional language
stimulation procedures containing features which have been traditionally used to address
expressive-grammar decits. A group of equivalent children awaiting treatment and
chosen from the same sample of children as the treatment participants served as a control
group. Blind assessments of outcomes were completed pre-, post-, and 3-months post-
treatment in a formal and informal context.
Results: C-AT and nC-AT participants signicantly outperformed controls pre-to-post to 3-
months post-treatment in both assessment contexts. No signicant differences in
treatment gains were found between C-AT and nC-AT.
Conclusion: Results suggested that treatments designed to directly address expressive-
grammar decits were better than no treatment for preschool SLI. Further, use of a C-AT
program may be another feasible treatment method for this disorder population.
Learning outcomes: As a result of this activity, the reader will learn that: (1)
expressive-grammar treatment is better than no treatment for immediate and continued
language growth, (2) use of a C-AT program containing specic features designed to
directly address expressive-grammar decits is another viable, but not necessarily a better
treatment option for the remediation of expressive-grammar decits in preschool children
with SLI, and (3) different outcome contexts yield distinct yet equally important ndings
about growth in childrens expressive-grammar skills with treatment.
2011 Elsevier Inc. All rights reserved.
* Corresponding author at: Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital and Graduate Department of Speech-Language
Pathology, University of Toronto, 150 Kilgour Road, Toronto, Ontario M4G 1R8, Canada. Tel.: +1 416 425 6220x3316; fax: +1 416 425 1634.
E-mail address: karlanadine@yahoo.co.uk (K.N. Washington).
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Please cite this article in press as: Washington, K. N., et al. Exploring the outcomes of a novel computer-assisted treatment
program targeting expressive-grammar decits in preschoolers with SLI. Journal of Communication Disorders (2011),
doi:10.1016/j.jcomdis.2011.01.002
Contents lists available at ScienceDirect
Journal of Communication Disorders
0021-9924/$ see front matter 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.jcomdis.2011.01.002
cannot be explained by decits in hearing, nonverbal ability, behaviour or emotional regulation, or neurological function
(Plante, 1998; Stark & Tallal, 1981). For these children, there can be long-term adverse outcomes extending beyond
continued oral language development (Conti-Ramsden, Botting, Simkin, & Knox, 2001) to literacy and academic progress
(Catts, Fey, Tomblin, & Zhang, 2002; Stothard, Snowling, Bishop, Chipchase, & Kaplan, 1998) and even behaviour (Baker &
Cantwell, 1987; Tomblin, Zhang, & Buckwalter, 2000). SLI is considered one of the most commonly occurring disorders in
schools, affecting approximately 7% of young children (Tomblin et al., 1997) and thus requires attention in the preschool
years to avoid potentially negative consequences.
1.1. Linguistic characteristics of children with SLI
Children with SLI demonstrate varying degrees of language difculty resulting in an assortment of proles with shared
core characteristics (Conti-Ramsden & Botting, 1999; Leonard, 1989). These children meet specic diagnostic criteria
demonstrating language production and/or comprehension decits (Leonard, 1989, 2009). Morphosyntactic errors are
considered the hallmark of SLI (Bishop & Edmundson, 1987; Leonard, Camarata, Pawlowska, Brown, & Camarata, 2006).
These errors include omission of function words (e.g., articles, the verb be in auxiliary form), inaccurate use of pronouns (e.g.,
subjective-objective case confusion) and omission of nite verb endings (e.g., person or tense inections) (Cleave & Rice,
1997). The nite verb form be in its auxiliary form is known to pose particular difculties for children with SLI due to the
required tense and number agreement considerations (Cleave & Rice, 1997).
Hypothesized decits in verbal working memory (VWM) are believed to underlie observed expressive-grammar decits
(Archibald & Gathercole, 2006; Washington, 2007, 2010). Children with SLI are thought to have inadequate short-term
memory representations for verbally presented information (Gathercole & Baddeley, 1996a, 1996b) that ultimately affects
speed of processing (Archibald & Gathercole, 2007; Kail, 1994; Leonard et al., 2007). The morphological errors observed in
childrens productions are therefore thought to be caused by the slow processing of rapid successive and unstressed
elements in the spoken language stream. The inability to process the auditory elements hinders the abstraction of underlying
grammatical rules and thus results in agrammatical productions. Consequently, children with SLI commonly omit
grammatical morphemes such as -is, -ing, s/he, or the in their productions.
It may be important therefore that specic treatment programs be designed, implemented, and evaluated for
effectiveness in addressing the observed expressive-grammar difculties hypothesized to be associated with VWM decits
and resource allocation constraints. Visual representation (i.e., providing picture support for nouns and verbs along with
markers for grammatical components) of every sentence element could decrease the burden on cognitive resources in VWM
(Washington & Warr-Leeper, 2006). These representations may allowfor more time to process all sentence elements so that
grammatical production can be achieved.
1.2. Treatment for expressive-grammar decits
While there is evidence froma recent meta-analysis (Law, Garrett, & Nye, 2003) conrming the positive effects of speech
and language therapy for children with expressive phonological and expressive vocabulary disorders, there is mixed
evidence for children with expressive-grammar decits. In particular, it is suggested that therapy for children with
expressive-grammar decits may be more effective if these children do not also have concomitant severe receptive-language
difculties.
A number of intervention programs exist that target the accurate production of sentences to address agrammatism (e.g.,
Reduced Syntax Therapy, REST; Schlenck, Schlenck, & Springer, 1995; Springer, Huber, Schlenck, & Schlenck, 2000; Syntactic
Slot-Filler Approach; Fokes, 1976). When addressing agrammatism in young children, compensatory options can be used by
rst training the accurate production of simple sentences and monitoring for generalization and expansion to more complex
sentences. Techniques such as sentence break-down (i.e., breaking the sentence down into component parts such as subject-
verb-object, SVO) and subsequent build-up (i.e., producing the sentence in its entirety) along with drill-play and emphatic
stress to highlight missed or errorful grammatical morphemes could also be helpful.
It has been shownthat non Computer-Assisted Treatment (nC-AT) of expressive-grammar decits facilitates gains in the use
of targeted structures (Beeke, Wilkinson, & Maxim, 2003; Leonard et al., 2006; Leonard, Camarata, Pawlowska, Brown, &
Camarata, 2008). Similarly, use of computers is suggested to be a potentially viable option for the remediation of
agrammatical productions (Cohen et al., 2005; Washington &Warr-Leeper, 2006). Using these therapeutic programs, decits
in language knowledge resulting in agrammatical productions can be addressed by attempting to highlight obligatory
elements in the spoken language stream. While the effectiveness of intervention programs for older children with mixed
receptive-expressive SLI has been established (e.g., Cohen et al., 2005), little is known about the impact of computer-assisted
treatment (C-AT) versus nC-AT for younger children with SLI who may have decits in language knowledge, but do not have
obvious receptive-language impairments.
1.2.1. Computer-assisted treatment (C-AT) for children with SLI
One tool that may be a useful adjunct to conventional language intervention is the computer. The computer may be an
ecologically valid treatment tool due to its common place use within childrens everyday experiences. Use of appropriate
computer software could effectively address expressive-grammar decits in children with SLI (Gillam, Crofford, Gale, &
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Please cite this article in press as: Washington, K. N., et al. Exploring the outcomes of a novel computer-assisted treatment
program targeting expressive-grammar decits in preschoolers with SLI. Journal of Communication Disorders (2011),
doi:10.1016/j.jcomdis.2011.01.002
Hoffman, 2001). Reported gains made in treatments using a computer have been attributed to the fact that C-AT helps
children attend to tasks presented, thereby improving their awareness, understanding, and use of targeted elements (Gillam
et al., 2001, 2008). Most of the literature to date regarding the benets of computers in treatment for children with SLI has
focused on the use of Fast ForWord (FFW; Tallal et al., 1996). FFW is an internet-based software program that consists of
seven computerized instructional games targeting speech discrimination, language comprehension, syntax, morphology,
vocabulary, and memory using acoustically modied input (i.e., lengthening fast formant transitions) and visual
representations. Its implementation has however been discouraged with children under the age of six and those who may
also have a behavioural problem(Cohen et al., 2005). Given that there is a population of kindergarten children who are under
six years of age and could potentially benet from C-AT, a novel computer program, My Sentence Builder, was designed to
target expressive-grammar decits.
1.2.1.1. My Sentence Builder. The rst and second authors of the present study designed and developed a novel C-AT program
called My Sentence Builder (Washington & Warr-Leeper, 2006) to address expressive-grammar decits in preschool children
with SLI of an expressive nature. My Sentence Builder features components for present progressive sentences, one of the
earliest developmental sentence types acquired, which can be used to create grammatically correct sentences by a clinician
client dyad. This programwas designed with specic features to directly address expressive-grammar difculties thought to
be associated with hypothesized decits in VWM that affect speed of processing. Using a syntactic slot-ller approach,
children are shown various colour-coded screens containing pictures for the subject, the verb action, and the object in a
sentence. Grammatical morphemes and function words depicted in written formin triangles are placed in their appropriate
position in the sentence. The authors of My Sentence Builder conjectured that the slow, gradual, and deliberate constructionof
each sentence element with visual support for each syntactic slot and grammatical morpheme could address the observed
expressive-grammar decits.
The syntactic slot-ller approach chosen for the computer program was adapted from earlier paper versions, such as the
Fokes Sentence Builder (Fokes, 1976). Using this approach, grammatical components are orally and visually categorized into
various grammatical slots (e.g., WHO, IS DOING, WHAT) to facilitate comprehension and production. The purpose of this
categorization in My Sentence Builder is to highlight core sentence elements that are potentially missed by children with SLI.
Given that My Sentence Builder was designed to address expressive-grammar decits in children with SLI, it is important to
establish the effects of exposure to this computer-assisted treatment program on expressive-grammar outcomes for this
population of children.
1.3. Assessing treatment outcomes for children with SLI
A variety of language treatment programs have been designed and implemented to address expressive-grammar decits
in children with SLI. While it is important to both design and implement treatment programs for this population of children,
it is also critical that the outcomes of these programs are established. Previous studies (Cohen et al., 2005; Leonard et al.,
2006, 2008) evaluating the outcomes of language treatment programs for children with SLI have typically reported post-
treatment and follow-up (i.e., long-term post) performance using one assessment context. It has been suggested, however,
that language outcomes should be evaluated in different assessment contexts so that a complete representation of language
skills can be established post-treatment (Cleave & Rice, 1997; Sealey & Gilmore, 2008).
Researchers (e.g., Sealey & Gilmore, 2008) have suggested that formal and informal elicitation contexts should be
utilized when assessing language skills in children. Possible differences in context demands for formal versus informal
contexts are thought to have an effect on language performance. Specically, language information obtained from formal
contexts (e.g., language testing using standardized assessment tools) can occur under more optimally supportive
conditions where support for production is provided. In contrast, informal assessment contexts using spontaneous
language samples, which are considered the gold standard for assessing language skills in children (Miller, 1996), occur
under more naturalistic conditions with limited or no support provided for production. An informal assessment context
also provides an ecological format free from the bias known to be inherent in more formal contexts (Sealey & Gilmore,
2008).
Ultimately, performance obtained from language tests (formal context) is complementary to, but offers different
information about grammatical performance compared to conversational samples (informal context) (Beeke et al., 2003).
Therefore, it is important that both elicitation contexts are employed for assessing the outcomes of language treatment for
children with SLI.
1.4. Project rationale
The motivation for the current study was to provide assessment and intervention services for a group of 3-to-5 year old
preschoolers within the Ontario Preschool Speech and Language Initiative (OPSLI)-tykeTALK who demonstrated language
proles consistent with SLI, in particular those with decits in expressive grammatical morphology. These childrenexhibited
normal receptive language skills on the Peabody Picture Vocabulary Test-IIIB (PPVT-III; Dunn & Dunn, 1997) and the Clinical
Evaluation of Language Fundamentals-Preschool (CELF-P; Wiig, Secord, & Semel, 1992) and were deemed to have typical
cognitive skills as determined by the Kaufman Brief Intelligence Test-2 (KBIT-2; Kaufman & Kaufman, 2004). However,
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Please cite this article in press as: Washington, K. N., et al. Exploring the outcomes of a novel computer-assisted treatment
program targeting expressive-grammar decits in preschoolers with SLI. Journal of Communication Disorders (2011),
doi:10.1016/j.jcomdis.2011.01.002
assessment by registered SLPs revealed delays in their expressive-grammar knowledge and development. Essentially, these
children had an unexplained expressive-grammar delay despite having the cognitive capacity to learn language.
The sample of children within the OPSLI-tykeTALK demonstrated errors of omission for function words (e.g., Boy running
home), inaccurate use of pronouns (e.g., Him is eating a hotdog) and omission of nite verb endings (e.g., The boy is eat a
hotdog) on a language test, a formal context, and during the collection of a spontaneous language sample, an informal
context. It is possible that the dual task requirements for both tense and number agreement may be too demanding for these
children. However, use of appropriate software that provides a visual representation for every element of the sentence may
be more benecial than nC-AT or no treatment in targeting these decits.
This study evaluated the impact of a novel C-AT program, My Sentence Builder, for the remediation of expressive-grammar
decits affecting the production of third person singular present progressive sentences in a small sample of preschoolers
with SLI demonstrating normal receptive language skills. The present study used a formal and an informal context to
evaluate language outcomes pre-treatment, post-treatment, and 3-months post-treatment. Two treatment groups, C-AT and
nC-AT, were included and compared to a no treatment (NT) group. The research questions were: (1) Does use of C-AT result in
signicantly greater gains in a formal context than nC-AT or a no treatment (NT) condition? and (2) Does use of C-AT facilitate
signicantly greater gains in an informal context than nC-AT or a NT condition?
2. Methods
2.1. Ethics approval
Ethical approval for this research project was granted by the University of Western Ontario Ofce of Research Ethics.
2.2. Sampling and assignment
Participants were recruited fromthe OPSLI-tykeTALK, which provides government-funded speech and language programs
for children birth to 5 years of age who have been identied with communication disorders. Sixty-three potential
participants for the study were identied during standard assessment for services by registered SLPs. Parents were informed
about the study through a Letter of Information and discussion with the researchers and signed a consent form prior to
assessment and initiation of the study. Following parental consent, participants were consecutively assigned to C-AT or nC-
AT and subsequently completed testing related to the study. Representatives for the OPSLI-tykeTALK preferred this type of
recruitment and assignment to treatment groups.
To establish the impact of C-AT or nC-AT over NT, a control group was required. Parents of children who were not receiving
treatment (i.e., awaiting treatment) were asked to participate. The types of morphological errors demonstrated by these
children were consistent with treatment participants. This convenience sample of children served as control participants, no
treatment (NT).
2.3. Diagnostic criteria for SLI
To identify participants demonstrating SLI with primary expressive-grammar decits, the following diagnostic criteria
were used: (a) documented normal hearing sensitivity (i.e., passed a pure tone hearing screening at 500,1000, 2000, 4000 Hz
at 20 dB HL); (b) no parental report of middle ear infection or any episode of otitis media in the 12-months preceding the
study; (c) parent or SLP report of the absence of oral motor or neurological decits and pervasive developmental disorders;
(d) nonverbal IQ of 85 or higher on the KBIT-2; (e) receptive language skills within the normal range (i.e., standard score 85
115 or higher) at word and sentence levels as indicated by scores on the PPVT-IIIB and the CELF-P, respectively; and (f) below
age-level expressive language abilities (i.e., at or belowthe 10th percentile) as measured by both the Structured Photographic
Expressive Language Test-Preschool (SPELT-P; Werner & Kresheck, 1983) and the Developmental Sentence Scoring (DSS; Lee,
1974). As recommended by previous researchers (e.g., Sealey & Gilmore, 2008), language skills were evaluated using two
assessment contexts in this study. The SPELT-P provides assessment information in a formal context eliciting oral language
under optimally supportive conditions, similar to clinical probes conditions. The SPELT-P is a standardized test yielding raw
scores (i.e., number of correct responses) and corresponding percentile rankings. The DSS procedure provides information
about language use in an informal or natural context with no prompting for correct responses. DSS yields multiple measures
of language level use, including complexity, from a spontaneous language sample gathered during play with a clinician.
It should be noted that because the lower age limit on the KBIT-2 assessment tool is 4 years; 0 month, formal evaluation of
cognitive functioning was delayed for younger participants. Following earlier research guidelines (Goffman &Leonard, 2000)
clinical impressions of the SLP in conjunction with normal receptive language skills and placement in regular kindergarten
classrooms or Early Learning Environments were used as a proxy to suggest normal nonverbal functioning. Administration of
the KBIT-2 was completed for younger participants once they were age-appropriate for testing.
2.3.1. Non diagnostic criteria for inclusion into the study
The non diagnostic inclusion criteria were as follows: (a) between 3;0 and 5;11; (b) identied by registered SLPs as having
expressive language decits, with normal receptive language scores; (c) monolingual English speaker; (d) not receiving
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Please cite this article in press as: Washington, K. N., et al. Exploring the outcomes of a novel computer-assisted treatment
program targeting expressive-grammar decits in preschoolers with SLI. Journal of Communication Disorders (2011),
doi:10.1016/j.jcomdis.2011.01.002
additional treatment outside the study; (e) limited grammatical skills for grammatical morphemes such as auxiliary is,
progressive ing, pronouns and/or noun phrases as evidenced by performance on the SPELT-P (formal context) and DSS
(informal context); and (f) able to followsingle and multi-step spoken instructions. To ensure that participants had the skills
necessary to use the computer program, an additional criterion (established through informal evaluation) was that they have
knowledge of basic colours, shapes, and pictures with actions. To ensure that participants failure to use grammatical
morpheme endings (e.g., is and ing) was not attributable to phonological limitations, stimulability testing was completed
using a subtest of the Goldman Fristoe-Test of Articulation-2 (GFTA-2; Goldman & Fristoe, 2000).
2.4. Participants
Thirty-four of the original 63 children met the inclusion and diagnostic criteria. Participants were between the ages of 3;6
and 4;11 (years; months, M= 4;3) at the outset of treatment and met the inclusion criteria with no attrition. Seven of the
participants were female and 27 were male. This discrepancy in female to male ratio was expected given the higher
identication of SLI among boys. The group of children receiving C-AT (n = 11) ranged in age from 3;11 to 4;6 (M= 4;4), the
group of children receiving nC-AT (n = 11) ranged in age from 4;0 to 4;10 (M= 4;5), and the group of controls, NT (n = 12)
ranged in age from 3;6 to 4;11 (M= 4;1). Despite participants limited grammatical skills, they all had early emerging use of
grammatical morphemes such as is, ing, and subjective pronouns (e.g., s/he). Results on One-Way ANOVAs revealed that
participants were equivalent in pre-treatment performance for age (p = .126), language (CELF-P, p = .374; PPVT-IIIB, p = .087;
SPELT-P, p = .080; DSS, p = .127) and cognition (p = .443). See Table 1.
2.5. Procedures
2.5.1. Assessment protocol
Participants completed a 90-minute pre-treatment assessment session where the SPELT-P, CELF-P, PPVT-IIIB, and KBIT-2
were administered and a spontaneous language sample was collected. The language assessment batteries were completed
by registered SLPs or graduate students supervised by registered SLPs. The IQ measure (i.e., the KBIT-2) was administered by
the rst author. Administration of the SPELT-P was completed pre-, post- and 3-months post-treatment by blinded assessors.
Given the high test-retest reliability of the SPELT-P (r = .94 for 3 year olds, r = .86 for 4 year olds, and r = .97 for 5 year olds)
learning effect issues for the three time administration over a 24-week period were not a major concern.
The spontaneous language samples were collected following the DSS procedures outlined by Lee (1974). Forty-ve-
minute language samples were obtained during play with a nave sampler (i.e., individual samplers blinded to the group
membership of each participant) in pre-, post- and 3-months post-assessment sessions. The same two books and a large-
scale doll house along with household objects and people were utilized to facilitate spontaneous productions for all
participants. Language samples were recorded digitally. A minimum of 100 complete and intelligible utterances were
collected fromeach participant. Testretest issues were less of a concern for the collection of language samples as these were
elicited under naturalistic conditions and responses were spontaneous at each assessment time point. However, reliability
for the procedures involved in collecting the language samples was addressed.
2.5.1.1. Transcription, scoring, and reliability for language samples. Four graduate students were recruited to assist in the
collection and analysis of spontaneous language samples collected at pre-, post-, and 3-months post-treatment. Two
graduate students were trained on two tasks: (a) procedures necessary to collect a representative sample and (b) accurate
transcription of samples. These graduate students were randomly assigned to collect or transcribe samples. A third graduate
student was trained on the selection of 50 different utterances to be used in scoring, while a fourth student received training
for DSS scoring of utterances. Each of the four individuals was unaware of participants group assignment and the studys
purpose. The individuals trained to collect and transcribe language samples were partially blinded to assessment time point
Table 1
Participants by group, age, sex, mean language and cognitive scores.
Group Age range Male Female Mean pre-treatment scores
KBIT-2 DSS SPELT-P PPVT CELF-P
Group 1 (C-AT) 3;11 to 4;6 8 3 112.27 4.81 10.09 103.64 103.36
(n = 11) SD= 12.35 SD= 1.08 SD= 2.30 SD= 5.71 SD= 8.65
Group 2 (nC-AT) 4;2 to 4;10 8 3 108.45 5.21 12.27 102.73 100.36
(n = 11) SD= 9.61 SD= .66 SD= 3.38 SD= 3.77 SD= 8.10
Group 3 (NT) 3;6 to 4;11 11 1 106.92 4.51 8.58 99.42 99.75
(n = 12) SD= 8.24 SD= .54 SD= 4.99 SD= 4.30 SD= 2.90
Total (Groups) 3;6 to 4;11 27 7 109.15 4.84 10.26 101.85 101.21
(n = 34) SD= 10.10 SD= .82 SD= 3.97 SD= 4.88 SD= 6.95
Note: K-BIT2: The Kaufman Brief Intelligence Test-2; PPVT-IIIB: Peabody Picture Vocabulary Test-IIIB; and CELF-P: The Clinical Evaluation of Language
Fundamentals-Preschool. Pre-treatment performance on the Structured Photographic Expressive Language Test-Preschool (SPELT-P) and Developmental
Sentence Scoring (DSS), obtained from a spontaneous language sample, was at or below the 10th percentile.
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Please cite this article in press as: Washington, K. N., et al. Exploring the outcomes of a novel computer-assisted treatment
program targeting expressive-grammar decits in preschoolers with SLI. Journal of Communication Disorders (2011),
doi:10.1016/j.jcomdis.2011.01.002
(i.e., not informed of the participants assessment time points). Even though the two assessors were randomly assigned to
collect and analyze the language samples, with only two trained assessors, it was possible that each assessor would have to
see a participant more than once, thus resulting in the assessors not being completely unaware of assessment time point. The
third and fourth graduate students who completed the assessment of outcomes portion of the language samples (i.e.,
selecting and scoring sentences) were completely blinded to participants group assignments and assessment time points.
2.5.1.1.1. Agreement analyses. Two additional graduate speech-language pathology students completed agreement
procedures. These students had linguistic studies backgrounds and were unfamiliar with the purpose and details of the
study. The agreement procedures included point-to-point comparisons for word transcription, appropriate DSS sentences,
and for DSS scoring. To complete the agreement procedures, the second author, a certied SLP and professor with expertise in
DSS, trained the two individuals to transcribe the original digitally recorded samples, to identify DSS appropriate sentences
from transcripts, and to assign DSS scores to sentences chosen. Ten of 102 samples (i.e., 10%) were randomly selected to
establish agreement between the original DSS information and those randomly selected for re-evaluation by the two
graduate SLP students. In accordance with previous research (Cleave & Rice, 1997) that has established reliability or
agreement for language samples, it was stipulated that each sample chosen was unique (i.e., froma different participant) and
that selected samples were chosen equally from the groups.
Point-to-point comparisons of independent ratings were utilized to determine average agreement across the randomly
chosen samples. Agreement of word transcription averaged 91.3%. Agreement for identication of DSS appropriate sentences
chosen from written transcripts averaged 97.2%. Final agreement of DSS scoring for DSS category and number assignment
was 90.8%. The original DSS scores were compared to the comparison scores for the collected samples. Differences averaged
only .09 DSS points.
2.5.2. Treatment procedures
2.5.2.1. Therapeutic program routine. Participants received ten, 20-minute treatment sessions occurring once weekly:
Step 1: All treatment sessions began with an introduction to the expected routine followed by a practice block, 2-to 7-
minutes in duration. Depending on the goals being addressed, a reminder would be givento use the before boy or girl or to use
the special word s/he when starting to talk about the boy or girl. To elicit the subject of the sentence the question, Who do
you want to play? was chosen. This question was deemed more appropriate if the target response was the boy or the
girl. However, if the target response were he or she, the clinician would probe further by saying, What word do we use for
the boy/girl whenwe start. This additional probing was deemed necessary as the pragmatic or natural response to the initial
who-question could be him/her.
Steps 2 and 3: The questions What is s/he doing and What does s/he want to play with were utilized to elicit the verb
and object of the sentence, respectively.
Step 4: The treatment session followed the routine outlined in Steps 13 until 80% accuracy on average over two
consecutive sessions was achieved. Participants moved directly to sentence build-up at the beginning of the subsequent
session.
Here, participants were told to put it all together when talking about what the boy or girl was doing. See Appendix B for
a sample treatment routine.
2.5.2.2. Treatment differences. C-AT: My Sentence Builder has seven colour-coded screens containing images to facilitate
production (see Fig. 1): (1) sentence creation; (2) subject selection; (3) verb selection; (4) object selection; (5) sentence
selection; (6) animation production containing audio recordings of actions; and (7) grammatical morpheme screen.
This program contained sequences where participants sentences were broken down to the phrase level (e.g., noun
phrase in the subject and object slots and a verb phrase) and then built up into a full sentence containing all necessary
elements. The clinician rst took clients to the sentence creation screen where it was highlighted that they were going to
make up things about boys or girls. Clients were then taken to the subject-selection screen and following the appropriate
wh-question, they selected a boy or a girl. Once the subject picture was selected, it was placed into a slot located in a
sentence box located at the bottomof the screen. The clinician then proceeded to the verb-selection screen. Once the verb
was selected, it was placed in the sentence box at the bottomof the screen. Finally, the object of the sentence was selected
and placed in the sentence box. Then, the client was prompted to put it all together and following correct production of
the sentence was then taken to the animation production screen where an animation, containing audio-recordings of
actions, was completed (see Fig. 1). The key difference between C-AT and nC-AT was the slowdeliberate attempt to provide
visual representation of every element of the sentence, including grammatical and inectional morphemes, needed to
produce a correct present progressive sentence. Therefore, potentially missed items could be highlighted, thus facilitating
production.
nC-AT: This training program consisted of typical table-top procedures where clinicianclient dyads engaged in
sentence production, using pre-determined materials (e.g., felt or paper doll house pieces including a couch, a car, a mommy
and a daddy) and clinician-facilitated play and drill-based activities in combination with focused stimulation. Participants
were given verbal instructions with limited visual support for production provided by objects in play. Emphatic stress was
included to facilitate attention to sentence components. This technique of oral manipulation (i.e., verbally stressing) has
been recommended (Fey, Long, & Finestack, 2003) to increase the salience of unstressed grammatical targets.
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doi:10.1016/j.jcomdis.2011.01.002
No treatment: A group of children awaiting treatment served as control participants.
2.5.3. Procedural validity
To ensure treatment delity one clinician, the rst author, a registered SLP, provided all intervention sessions. To
determine adherence to treatment protocol for the present study, 20% of sessions (i.e., 44 sessions) were randomly recorded
and scored for accuracy of the treatment implementation by graduate students in speech-language pathology. A checklist of
the critical treatment elements was utilized for scoring. Of the 44 sessions selected, it was determined that the clinician
adhered to an invariant protocol 100% of the time for all intervention sessions.

Fig. 1. Sample screens for My Sentence Builder (MSB). Viewing order: sentence creation, agent selection, action selection, recipient selection, animation
selection, and lastly animation Production. The treating clinician viewed the grammatical screen while formulating the sentence creation screen.
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doi:10.1016/j.jcomdis.2011.01.002
3. Statistical analyses
One-way Analyses of Covariance (ANCOVA) were completed to answer each research question. For each ANCOVA the
independent variable group included three levels, C-AT, nC-AT and NT. The dependent variables were post-treatment or 3-
months post-treatment raw scores on the SPELT-P or DSS and the covariate was SPELT-P or DSS pre-treatment raw scores.
Preliminary analysis for the SPELT-P post-treatment ANCOVA did not support the homogeneity-of-slopes assumption. As
recommended (Green & Salkind, 2008) a simple main effects test using the Univariate Analysis of Variance (ANOVA) was
used for this question only. Planned posthoc tests were completed for signicant F values. An alpha level of .05 was used for
to establish statistical signicance unless otherwise specied.
Raw scores were entered into the Statistical Program for the Social Sciences (SPSS) Version 18.0.0 computer program
(PASW Statistics, 2009) to complete the ANCOVAs. Use of raw scores has been recommended when determining
treatment outcome for children with language impairments because it is not realistic to expect noticeable relative gains
(i.e., standard score or percentile rank changes) over a limited period of time in treatment (Hadley, Olsen, & Earle, 2005).
Please note that the term post-treatment used in the results refers to the time point immediately following the end of
treatment.
4. Results
4.1. Research Question 1: does use of C-AT result in signicantly greater gains in a formal context than nC-AT or a NT condition?
4.1.1. Assessing mean differences between groups for SPELT-P post-treatment performance
To complete the Univariate ANOVAs, three levels on the covariate were chosen representing low (one
standard deviation below the mean), medium (the mean), and high (one standard deviation above the mean) values.
The mean and standard deviation (SD) on SPELT-P raw scores, across groups, were 10.26 and 3.97, respectively.
Accordingly, low, medium, and high values were 6.29, 10.26, and 14.23. Simple group main effect analyses assessed
differences among group means at low, medium, and high values on the covariate. Using a Bonferroni correction, a p
value of .017 (.05/3) was required for signicance for each of these tests. If any one simple group main effect was
signicant, post hoc analyses using pairwise comparisons were evaluated at the same level (i.e., .017) as the simple
main effect test.
The simple group main effect test was signicant for low, F(2, 28) = 3.57, p <.001, partial h
2
of .69 and medium, F(2,
28) = 31.47, p <.001, partial h
2
of .69, values on the covariate. In contrast, the simple group main effects test was
not signicant for a high pre-treatment SPELT-P raw score, F(2, 28) = 4.65, p = .018, partial h
2
of .25. Pairwise comparisons
revealed C-AT and nC-AT yielded signicantly higher SPELT-P scores at post-treatment than the NT condition for both
low and medium pre-treatment SPELT-P scores. There were however, no signicant differences between C-AT and nC-
AT. These results suggested that use of C-AT did not result in signicantly greater gains post-treatment in a formal
context compared to nC-AT. However, signicant differences in performance between the use of C-AT and NT were
evident.
4.1.2. Completion of the ANCOVA for 3-months post-treatment SPELT-P scores
Another ANCOVA was completed to determine if signicant differences existed among SPELT-P scores collected at 3-
months post-treatment for participants in C-AT, nC-AT, and NT. The ANCOVA was signicant, F(2, 30) = 36.83,
MSE = 6.922, p <.001. The strength of relationship between group and post-treatment raw score was very strong as
assessed by a partial h
2
, with group accounting for 71% of the variance of the dependent variable, holding constant
SPELT-P pre-treatment scores. C-AT had the largest adjusted mean (M= 20.73), nC-AT had a smaller adjusted mean
(M= 19.18), and the NT condition had the smallest adjusted mean (M= 11.42). Planned post hoc tests (p = .017) were
completed using tukey HSD. Evaluation of pairwise differences among the adjusted means demonstrated that both C-AT
and nC-AT participants had signicantly higher SPELT-P scores than NT participants. Differences were not signicant
(p = .020) between the C-AT and nC-AT; however, treatment worked better than NT in improving participants abilities for
grammatical productions when probed 3-months post-treatment. See Fig. 2 for post-treatment and 3-months post-
treatment SPELT-P performance.
4.1.3. Clinically meaningful differences in SPELT-P performance
Establishing clinically meaningful differences in performance post-treatment and 3-months post-treatment is important
to help determine the effectiveness of implemented treatment programs. To establish whether or not differences were
clinically meaningful, movement in mean score performance beyond the 10th percentile was examined at post-treatment
and 3-months post-treatment. Inspection of mean performance on the SPELT-P revealed movement beyond the 10th
percentile (i.e., clinically meaningful change) pre-to-post-treatment for: (1) eight of 11 C-AT participants; (2) all 11 nC-AT
participants; and (3) two of 12 NT participants. For post-treatment to 3-months post-treatment performance, the following
was observed: (1) eight of 11 C-AT participants; (2) six of 11 nC-AT participants; and (3) zero NT participants. This
information demonstrated that the preschoolers receiving treatment were able to achieve movement beyond their starting
point levels compared to their NT cohorts.
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doi:10.1016/j.jcomdis.2011.01.002
4.2. Research Question 2: does use of C-AT facilitate signicantly greater gains in an informal context than nC-AT or a NT condition?
4.2.1. Completion of the ANCOVA for post-treatment DSS scores
The ANCOVA for post-treatment scores was signicant, F(2, 30) = 13.44, MSE = .96, p = .342. The strength of relationship
between group and post-treatment DSS scores was very strong, as assessed by partial h
2
, with group accounting for 47% of
the variance in the post-treatment scores, holding constant the pre-treatment DSS scores. Post-treatment scores adjusted for
initial differences were ordered as expected across the three groups. C-AT participants had the highest adjusted mean
(M= 6.32), followed by nC-AT participants (M= 5.70), and then NT participants with the smallest adjusted mean (M= 4.21).
Planned post hoc tests (p = .017) were completed using tukey HSD values.
Evaluation of pairwise differences among the adjusted means demonstrated that both C-AT and nC-AT participants had
signicantly higher DSS scores than NT participants. There were no signicant differences between the C-AT and nC-AT,

Fig. 2. Estimated mean performance on the SPELT-P at post- and 3-months post-treatment for ANCOVA analyses.
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suggesting equivalence in performance levels. Once again, the use of C-AT resulted in signicantly greater gains in
expressive-grammar skills post-treatment compared to NT only.
4.2.2. Completion of the ANCOVA for 3-months post-treatment DSS scores
A signicant ANCOVA was also noted for 3-months post-treatment DSS scores F(2, 30) = 15.78, MSE = 1.61, p <.001. The
strength of relationship between group and post-treatment DSS scores was very strong, as assessed by partial h
2
, with group
accounting for 51% of the variance in the 3-months post-treatment scores, holding constant the pre-treatment DSS scores.
Three-month post-treatment scores adjusted for initial differences showed the same order as post-treatment: C-AT
participants (M= 7.24), followed by nC-AT participants (M= 6.63), and then NT participants (M= 4.34). Planned post hoc tests
(p = .017) were completed using tukey HSD values. Both C-AT and nC-AT participants had signicantly higher DSS scores than
NT participants. There were no signicant differences between C-AT and nC-AT. See Fig. 3 for DSS post-treatment and 3-
months post-treatment performance.

Fig. 3. Estimated mean performance on DSS for at post and 3-months post-treatment for ANCOVA analyses.
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4.2.3. Clinically meaningful differences in DSS performance
Similar to SPELT-P performance, DSS scores revealed movement above the 10th percentile (i.e., clinically meaningful
change) pre-to-post-treatment for: (1) seven of 11 C-AT participants; (2) two of 11 nC-AT participants; and (3) no NT
participants. For post-treatment to 3-months post-treatment: (1) nine of 11 C-AT participants; (2) four of 11 nC-AT
participants; and (3) zero NT participants demonstrated movement above the 10th percentile. Results suggested that C-AT
and nC-AT facilitated immediate and continued language growth for spontaneous use of language better than NT. It appears
that participants spontaneous language skills at post-treatment and 3-months post-treatment greatly benetted from
treatment targeting expressive-grammar decits. For this sample of children, participants in the NT group did not experience
noted gains in their spontaneous language skills at either time point. Examination of DSS transcripts revealed that C-AT and
nC-AT participants produced sentences beyond the S-V-O present progressive sentences drilled in intervention (see
Appendix C).
5. Discussion
The primary purpose of this study was to establish the outcomes of a novel C-AT programdesigned with specic features.
The program provided visual representation of every sentence element to address expressive-grammar decits in children
with SLI. The outcomes of language treatment were evaluated in two different assessment contexts across time to establish a
complete representation of language skills following intervention. Two comparison groups, nC-AT and NT, were included to
address the studys research questions: (1) Does use of C-AT result in signicantly greater gains in expressive-grammar skills
in a formal context than nC-AT or a NT condition? and (2) Does use of C-AT result in signicantly greater gains in expressive-
grammar skills in an informal context than nC-AT or a NT condition?
5.1. General ndings
Two primary ndings were obtained fromthe results of this study. First, treatment, regardless of its type, was better than
NT for facilitating signicantly greater expressive-grammar gains in a formal and informal context in young children with
SLI. The second nding was that the use of the C-AT program, My Sentence Builder, does not result in signicantly greater gains
compared to nC-AT in either assessment context. These results suggest that use of C-AT does not offer a therapeutic
advantage over use of nC-AT for the remediation of expressive-grammar decits. A discussion of these ndings follows in the
proceeding sections of this paper.
5.1.1. Outcomes of language treatment
Results from ANCOVAs and assessments of mean differences for groups support the conclusion that use of both C-AT and
n-CAT provided a therapeutic advantage over NT. This advantage was maintained for expressive-grammar outcomes
established post-treatment and 3-months post-treatment on the SPELT-P (a formal, contrived context) and DSS of
spontaneous language samples (an informal, non-contrived context). The statistically signicant gains in performance for
both treatment groups over NT were also found to be clinically meaningful with improvements occurring beyond the 10th
percentile for a large percentage of C-AT and nC-AT participants. In a formal context 86% of treatment participants
experienced clinically meaningful gains in performance post-treatment and 63% of these participants maintained these
gains at 3-months post-treatment. In an informal context, 40% of treatment participants achieved improvements beyond the
10th percentile post-treatment and 59% maintained these gains at 3-months post-treatment. However, only 17% of NT
participants experienced clinically meaningful gains at post-treatment in a formal context. Further, participants in the NT did
not experience clinically meaningful gains in performance in an informal context at post-treatment or at 3-months post-
treatment.
Improvements beyond the 10th percentile in this study were an important clinical marker in performance as it
demonstrated the effectiveness of intervention regardless of treatment type in two different assessment contexts.
Meaningful language gains beyond that of a contrived context, where optimal support is provided for production, can
therefore be achieved when C-AT or nC-AT rather than NT is utilized. These results provide added support for the benecial
role of treatment over NT for the remediation of expressive-grammar skills in this sample of preschoolers with SLI,
uncomplicated by receptive language difculties.
The lack of signicance found between outcomes for C-AT and nC-AT is consistent with previous treatment studies (e.g.,
Cohen et al., 2005) involving older children with SLI with obvious receptive language difculties. Therefore, it can be
concluded that C-AT is as effective as nC-AT in remediating expressive-grammar decits in older and younger children with
SLI. Further, the equivalence in results found in the current study suggests that both types of treatment programs are
benecial intervention tools. Accordingly, results of this study provide experimental support for the implementation of C-AT
and nC-AT as viable treatment options for preschoolers with SLI with primary decits in expressive-grammar skills.
5.1.2. Features of C-AT and nC-AT providing a therapeutic advantage over NT
Given that the use of C-AT and nC-AT were found to be equally effective in addressing expressive-grammar decits, it is
possible that shared features for both treatment programs rather than unique features of C-AT were also important to
successfully addressing expressive-grammar decits. For C-AT, unique features included use of a syntactic slot-ller
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approach with visual representation of all sentence elements to demonstrate their appropriate placement in target present
progressive sentences. C-AT participants were thought to therefore have more time to slowly, sequentially, and directly
observe how these sentences were constructed.
For nC-AT, the unique feature was use of repeated emphatic stress. This oral manipulation technique was included to
highlight unstressed grammatical targets in sentences. The use of oral manipulation without an abundance of visual support
was another way of addressing expressive-grammar decits. Therefore, participants receiving nC-AT were also exposed to
techniques (i.e., verbally stressing) designed to facilitate an awareness of all parts of sentence construction, including
typically unstressed grammatical components.
For both C-AT and nC-AT, there were several shared features of the treatment programs. These included: (1) repetitious
exposures to target forms, (2) use of elicitation techniques and multiple practice opportunities, and (3) cognitive load placed
on VWM. These shared features are possible reasons why treatment was better than NT in facilitating expressive-grammar
skills for the sample of preschool children. Each of these features will be discussed separately.
5.1.2.1. Repetitious exposures to target forms. According to Cleave and Rice (1997), children with SLI benet from more
rigorous treatment approaches that emphasize language production to facilitate the development of expressive-grammar
skills. In this study, the numerous exposures to the target forms (approximately 20003000 over the treatment block)
facilitated treatment participants increased awareness of the accurate forms for grammatical structures. The results of this
study therefore support the benet of numerous repetitions of grammatical structures to facilitate the correct production of
sentences.
5.1.2.2. Use of elicitation techniques and multiple practice opportunities. Drill-play and indirect language stimulation (i.e.,
sentence break-down and sentence build-up) within focused stimulation activities were included within both treatment
programs. Use of these programs may have helped to increase treatment participants knowledge about all of the necessary
components of a grammatically correct sentence. Further, because there were multiple opportunities of focused practice, the
routine for learning may have become more automatic. As a result, treatment participants potentially exerted less cognitive
effort to create grammatically accurate and more complex productions thus increasing processing abilities.
5.1.2.3. Cognitive load placed on VWM. It is conjectured that children with SLI experience inadequate short-term memory
representations for verbally presented information that negatively affects speed of processing (Archibald & Gathercole,
2006; Leonard et al., 2007). These children therefore require the implementation of appropriate language interventions to
address the load placed on VWM. In the current study, the implemented language treatments contained specic shared
features (e.g., repetitious exposures to target forms, use of elicitation techniques, and multiple practice opportunities) that could
have helped to decrease the amount of learning effort expended by treatment participants. In particular, the combination of
these features possibly facilitated the enhancement of each treatment participants language knowledge needed to support
time-dependent grammatical learning. In contrast however, NT participants were not exposed to these therapeutic program
features that provided opportunities in language learning to help address their learning effort.
5.1.3. Observations of the interventionist
It has been acknowledged that shared features of both treatment programs facilitated an advantage over NT and that no
differences in outcomes existed between the two treatment programs for post-treatment and follow-up performance in
either assessment context. However, the interventionist (rst author) did observe anecdotal differences in motivation and
behavior (e.g., attention, cooperation) between the two groups of treatment participants across sessions. Using informal
clinical observations, the interventionist noted that compared to nC-AT participants during their treatment sessions, C-AT
participants: (1) were more eager, attentive and engaged during training, (2) were more cooperative with tasks, (3) had more
tolerance for making mistakes, (4) required less prompting to participate (i.e., redirection to tasks), and (5) were more
patient with the multiple requests for productions made by the interventionist. Further, it was noted that the use of the
computer software program may have had an intrinsic reward, as C-AT participants did not make as many requests for
external reinforcers compared to nC-AT participants. In the end, it appeared that C-AT participants may have experienced
more enjoyment for their medium of instruction compared to their nC-AT cohorts, resulting in less effort on the part of the
interventionist to elicit cooperation. These observations are in part supported by earlier research (e.g., Gillam et al., 2001,
2008) suggesting the use of C-AT helped children attend to tasks presented, thus contributing to their improved awareness,
use, and understanding of targeted structures. Given that behaviour management can be a signicant challenge for SLPs
working with children with communication disorders, it might be important for SLPs to know that use of C-AT, via My
Sentence Builder, resulted in better cooperation compared to nC-AT.
5.1.4. Wide-range impact (functional effects) of treatment
Threats (2003) suggests that the question of whether a child is able to move beyond that targeted in treatment, allowing
for participation in the mainstream, should be addressed. This type of generalization is considered to be the ultimate
therapeutic outcome.
A review of the participating childrens spontaneous language samples collected at post-treatment and 3-months post-
treatment revealed many sentence constructions well beyond the S-V-O sentences drilled in treatment. Successful and
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doi:10.1016/j.jcomdis.2011.01.002
unsuccessful attempts at using other grammatical features in sentences were observed (e.g., use of prepositions, negation,
subordinating and coordinating conjunctions). DSS scoring detected these grammatical features as advancement in the use
of grammatical structures. The signicantly greater DSS scores achieved by C-AT and nC-AT participants compared to NT
participants were suggestive of improved general language development in the spontaneous use of expressive-grammar
skills outside the clinical setting.
According to Gillam et al. (2001) performance measures that use language samples are better indicators of childrens
abilities to effectively apply expressive-grammar rules in their everyday settings than are standardized tests or probes. The
signicant impact of both treatments over NT established in an informal and uncontrived context suggested that achieved
language gains were extended to functional (i.e., real life) situations. Parents of preschool children receiving treatment
provided unsolicited comments that their children produced spontaneous sentences that were more mature, creative,
complete, and informative. However, parents of control participants commented that continued difculties in producing
grammatically correct productions were obvious.
Differences in the impact of spontaneous language skills on childrens participation (involvement in a life situation;
World Health Organization, 2007) were also observed. Parents of treatment participants reported that as a result of the
progression in their childs oral language skills, they were more likely to initiate and also be included in social interactions
with others. However, parents of control participants reported that less mature oral language skills had a negative effect on
participating in games and socializing well with others. These comments suggest that the improved language skills of the
treated children facilitated productive social communication skills.
5.1.5. Summary
Participants receiving NT did not receive frequent or rigorous targeted practice nor was the load on VWM addressed.
These factors may have resulted in the lower expressive-grammar gains observed in both assessment contexts compared to
the treatment groups. According to Cleave and Rice (1997), children with SLI have an erroneous rule about grammatical
morphemes (i.e., optional use versus obligatory use) due to their lack of knowledge about the critical role played in
producing complete and accurate sentences. Consequently, directly addressing decits in language knowledge is needed to
support production. Further, it appears that treatment is needed to facilitate a wide-range impact on childrens functional
communication skills post-therapy, resulting in greater inclusion in the mainstream.
6. Clinical implications
The results of this study are important because they support the effectiveness of language therapy for this group of
children. It has been suggested that, without effective treatment, noteworthy gains in the areas of grammar may not be
observed (Fey, Cleave, Long, & Hughes, 1993, p. 149). Use of C-AT and nC-AT resulted in signicant gains immediately
following treatment and were maintained 3-months post-treatment. Additionally, evidence of clinically meaningful gains
(i.e., improvement beyond the 10th percentile) in language performance following language therapy was evident. The
importance of the assessment context in evaluating treatment effectiveness was also highlighted in the present study.
Specically, only treatment participants demonstrated expressive-grammar gains in both a formal context (i.e., language
testing using the SPELT-P) and an informal context (i.e., spontaneous language samples analyzed for grammatical growth
utilizing DSS procedures). Lastly, while there was no evidence to support an advantage for C-AT over nC-AT for post-
treatment and follow-up expressive-grammar outcomes, it does appear that use of C-AT can facilitate more cooperation and
attention during training tasks across treatment sessions for this population of children.
7. Conclusion
Treatments designed to directly address expressive-grammar decits can lead to signicantly greater increases in
expressive-grammar skills compared to NT. Use of C-AT is as effective as nC-AT making it another viable tool for enhancing
the effectiveness of expressive-grammar treatment for children with SLI. VWM appears to play a signicant role in
expressive-grammar skills development and needs to be considered when working with children with SLI. In particular,
when creating treatment programs to address expressive-grammar decits, the load placed on VWMneeds to be considered.
Because this disorder population struggles with the proper development of expressive-grammar skills that can lead to
long-term negative consequences in both the academic (e.g., literacy) and social realms, it is important that all effective
treatment routines be considered. Given the increased need for evidence upon which to base, guide, and continuously
improve clinical practice for this population, it is necessary that continued research using multiple assessment contexts be
completed.
8. Limitations of study and future directions
Application of the study ndings to typical general clinical populations of preschoolers with language impairment who
also have receptive problems may be limited. Another limitation was that a true randomization selection procedure could
not be utilized. It is possible that because these parents self-selected for the study, they were more likely to complete the
study than parents who were randomly selected. Finally, the small sample size restricts the weight of the conclusions that
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can be drawn. In particular, the tendency noted for larger post-treatment and 3-months post-treatment mean scores for C-AT
compared to nC-AT requires further exploration.
In this study, potentially meaningful between treatment group differences may not have been detected due to power
limitations. Results approached signicance for post-treatment and 3-months post-treatment scores on the SPELT-P and DSS.
A larger sample may have detected a between groups difference for C-AT and nC-AT. Continued research is needed to conrm
the observed trend in mean scores. Future investigations could be completed using a larger and more representative sample
of preschoolers with SLI to more condently establish outcomes with different treatments for this population of children.
Acknowledgements
The current research was supported by the Canadian Language and Literacy Research Network (CLLRnet), Graduate
Scholarships fromthe Ontario Government, the Research Alliance for Children with Special Needs (RACSN), and a University
of Western Ontario Graduate Thesis Award. We thank tykeTALK families, children and clinicians (Melissa McDonald, Amy
Price, Jennifer Schidowka, and KimSpylo) associated with this project. We especially thank Caitlin Zammit, Ellyn Thompson,
Julia Colangeli and Andrea Chance for their invaluable contributions. Software developers fromDykstra Consulting and Juan-
Carlos Bodo Inc are also acknowledged for their contributions. Further gratitude is extended to research clerks, graduate
students, and volunteers who assisted in various stages of this study.
Appendix A. Continuing Education Questions
(1) Children with SLI demonstrate decits in language knowledge. True/False
(2) Children with SLI demonstrate hypothesized decits in verbal working memory. True/False
(3) Morphological decits affecting grammatical productions are not a common manifestation in children with SLI. True/
False
(4) Which outcome contexts were described in this study for use in evaluating expressive-grammar skills in children with
SLI?
a. Formal contexts (e.g., more standardized approach to testing)
b. Informal contexts (e.g., spontaneous language sampling)
c. All of the above
(5) C-AT is another viable option in the remediation of expressive grammar decits in preschoolers with SLI. True/False
Appendix B. Sample ClinicianClient Intervention Dyad
Clinician: We are going to talk about boys or girls doing different things. You will have lots of time to practice telling me what
different boys or girls are doing. I will be helping you a lot. Now lets start.
Clinician: Who do you want to play with?
Client: boy.
Clinician (using emphatic stress or pointing to grammatical image): Boy?
Client: The boy.
Clinician: What is the boy doing? The boy. . .
Client: catching.
Clinician (using emphatic stress or pointing to grammatical image): catching?
Client: is catching.
Clinician: What is the boy catching? The boy is catching. . .
Client: A sh.
Clinician: Now put it all together.
Client: The boy is catching a sh.
Appendix C. Sample DSS transcripts
Assessment
time point
C-AT nC-AT NT
Pre Book reading activity
Clinician This is called Spot Bakes
a Cake. Does he look like hes
baking a cake on the front?
Participant He licking a poon.
(DSS = 2)
Playing with objects and a doll house
Clinician Hey what are they doing?
Participant Them baking a cake.
(DSS = 0)
Book reading activity
Clinician Whats happening?
Participant He eating cake.
(DSS = 2).
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Please cite this article in press as: Washington, K. N., et al. Exploring the outcomes of a novel computer-assisted treatment
program targeting expressive-grammar decits in preschoolers with SLI. Journal of Communication Disorders (2011),
doi:10.1016/j.jcomdis.2011.01.002
Appendix A (Continued )
Assessment
time point
C-AT nC-AT NT
Post-treatment Book reading activity
Clinician But if Mom puts the
cake in the oven and the mouse
popped up, what would Mom say?
Participant I dont know where
my friend Mouse went. (DSS = 21)
Playing with objects and a doll house
Clinician Lets go check the mail.
Participant We dont have any
mail. (DSS = 19)
Playing with objects and a dolls
Clinician Theres cake, yeah.
Go easy on the icing.
Participant Do you like those?
(DSS = 15)
3-months
Post-treatment
Playing with objects and a doll house
Clinician Watch out for sneaky
animals?
Participant Dont let them get any
food. (DSS = 24)
Book reading activity
Clinician Were going to read a
book. Lets sit at this table.
Participant I didnt know we had
another table. (DSS = 22)
Playing with objects and a doll house
Clinician Maybe we can get the
brother to play with his sister?
Participant He wont do it.
(DSS = 16)
Note: Sample transcripts were randomly chosen for three participants. For pre-treatment, the sample sentences chosen represented the lowest DSS score in
the transcript for each participant. For post-treatment and 3-months post-treatment, the sample sentences chosen represented the highest DSS scores in
the transcript for each participant.
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doi:10.1016/j.jcomdis.2011.01.002