***** I would like to use the Reversal Design (ABA) to conduct research on the number of correct homework completion with the addition of an intervention.
Designing Research
In this section, you will now consider a research study you would be interested in conducting. Considering all of material from this course, please answer the following prompts that would be in your introduction and methods section. Introduction (30 points)
- a) Topic: Briefly describe your topic of interest and why it is important. Importance should be related to previous research in the field and need to assess the intervention. (5 points)
- b) Literature Review: Locate an article related to your topic of interest. Indicate how it is related to your topic of interest. Be sure to cite it in APA style. (5 points)
- c) Research Question :Create a research question based on the topic. Remember to include all of the components of a good research question. (10 points)
- d) Independent Variable: Identify the intervention or treatment package. (5 points)
- e) Dependent Variable: Identify the target behavior(s). (5 points)
Method (70 points)
- a) Participant(s):Describe the population and justify why they were selected for your study. (5 points)
- b) Measurement Procedure: Identify how you will capture the dependent variable and include whether the measurement you selected is continuous or discontinuous. (10 points)
- c) Design: Select one single-case design and justify the reason for selection. (10 points)
- d) Measurement Integrity: Based on your measurement procedure and design, indicate which IOA procedure you will use. (10 points)
- e) Procedural Integrity: Describe how you will account for treatment integrity. (5 points)
EDF 6437 FINAL PROJECT Method (70 points) Continued
- f) Maintenance and Generalization: Describe considerations for maintenance and generalization. (10 Points)
- g) Social Validity :Defend how your study has social validity(5points)
- h) Ethical Considerations: Identify any ethical considerations in your research, such as consent, assent, conflicts of interest, etc. (5 points)
- i) General: Indicate where your visual display of data be located in a scientific paper. (5 points)
- j) General: Indicate where you would place the implications of your results in a scientific paper? (5 points)
LSHSS
Research Article
Explicit Grammar Intervention in Young
School-Aged Children With Developmental
Language Disorder: An Efficacy Study
Using Single-Case Experimental Design
Samuel D. Calder,a Mary Claessen,a Susan Ebbels,b,c and Suze Leitãoa
Purpose: This study evaluated the efficacy of an explicit,
combined metalinguistic training and grammar facilitation
intervention aimed at improving regular past tense marking for
nine children aged 5;10–6;8 (years;months) with developmental
language disorder.
Method: This study used an ABA across-participant
multiple-baseline single-case experimental design.
Participants were seen one-on-one twice a week for 20-
to 30-min sessions for 10 weeks and received explicit
grammar intervention combining metalinguistic training
using the SHAPE CODING system with grammar facilitation
techniques (a systematic cueing hierarchy). In each session,
50 trials to produce the target form were completed,
resulting in a total of 1,000 trials over 20 individual therapy
sessions. Repeated measures of morphosyntax were
collected using probes, including trained past tense verbs,
untrained past tense verbs, third-person singular verbs
as an extension probe, and possessive ’s as a control
probe. Probing contexts included expressive morphosyntax
and grammaticality judgment. Outcome measures also
included pre–poststandard measures of expressive and
receptive grammar.
Results: Analyses of repeated measures demonstrated
significant improvement in past tense production on trained
verbs (eight of nine children) and untrained verbs (seven of
nine children), indicating efficacy of the treatment. These gains
were maintained for 5 weeks. The majority of children made
significant improvement on standardized measures of expressive
grammar (eight of nine children). Only five of nine children
improved on grammaticality judgment or receptive measures.
Conclusion: Results continue to support the efficacy
of explicit grammar interventions to improve past tense
marking in early school-aged children. Future research
should aim to evaluate the efficacy of similar interventions
with group comparison studies and determine whether
explicit grammar interventions can improve other aspects
of grammatical difficulty for early school-aged children
with developmental language disorder.
Supplemental Material: https://doi.org/10.23641/asha.
11958771
D
evelopmental language disorder (DLD) refers to
a condition in which children experience lan-
guage difficulties in the absence of known bio-
medical conditions or acquired brain injury (Bishop,
Snowling, Thompson, Greenhalgh, & CATALISE-2 Con-
sortium, 2017). Compared to typically developing peers,
children with DLD present with particular difficulties in
morphosyntactic skills, such as the use (Rice, Wexler, &
Hershberger, 1998) and judgment (Rice, Wexler, & Redmond,
1999) of grammatical morphemes associated with tense.
Finiteness marking is challenging for children with
DLD (see Leonard, 2014, for a review). Finiteness refers
to the obligatory marking of verbs indicating subject–verb
agreement and tense, including affixation of morphemes –ed
(e.g., the girl walked) and –s (e.g., the girl walks) to verbs
for past and present tenses, respectively. Within English and
cross-linguistically, finiteness is a quality of well-constructed
clauses (Dale, Rice, Rimfeld, & Hayiou-Thomas, 2018).
There is evidence supporting disordered finiteness as a
distinct etiological construct and predictive marker of lan-
guage growth for DLD (Bishop, Adams, & Norbury, 2006).
aSchool of Occupational Therapy, Social Work and Speech Pathology,
Curtin University, Perth, Western Australia
bMoor House Research and Training Institute, Moor House School
& College, Oxted, United Kingdom
cLanguage and Cognition, University College London, United Kingdom
Correspondence to Samuel D. Calder:
samuel.calder@postgrad.curtin.edu.au
Editor-in-Chief: Holly L. Storkel
Editor: Amanda J. Owen Van Horne
Received March 19, 2019
Revision received July 1, 2019
Accepted October 5, 2019
https://doi.org/10.1044/2019_LSHSS-19-00060
Publisher Note: This article is part of the Forum: Morphosyntax
Assessment and Intervention for Children.
Disclosure: The authors have declared that no competing interests existed at the time
of publication.
Language, Speech, and Hearing Services in Schools • Vol. 51 • 298–316 • April 2020 • Copyright © 2020 American Speech-Language-Hearing Association298
https://doi.org/10.23641/asha.11958771
https://doi.org/10.23641/asha.11958771
https://doi.org/10.1044/2019_LSHSS-19-00060
Children’s grammar difficulties are a primary source of pa-
rental concern when considering referral for clinical services
(Bishop & Hayiou-Thomas, 2008).
Grammar Interventions
Treatment for DLD aims to accelerate language growth
and remove barriers to functional communication by har-
nessing strengths (Justice, Logan, Jiang, & Schmitt, 2017).
Ebbels’s (2014) review indicates an emerging evidence base
for the effectiveness of grammar intervention for school-
aged children with DLD. Current evidence is parsed into
implicit and explicit approaches to intervention. According
to Ebbels’s framework, implicit interventions target production
and understanding of grammar using grammar facilitation
techniques implicitly by responding to children’s errors in a
naturalistic way (Fey, Long, & Finestack, 2003). Children’s
learning and the knowledge acquired are not necessarily
associated with awareness. Explicit interventions target in-
creased awareness of the goals of intervention with a pre-
established concept of the criteria for success: Learning is
conscious and deliberate, and information can be recalled
on demand (Shanks, 2005). Within each approach to inter-
vention, specific techniques are used to improve acquisition
of grammar.
Implicit Interventions Using Grammar Facilitation
Intervention and scaffolding techniques used in im-
plicit approaches are described as grammar facilitation (e.g.,
Fey et al., 2003), which aims to facilitate the acquisition of
grammar by increasing the frequency and quality of target
forms in input and output. Greater exposure to and oppor-
tunities to learn and use language theoretically accelerates
the likelihood of language growth (Leonard, 2014). Studies
have empirically tested grammar facilitation techniques sup-
porting their use with expressive morphosyntax targets,
including imitation (Nelson, Camarata, Welsh, Butkovsky,
& Camarata, 1996), modeling (Weismer & Murray-Branch,
1989), focused stimulation (Leonard, Camarata, Brown, &
Camarata, 2004), and conversational recasting (see Cleave,
Becker, Curran, Van Horne, & Fey, 2015, for a review).
Recently, Van Horne, Fey, and Curran (2017) reported on
a primarily implicit intervention, in which procedures in-
cluded a combination of sentence imitation, observational
modelling, storytelling and focused stimulation, recasting,
and cueing for incorrect responses. All eighteen 4- to 10-year-
old children with DLD enrolled in the study improved
their use of regular past tense. Notably, as participants
were dismissed from the study following 36 sessions, many
still did not achieve mastery of the intervention target. In
general, outcomes following implicit intervention are favor-
able for morphosyntax in preschool-aged children (Leonard,
2014); however, mastery of intervention targets is rarely
reported.
Explicit Intervention Using Metalinguistic Training
Difficulties with morphosyntax often persist into
school age for children with DLD (Bishop, Bright, James,
Bishop, & Van der Lely, 2000). An alternative approach
may be required because children with DLD may have
difficulty learning grammar through implicit grammar fa-
cilitation. Metalinguistic training aims to improve children’s
learning of the rules of grammar by creating conscious
awareness of grammar through explicit metacognitive teach-
ing (Ebbels, 2014), allowing children to actively reflect on
language targets. Meta-awareness is enhanced, so rules of
grammar are learned explicitly in a compensatory way.
Metalinguistic techniques can be used explicitly to
teach grammar through metacognitive strategies using visual
supports and graphic organizers (Ebbels, 2014). The SHAPE
CODING system is designed to explicitly teach oral and
written syntax to children with language disorder (Ebbels,
2007). Ebbels, van der Lely, and Dockrell (2007) compared
use of the SHAPE CODING system with semantic therapy
and a no-treatment control group with 27 children with
DLD aged between 10 years and 16;1 (years;months). The
authors concluded that the SHAPE CODING system is a
viable and efficacious treatment approach to improve verb
argument structure in older school-aged children. Although
evidence for improvement in grammar comprehension is
mixed (e.g., Zwitserlood, Wijnen, van Weerdenburg, &
Verhoeven, 2015), children may be able to consciously re-
flect upon the rules of grammar through explicit interven-
tions in the presence of receptive language difficulties to
improve understanding, especially older children (Ebbels,
Marić, Murphy, & Turner, 2014).
Grammar intervention approaches effective for chil-
dren above 8 years old should be tested with younger chil-
dren to address the concerning gap in evidence for this age
group (Ebbels, 2014). Furthermore, Ebbels (2014) suggested
there may be benefit to integrating therapy techniques to
include grammar facilitation and metalinguistic training in
a range of activities (e.g., Fey et al., 2003). Combined ap-
proaches are yet to be explored extensively.
Combined Intervention Approaches
In an early-stage efficacy study, Finestack (2018)
used a combined implicit/explicit metalinguistic approach
compared to an implicit approach to teach novel morphemes
to 6- to 8-year-old children with DLD. The combined ap-
proach was more efficacious than the implicit approach,
with gains being maintained and generalized. In a random-
ized controlled trial of 31 preschool-aged children, Smith-
Lock, Leitão, Prior, and Nickels (2015) used explicit teaching
principles combined with a systematic cueing hierarchy,
which was effective in improving use of expressive morpho-
syntax when compared to conversational recasting alone.
Importantly, the study included a metalinguistic component
where children in the explicit group were aware of the thera-
peutic goal (Smith-Lock et al., 2015). Kulkarni, Pring, and
Ebbels (2013) conducted a clinical evaluation of the SHAPE
CODING system combined with elicited production and
recasting to improve the use of past tense for two children
with DLD aged 8;11 and 9;4. Both made significant gains
in their use of the target structure.
Calder et al.: Grammar Intervention in Young Children With DLD 299
Although grammar facilitation is generally considered
implicit (Ebbels, 2014; Fey et al., 2003), there is evidence
that the techniques can be used explicitly. In a pilot efficacy
study, Calder, Claessen, and Leitão (2018) combined the
SHAPE CODING system with the systematic cueing hier-
archy detailed in Smith-Lock et al. (2015) to improve gram-
mar in three children with DLD aged 7 years. Importantly,
systematic cueing as a grammar facilitation technique in
this study was explicit. Cues ranged from least to most sup-
port, and there was a focus on teaching correct production
of grammar through errors to avoid the child perceiving
the error to be semantic in nature, as may be the case when
using conversational recasting without stating the goal of
intervention first. The findings provided early evidence
supporting the use of combined intervention approaches to
improve receptive and expressive grammar, particularly
production of regular past tense following 5 weeks of inter-
vention. Notably, participants made gains in expressive
grammar following only 10 intervention sessions across
5 weeks, which is markedly shorter duration than reported
in many intervention studies. However, the authors ac-
knowledge that including measures of teaching, maintenance,
and generalization (e.g., Finestack, 2018) would have broad-
ened understanding of treatment effects and that a longer
period of intervention might be necessary.
Grammar Interventions in Clinical Practice
Recently, Finestack and Satterlund (2018) reported
on a national survey of speech-language pathology practice
in the United States. Past tense verb production was a
common intervention goal for practitioners in both early
(40%) and elementary education settings (60%). Interest-
ingly, overall between 60% and 70% used explicit presenta-
tions as an intervention procedure, despite relatively little
investigation in this area until recently. Therefore, it appears
explicit instruction to improve past tense may not only be
supported by an emerging evidence base but is also fre-
quently used in clinical practice.
The Current Study
For early school-aged children, preliminary data sug-
gest that explicit, combined metalinguistic and grammar
facilitation approaches are efficacious in treating the use of
tense marking and for improving receptive grammar more
generally (Calder et al., 2018). Building on early-stage
studies of treatment efficacy is required to determine if treat-
ment procedures are considered evidence based. Fey and
Finestack (2008) outline the need for a programmatic ap-
proach to pursuing intervention research, specifically noting
the value of small-scale studies aimed at exploring and
identifying specific components of intervention approaches
and their effects on specific populations. This study forms
a part of a program of research to design, develop, and
evaluate the efficacy of an explicit, combined grammar in-
tervention in line with Robey’s phases of clinical research
(Robey, 2004). We report on a range of measures to evaluate
the efficacy of explicit intervention to improve grammar.
Single-case experimental design (SCED) methodology was
used to test the following confirmatory hypotheses and is
reported as per the Single-Case Reporting guideline In
BEhavioural interventions (Tate et al., 2016):
1. For young school-aged children with DLD (specifically
aged 5;10–6;8), there will be a significant treatment
effect on trained past tense verbs and a generalized
effect to untrained verbs across 20 sessions of explicit
intervention combining metalinguistic and grammar
facilitation techniques.
2. These children will improve significantly on pre–
poststandardized measures of expressive and receptive
grammar.
Method
Research Design
Design
The current study was an ABA across-participant
multiple-baseline SCED, including a minimum of five data
points (i.e., sessions) for each phase (Kratochwill et al.,
2012). Multiple baselines were conducted for varied dura-
tions across participants, and introduction of treatment to
participants was staggered. Repeated measures were col-
lected throughout the intervention phase and posttreatment
maintenance phase (Dallery & Raiff, 2014), including the
target behavior (past tense verbs), an extension of the tar-
geted behavior (third-person singular [3S] verbs), and a
control behavior (possessive ’s). This design is noted for
robustness regarding strengths of internal validity and exter-
nal validity when compared to other SCEDs (Tate et al.,
2016). As a Phase I–II study, we replicated and built on
findings from Calder et al. (2018) by refining intervention
protocols, determining optimal dosage, and evaluating du-
ration of therapeutic effect (Robey, 2004).
Randomization
To improve internal validity further, participants
were randomly assigned to one of three predetermined
staggered onset to intervention conditions. To ensure con-
cealed allocation, participants were assigned a code that
was entered into a random list generator by a blinded re-
searcher. Participants received five (P1, P3, P8), seven (P5,
P7, P9), or nine (P2, P4, P9) pre-intervention baseline
sessions over as many weeks; 20 intervention sessions over
10 weeks; and five postintervention sessions to evaluate
maintenance. Participants were also randomized to gram-
maticality conditions described below.
Blinding
Participant caregivers and teachers were aware chil-
dren were receiving grammar intervention but were blinded
to the intervention target. Postintervention measures were
collected via blinded assessment using trained student speech-
language pathologists (SLPs).
300 Language, Speech, and Hearing Services in Schools • Vol. 51 • 298–316 • April 2020
Participants
Selection Criteria
Participants included nine early school-aged children
diagnosed with DLD. The inclusion criteria were aged
between 5;6 and 7;6, English as a primary language, and
grammar difficulties associated with DLD. Exclusionary
criteria included a neurological diagnosis, a cognitive im-
pairment, and hearing outside normal limits. Participants
were recruited from a specialized educational program for
students diagnosed with DLD. Ethical approval for the
study was obtained from the Curtin University Human
Research Ethics Committee (approval number: HRE2017-
0835) and the Western Australian Department of Educa-
tion. The principal consented school participation and
then provided information letters and consent forms to the
parents/carers of potential participants identified by SLPs
and teachers employed at the educational program. Parents
returned the completed consent forms if they wished their
child to participate. The study reached capacity at nine
participants so we could achieve three replications over three
baseline conditions as per reporting standards (Kratochwill
et al., 2012).
Participant Characteristics
The participants’ school enrolment package was
accessed, including the assessment protocol and the most
recent standardized assessment scores available. Data in-
cluded Clinical Evaluation of Language Fundamentals
Preschool–Second Edition (Wiig, Secord, & Semel, 2004),
a test of nonverbal IQ, and a comprehensive exploration
of previous medical history to identify contributing factors
to language difficulties, such as acquired neurological dam-
age, or hearing loss. These factors combined are consid-
ered evidence of a diagnosis for DLD (Bishop, Snowling,
Thompson, Greenhalgh, & CATALISE Consortium, 2016).
Participants then passed a hearing acuity test. All partici-
pants passed the Phonological Probe from the Test of Early
Grammatical Impairment (Rice & Wexler, 2001) for artic-
ulation of phonemes necessary for morphosyntactic pro-
duction targets.
All demographic information is presented in Table 1.
Participants included eight boys and one girl aged between
5;10 and 6;8 at initial assessment. Ages at enrolment to
the specialist school varied from 3;8 to 5;11. P1, P2, P4,
and P8 were in their third year of placement at the school;
P3, P5, P7, and P9 were in their second; and P6 was in her
first.
Measures
Repeated Measures
Repeated measures of morphosyntax were collected
at every data point using various probes, including trained
probes, untrained probes, an extension probe, and a control
probe (elaborated in the following sections). Probing con-
texts included both expressive morphosyntax and grammati-
cality judgment. Grammaticality judgment was selected
as a method of measuring grammatical progress, as there
is evidence performance on such tasks mirrors production
tasks (Rice et al., 1998, 1999). As grammaticality judgment
is a clinical marker of DLD (Dale et al., 2018; Rice et al.,
1999), identification of grammatically correct sentences in
the studied participants was expected to be below chance
levels of accuracy prior to intervention.
Trained probes. Regular past tense (–ed) repeated
measures of trained verbs were probed in two conditions:
12 –ed verbs trained within sessions were measured, and
12 –ed verbs from the previous session were measured. All
–ed verbs were predetermined at the outset of intervention
and selected based on their suitability to intervention activi-
ties. We also chose verbs that were not in the Grammar
Elicitation Test (GET; described below; Smith-Lock, Leitão,
Lambert, & Nickels, 2013) to allow comparison between
trained and untrained verbs. These probes were adminis-
tered during the intervention phase at the end of Session 2
(i.e., data point B1 the first week of intervention) and every
even session thereafter.
Untrained probes. Repeated measures of untrained
expressive morphosyntax probes were selected from an
adapted version of the GET. This experimental test was
designed to elicit multiple instances of specific expressive
morphosyntax targets, including 30 items probing the treated
grammatical structure (–ed). Repeated measures were also
developed for a grammaticality judgment task including
30 –ed probes. Videos of actions depicting the declarative
clauses containing –ed were created as stimuli for untrained
probes. Accompanying audio for each task item, both
Table 1. Demographic information.
Participant ID Sex
Age at enrolment to school
(years;months)
Current year at specialized
educational program
Age at initial assessment
for study (years;months)
P1 Male 4;0 3rd 6;3
P2 Male 3;11 3rd 6;2
P3 Male 4;7 2nd 5;10
P4 Male 5;4 3rd 6;8
P5 Male 5;2 2nd 6;6
P6 Female 5;11 1st 6;2
P7 Male 5;3 2nd 6;7
P8 Male 3;8 3rd 6;0
P9 Male 4;9 2nd 6;1
Calder et al.: Grammar Intervention in Young Children With DLD 301
grammatical and ungrammatical (e.g., The girl painted a
picture. vs. The girl paint* a picture.), was recorded by a
woman with an Australian accent, blinded to the purpose
of the research. Each video with corresponding audio was
embedded into a Microsoft PowerPoint presentation.
Participants wore Sony noise-cancelling headphones during
administration and were required to decide if the sentence
“sounded right” by pressing “yes” or “no” on a tablet app.
Items were counterbalanced for grammaticality, so partici-
pants did not receive the same combination of grammatical/
ungrammatical items, and there was no pattern in the pre-
sentation of grammatical/ungrammatical items to counter-
act a priming effect.
Complete sets of 30 untrained –ed verbs were probed
pre- and postintervention. Sets were randomized for ad-
ministration at the initial assessment (Timepoint 1), 1 week
prior to intervention commencing (Timepoint 2), 1 week
following intervention (Timepoint 3), and 5 weeks following
cessation of intervention (Timepoint 4). Both expression
and grammaticality judgment were assessed.
Reduced randomized sets were generated for each
other data point using nine expressive probes and 12 gram-
maticality judgment probes. All possible allomorphs were
included (i.e., [d], [t], and [əd]) and equally distributed. Probes
were administered via laptop during the pre-intervention
baseline phase, at the beginning of Session 3 (i.e., data point
B2 in the second week of intervention) and every odd ses-
sion thereafter during the intervention phase, and in the
postintervention maintenance phase.
Extension probes. Expressive repeated measures of
3S served as an extension of the treated structure. Items in-
cluded 30 probes and were taken from the GET. A gram-
maticality judgment task was also developed as per the
untrained –ed probes (e.g., The man sneezes. vs. The man
sneeze*.). 3S was considered an extension measure due to
the structure’s relative complexity compared to –ed, since
bare stem forms are grammatical when used with first-
person subject pronouns or plural subject nouns (e.g., I like
ice cream vs. The boys like ice cream vs. The boy likes ice
cream). We also expected there might be improvement in
3S due to the frequent instances of input during therapy
(see Intervention section) and increased awareness of the
need for tense marking.
Control probes. Similarly, expressive repeated measures
of possessive ’s served as a control probe. Items included
30 probes and were taken from the GET. As above, a
grammaticality judgment task was developed (e.g., The
spider is living on a leaf. This is the spider’s leaf. vs. The spi-
der is living on a leaf. This is the spider* leaf.). For ’s, still
images of nouns depicting ownership were retrieved from
copyright-free image sources. ’s was considered a control
as this noun possession was not taught as part of therapy
and therefore should remain stable throughout the inter-
vention period.
For extension and control probes, all possible allo-
morphs were included (i.e., [s], [z], [əz]) and equally distributed.
Randomized sets of nine expressive and 12 grammaticality
judgment items were generated and administered as per the
untrained –ed probes during pre-intervention, intervention,
and postintervention phases.
Pre–Post
The Structured Photographic Expressive Language
Test–Third Edition (SPELT-3; Dawson, Stout, & Eyer,
2003) and the Test of Reception of Grammar Version 2
(TROG-2; Bishop, 2003) were administered both pre- and
postintervention as expressive and receptive standardized
grammar measures, respectively. The SPELT-3 measures
expressive morphosyntax using 54 items across a range of
structures and was normed on children aged 4–9 years. To
address discriminant accuracy of the test, Perona, Plante,
and Vance (2005) determined 90% sensitivity and 100% sen-
sitivity at 95 cutoff (−0.33 SD). This cutoff score was used
for the current study based on the recommendation, al-
though it is noted that while other studies applied this cut-
off with older children (e.g., Van Horne et al., 2017), Perona
et al. (2005) sampled children aged 4–5 years. The TROG-2
measures a total of 20 different grammatical structure con-
trasts and was normed on children aged 4–16 years. Dis-
criminant accuracy was evaluated on a sample of 30 children
aged 6;2–10;11, which confirmed the test is sensitive to
identifying communication difficulties in children (Bishop,
2003). Both tests have strong reliability and appropriate
validity.
Reliability
A blinded researcher scored 20% of all measures au-
dio- and video-recorded throughout the study. Interrater
reliability for experimental measures was calculated using
intraclass correlation coefficients (ICCs) using absolute
agreement and single measures in a two-way mixed-effects
model. Interpretation of ICC values is as follows: < .40 =
poor, .40–.59 = fair, .60–.74 = good, and .75–1.00 = excel-
lent (Cicchetti, 1994). For trained –ed probes, the ICC for
expressive measures was .879, and the ICC for grammati-
cality judgment was .977. The ICC for expressive un-
trained –ed, 3S, and ’s probes was .937, and the ICC for
the grammaticality judgment of untrained –ed, 3S, and ’s
probes was .985. Therefore, excellent agreement was observed
across all experimental measures.
Intervention
All intervention sessions were videotaped and carried
out in a quiet space at the site of the educational program.
Procedures were similar to those reported by Calder et al.
(2018) and are explained within the model suggested by
Warren, Fey, and Yoder (2007) for describing treatment
intensity. The dose was 50 trials within 20- to 30-min ses-
sions; dose form was explicit intervention combining meta-
linguistic training using the SHAPE CODING system
(Ebbels, 2007) with a systematic cueing hierarchy (Smith-
Lock et al., 2015); dose frequency was twice a week, total
intervention duration was 10 weeks, and cumulative interven-
tion intensity was 50 trials × 2 times per week × 10 weeks,
resulting in a total of 1,000 trials over 20 individual
302 Language, Speech, and Hearing Services in Schools • Vol. 51 • 298–316 • April 2020
therapy sessions through roughly 7–10 hr of therapy. This
is double the intervention duration in the pilot study (Cal-
der et al., 2018), where authors suggested that participants
may demonstrate larger treatment effects following a lon-
ger duration. Training of morphosyntax was embedded
within engaging and naturalistic activities suited to early
school-aged children, including playdough, board
games, and playing with puppets as well as farm and sea
creature manipulatives. Target morphemes were presented
in syntactic structures as they occurred felicitously within
these activities. The first author (S. D. C.), a trained
SLP, delivered all interventions.
Each session began with a short recap of the aims:
to say WHAT DOING words (verbs) that have already
happened and to add the sounds ([d], [t], [ǝd]) onto the end
of those words. Next, the SLP would direct the child’s atten-
tion to the laminated shapes and arrows used as a visual
organizer throughout session activities. See Figure 1 for es-
sential shapes, including the oval (subject noun phrase WHO/
WHAT?), the hexagon (verb phrase WHAT DOING?),
and the rectangle (object noun phrase WHO/WHAT?).
Additional visual cues included three separate laminated
cards that depicted a “left down arrow” to depict –ed and
an orthographic representation of the allomorphs (i.e., “d”
for [d], “t” for [t], and “ed” for [ǝd]). The SLP said, “Last
time, we used our shapes and arrows to help us. Like this:
‘We move our shapes and arrows. What did we do? We moved
[bring ‘d’ arrow into the WHAT DOING? hexagon] our
shapes and arrows. The [d] at the end of moved lets us know
it’s already happened.” The participant was reminded, “I
(the SLP) will say what we do in the session (i.e., present
tense) and you will say what we did (i.e., past tense).” This
was followed by two activities that were designed to give
the participants ample opportunities to produce –ed verbs
in response to an interrogative (e.g., What did you do? Did
you just VERB? Tell me….).
Each activity began with explicit instruction of how
to apply –ed inflection, using one exemplar from each of
the allomorphic categories. Within each activity, there were
approximately 25 opportunities for the child to respond to
an interrogative (e.g., You roll the playdough! What did you
do?) using –ed verbs while the SLP gestured to the shapes
and arrows (see Figure 1). The child was therefore encour-
aged to respond using a subject–verb–object syntactic frame,
consistently. If the child responded with an unmarked verb
(i.e., bare stem) or overgeneralized form (e.g., playded ),
he or she was supported with a systematic cueing hierarchy
moving from least to most support outlined in Figure 2.
As much as possible, verbs were blocked according to allo-
morphs and presented from least to most difficult (i.e.,
[d]➔[t]➔[ǝd]) in accordance with Leonard (2014) and
Marshall and van der Lely (2006). At the end of every ac-
tivity, the SLP recapped what the participant had learned
using the shapes and arrows and comprehension questions.
For example, if the target sentence had been “I rolled play-
dough,” the SLP would gesture to the WHO?/WHAT?
oval and ask, “WHO rolled the playdough?” Then, gesture
to the WHAT DOING? hexagon while bringing down the
“d” left down arrow and ask, “What DID you DO?” and
finally gesture to the WHO?/WHAT? rectangle and ask,
“WHAT did you roll?” A plausible response to all of these
questions is “I rolled the playdough,” giving further oppor-
tunity to reinforce production using a consistent syntactic
frame. If an error occurred, the same systematic cueing
hierarchy described above was employed. The shapes and
arrows were then removed, and the interrogative (What DID
you DO?) was repeated without visual support for an exem-
plar from all three allomorphic categories, reinforcing in-
ternalization of the grammatical rule. If a child had achieved
80% success over three sessions on any measure, “silly
sentences” were introduced, a metalinguistic subactivity
whereby three sentences were said, either grammatically or
ungrammatically (i.e., –ed morphemes were either included
or omitted), and the child would decide if the sentence
“sounded right.”
These procedures were repeated for a second activ-
ity, giving 50 opportunities to use –ed inflection during the
activity that was bookended with explicit teaching and
comprehension questions using three exemplars from each
allomorphic category. At the end of each session, the child
was reminded of the goal of the session and why it is im-
portant to say the sounds at the end of “WHAT DOING?”
words that have already happened and to listen out for
those sounds.
Procedural Fidelity
A blinded researcher scored 20% of videotaped ses-
sions on percentage accuracy using a priori established cri-
teria for intervention procedures. A total of 19 items were
scored for sessions (see Appendix A for a checklist for
scoring intervention procedure fidelity). Note that if chil-
dren were introduced to “silly sentences,” sessions were
scored against an additional two (total 21) items. Intra-
observer agreement was calculated using ICC. The aver-
age score was 97.1% for percentage accuracy, and the ICC
for treatment procedures was .996.
Figure 1. Visual depiction of visual cues used during the intervention phase.
Calder et al.: Grammar Intervention in Young Children With DLD 303
Analysis
Single-Subject Analyses
Treatment effects of teaching, generalization, and
maintenance through repeated measures of morphosyntax
were statistically evaluated using Tau-U by combining
nonoverlap and trend of data (Parker, Vannest, Davis, &
Sauber, 2011) across all phases and data points. Tau-U uses
Kendall’s S to interpret significance testing and outputs
p values. Raw scores on probes were converted to percent-
age correct. Baselines were contrasted using the Tau-U
online calculator (Vannest, Parker, Gonen, & Adiguzel,
2016), and the Tau value was checked for trend of baseline
in pre- and postintervention phases. For pre-intervention
baseline, Tau values above 0.40 (increasing trend) or below
−0.40 (decreasing trend) were deemed unstable and cor-
rected, as recommended by Parker et al. (2011). This was
repeated for all applicable baseline versus intervention con-
trasts. Finally, phase contrasts were aggregated to provide
an omnibus effect size for study participants, where, using
Cohen’s standard, 0.2 is small, 0.5 is medium, and 0.8 is
large.
To evaluate performance on the full sets of untrained
–ed verbs, a concurrent within-group approach was used
(e.g., Zwitserlood et al., 2015) where Friedman nonpara-
metric two-way analysis of variance (ANOVA) tested dif-
ferences between Timepoints 1 and 2 pre-intervention and
Timepoints 3 and 4 postintervention scores. Participant
scores determined a group mean and standard deviation in
expressive and grammaticality judgment probes within each
timepoint. Post hoc Wilcoxon signed-ranks tests made
pairwise comparisons between testing points. These statistics
were computed using IBM SPSS Version 25.
Kratochwill et al. (2012) outline standards for analysis
of repeated measures via visual inspection to report on a
functional relation between dependent and independent var-
iables, which includes comments on level, trend, and vari-
ability within phases and comments on immediacy, overlap,
and consistency between phases. For the current study,
within-phase level performance was evaluated with group
statistics. Furthermore, Tau-U handles within-phase level,
and trend and variability within and between phases, as
well as overlap between phases. Therefore, reporting on
visual inspection is limited to the immediacy of the func-
tional relation between –ed use and understanding, and the
staggered introduction of intervention across participants.
Pre–postanalyses. Pre–postdifferences on standard-
ized measures were tested in a case series approach by
calculating the Reliable Change Index (RCI; Unicomb,
Colyvas, Harrison, & Hewat, 2015). The RCI statistic cal-
culates whether an individual’s change in score (i.e., pre–
postdifference in standard scores) is statistically significant
by using the reliability values of a standardized test. The
RCI is calculated using the formula x2 – x1 / Sdiff, where x1
is the participant’s pretest score, x2 is the same participant’s
posttest score, and Sdiff is the standard error of difference
between the two test scores. An RCI above 1.96 is consid-
ered statistically significant at 0.05 significance level.
Results
Sequence Completed
All participants completed planned sessions within
pre-intervention baseline (A), intervention (B), and post-
intervention maintenance (A) phases. There was an average
of 50.74 (SD = 1.2, range: 48–56) trials for each participant
to produce –ed. Out of the nine participants, six (P1, P2,
P3, P4, P5, and P7) demonstrated at or above 80% perfor-
mance on at least one measure of –ed marking over three
sessions. These participants engaged in the “silly sentences”
aspect of intervention procedures as described in the Inter-
vention section.
Outcomes and Estimation
Single-Subject Treatment Effects (Expressive)
Data not reported in tables are available in the Sup-
plemental Materials (see list of Supplemental Materials
in Appendix B). Pre-intervention baselines on production
Figure 2. Systematic cueing hierarchy used when the child produced the target verb in error.
304 Language, Speech, and Hearing Services in Schools • Vol. 51 • 298–316 • April 2020
of –ed verbs taken from the GET were stable for 4/9 par-
ticipants. P1 (Tau = −0.70), P3 (Tau = −0.70), P4 (Tau =
0.58), P8 (Tau = 0.60), and P9 (Tau = −0.71) had baselines
corrected for subsequent analyses. Data from expressive
repeated measures are presented in Figures 3–5, and results
from Tau-U analyses are reported in Table 2. Of the nine
participants, eight (P1–P7 and P9) demonstrated statisti-
cally significant trend in production of trained verbs tested
within session during the intervention phase (see Figure 3).
Phase contrasts were combined and yielded an aggregated
effect size of 0.88, which is considered large. For trained
verbs tested between sessions (see Figure 4), seven (P1–P5,
P7, and P9) of nine participants demonstrated statistically
significant performance during the intervention phase, with
a large aggregated effect size of 0.83. Seven (P1–P7) of nine
participants demonstrated a statistically significant trend
in production of untrained –ed verbs during the intervention
phase (see Figure 5), yielding a medium effect size of 0.64.
Analysis of Tau scores revealed a significant negative
trend in performance for P1 (Tau = −0.40), P6 (Tau = −0.40),
and P7 (Tau = −0.40) across five data points in the post-
intervention maintenance phase. Note the Tau values for these
three participants are at the minimum level for baseline trend
(Tau = ± 0.40) corrections according to Parker et al. (2011).
Figure 3. Percentage correct on expressive trained within-session probe repeated measures for Groups 1–3.
Calder et al.: Grammar Intervention in Young Children With DLD 305
For expressive 3S extension probes, P7 (Tau = 0.62),
P8 (Tau = 0.60), and P9 (Tau = 0.57) demonstrated an
unstable baseline with a positive trend. During the inter-
vention phase, P6 demonstrated significant improvement
(p = .03), and P9 demonstrated significant decline (p = .03).
Phase contrasts yielded a nonsignificant (p = .65) aggre-
gated effect size of −0.05. P1 (Tau = 0.80), P2 (Tau = 0.40),
and P4 (Tau = 0.70) demonstrated a positive trend in the
postintervention maintenance phase.
For expressive ’s control probes, P2 (Tau = 0.69)
and P4 (Tau = 0.61) showed unstable baselines with positive
trends, while P9 (Tau = −0.43) showed an unstable base-
line with a negative trend. Of the nine participants, both
P1 (p = .013) and P3 (p = .004) demonstrated significant
improvement during the intervention phase. Phase con-
trasts yielded a nonsignificant (p = .33) aggregated effect
size of 0.10. P5 (Tau = 0.40) continued to show a positive
trend in the postintervention maintenance phase, while P7
Figure 4. Percentage correct on expressive trained between-session probe repeated measures for Groups 1–3.
306 Language, Speech, and Hearing Services in Schools • Vol. 51 • 298–316 • April 2020
(Tau = −0.50), P8 (Tau = −0.40), and P9 (Tau = −0.40)
showed a negative trend.
Single-Subject Treatment Effects
(Grammaticality Judgment)
Pre-intervention baselines for past tense grammati-
cality judgment probes were stable for all participants. Only
one participant (P5) improved significantly in correctly
judging grammaticality on trained verbs tested within ses-
sions (p = .02). P1 (p = .04) and P4 (p = .04) improved sig-
nificantly on trained verbs tested between sessions, and a
small (0.26) yet significant (p = .009) effect size across
participants was calculated. Only one (P2) participant
demonstrated a significant trend in correct grammaticality
judgment of untrained –ed verbs during the intervention
phase (p = .02).
For grammaticality judgment 3S extension probes, P8
showed an unstable baseline with a negative trend, Tau =
−0.40. P4 demonstrated a significant improvement during
intervention (p = .02), and P8 demonstrated a significant
negative trend (p = .02). P2 (Tau = −0.80). Phase contrasts
yielded a small, yet significant (p = .03) aggregated effect
Figure 5. Percentage correct on expressive untrained probe repeated measures for Groups 1–3.
Calder et al.: Grammar Intervention in Young Children With DLD 307
size of 0.22. P8 (Tau = −0.40) demonstrated a negative trend
in the maintenance phase, while P3 (Tau = 0.53) demon-
strated a positive trend.
For grammaticality judgment ’s control probes, P4
demonstrated a negative trend, while P7 (Tau =0.65) and
P8 (Tau =0.90) demonstrated a positive trend during base-
line. P2 demonstrated a significant positive trend during
intervention (p = .02). Phase contrasts yielded a nonsignifi-
cant (p = .76) aggregated effect size of 0.03. P4 demonstrated
a negative trend in the maintenance phase, Tau = −0.40.
Within-Group Concurrent Approach
Mean scores and standard deviations for –ed pro-
duction and grammaticality judgment at four timepoints are
presented in Table 3. A Friedman two-way ANOVA demon-
strated that the production of untrained –ed verbs differed
significantly between timepoints, χ2(F = 22.47), df =3,
p < .001. Post hoc Wilcoxon signed-ranks tests and a Bonferroni-adjusted α of .0167 (0.05/3 comparisons: Time- point 1 vs. Timepoint 2, Timepoint 2 vs. Timepoint 3, and Timepoint 3 vs. Timepoint 4) showed –ed production was significantly higher at Timepoint 3 (mean rank = 3.78) than at Timepoint 2 (mean rank= 1.56), z = –2.67, N-Ties = 9, p = .008. Differences between other timepoints were non- significant, suggesting a stable pre-intervention baseline, an observable treatment effect between pre- and postinterven- tion testing points, and a maintenance of gains at a group level. Tests for grammaticality judgment were nonsignificant.
Analysis of Pre–Postresults
Pre- and postintervention standard scores on the
SPELT-3 and the TROG-2 are reported in Table 4. Ex-
ceeding the RCI of 1.96 indicates statistically significant
improvement. All but one participant (P6) exceeded the
Table 2. Summary of expressive repeated-measures baseline versus treatment phase contrasts on trained
and untrained targets.
Participant ID Kendall’s S z score p value Tau 90% CI
Within session
P1a 55 3.37 < .001* 1.1 [0.56, 1]
P2 88 3.60 < .001* 0.98 [0.53, 1]
P3a 51 3.12 .002* 1.02 [0.48, 1]
P4a 69 2.82 .005* 0.77 [0.32, 1]
P5 70 3.42 < .001* 1 [0.52, 1]
P6 66 2.70 .007* 0.73 [0.29, 1]
P7 56 2.73 .006* 0.80 [0.32, 1]
P8a 15 0.92 .36 0.30 [0.24, 0.84]
P9a 85 4.15 < .001* 1.21 [0.73, 1]
Aggregated ES
Group — — < .001* 0.88 —
Between session
P1a 57 3.49 < .001* 1.14 [0.60, 1]
P2 88 3.59 < .001* 0.98 [0.53, 1]
P3a 57 3.49 < .001* 1.14 [0.60, 1]
P4a 57 2.33 .02* 0.63 [0.19, 1]
P5 70 3.42 < .001* 1.00 [0.52, 1]
P6 37 1.51 .13 0.41 [−0.04, 0.86]
P7 48 2.34 .02* 0.69 [0.20, 1]
P8a 15 0.92 .36 0.30 [−0.24, 0.84]
P9a 85 4.13 < .001* 1.21 [0.73, 1]
Aggregated ES
Group — — < .001* 0.83 —
Untrained
P1a 40 2.67 .007* 0.89 [0.34,1]
P2 79 3.49 < .001* 0.98 [0.52, 1]
P3a 30 2.00 .05* 0.67 [0.12, 1]
P4a 56 2.47 .01* 0.69 [0.23, 1]
P5 45 2.38 .02* 0.71 [0.22, 1]
P6 73 3.22 .001* 0.90 [0.44,1]
P7 44 2.33 .02* 0.70 [0.21, 1]
P8a 13 0.87 .39 0.29 [0.26, 0.84]
P9a −8 −0.42 .67 −0.13 [0.62, 0.37]
Aggregated ES
Group — — < .001 0.64 —
Note. Em dashes indicate data not available. CI = confidence interval; ES = effect size.
aUnstable baseline corrected.
*Significant.
308 Language, Speech, and Hearing Services in Schools • Vol. 51 • 298–316 • April 2020
RCI for the SPELT-3. Furthermore, for the majority of
participants, postintervention standard scores exceeded the
manual-reported confidence intervals (90% and 95%) around
their pre-intervention standard scores. Note, however, that
even though P1’s RCI was significant, his post-SPELT-3
standard score of 76 does not exceed the 90% and 95%
confidence intervals around his pre-SPELT-3 standard
score of 69. One participant (P8) exceeded the RCI for the
TROG-2 (2.12).
Adverse Events
In the case of absence during the intervention phase,
participants (P5, P6, P7, P8, and P9) attended a make-up ses-
sion in the final week of intervention in which within-session
and between-session teaching probes were collected. Due to
issues with attention and engagement, procedural changes
occurred for P6, who received 30 trials per session, and the
systematic cueing hierarchy was limited to elicited imitation.
Discussion
This study evaluated the efficacy of an explicit gram-
mar intervention combining metalinguistic training and
grammar facilitation aimed to improve regular past tense
(–ed) marking for nine children with DLD aged 5;10–6;8.
Intervention taught –ed marking through explicit rule
instruction and visual supports using the SHAPE COD-
ING system. A systematic cueing hierarchy (Smith-Lock
et al., 2015) was used to support participants. This study con-
tributes to the design, development, and evaluation of inter-
vention efficacy by moving through levels of evidence and
analogous research designs (Robey, 2004).
Treatment Effects
Single-Subject Analyses
We hypothesized participants would improve signifi-
cantly on –ed verbs trained and probed within sessions
and between sessions. Most participants improved on expres-
sive repeated measures of trained verbs with large effects,
indicating this intervention is efficacious for improving pro-
duction of –ed verbs taught in sessions. Furthermore, most
participants improved on untrained verbs with medium
effects, suggesting generalization. Within-group Friedman
nonparametric two-way ANOVA also demonstrated a gen-
eralized treatment effect, which was maintained for 5 weeks.
For grammaticality judgment, only three participants im-
proved on trained verbs, one improved significantly on un-
trained verbs, and another continued to improve 5 weeks
postintervention. Few gains were observed across partici-
pants on an extension measure (3S) and on control mea-
sures of ’s both production and grammaticality judgment.
Limited progress on control probes strengthens our ability to
Table 3. Mean scores on complete sets of untrained past tense verbs across four timepoints.
Measure
Pre-intervention Postintervention
Timepoint 1 Timepoint 2 Timepoint 3 Timepoint 4
Expressive (/30) 7.44 (SD = 4) 7.44 (SD = 5.47)† 22.89 (SD = 5.97)* 21.89 (SD = 7.23)††
Grammaticality judgment (/30) 15.22 (SD = 1.87) 16.22 (SD = 1.03)† 19.25 (SD = 4.97) 18.78 (SD = 6.25)
*Significant difference between pre- and postintervention timepoints = observed treatment effect.
†Nonsignificant difference between pre-intervention baseline timepoints = stable baseline. ††Nonsignificant difference between postintervention
timepoints = maintained treatment effect.
Table 4. Pre- and postintervention standard scores.
Participant
ID
SPELT-3 TROG-2
Pre-intervention Postintervention Pre-intervention Postintervention
P1 69 76 (2.78)* 74 76 (0.24)
P2 90 111 (9.33)* 97 95 (0.24)
P3 79 102 (6.83)* 86 93 (0.83)
P4 71 105 (13.54)* 81 83 (0.24)
P5 57 90 (13.14)* 81 86 (0.35)
P6 72 78 (0.64) 65 58 (−0.83)
P7 84 100 (6.37)* 62 74 (1.42)
P8 69 88 (7.54)* 79 97 (2.12)*
P9 57 78 (8.33)* 65 67 (0.24)
Note. Scores are standard scores with a mean of 100 and SDs of 15. SPELT-3 = Structured Photographic Expressive Language Test–Third
Edition; TROG-2 = Test of Reception of Grammar Version 2.
*Statistically significant, that is, above 1.96.
Calder et al.: Grammar Intervention in Young Children With DLD 309
attribute improvement on –ed production to intervention.
Results support the efficacy of intervention to improve –ed
production on trained and untrained verbs; however, we ob-
served limited gains on grammaticality judgment measures.
Visual inspection of expressive repeated measures
reflects results from statistical analysis regarding the imme-
diacy of the functional relation between –ed production and
intervention. That is, a positive trend is observable upon
the staggered introduction of intervention across participants.
Specifically, trained expressive probes appeared to improve
more rapidly, as early as Week 1 of intervention, whereas
for untrained verbs, gains are observable around the 5-week
mark across participants. Finally, visual inspection revealed
production of –ed on untrained verbs remained relatively
stable for all children during the postintervention phase,
supporting findings from a within-group statistical analysis.
Pre–Postcomparisons
Pre–postcomparisons of standard measures of ex-
pressive and receptive grammar across participants mirrored
single-subject analyses. Of the nine participants, eight
exceeded the RCI for expressive grammar, and one child
exceeded the RCI for receptive grammar. Overall, pre–
postanalyses suggest the intervention had a broad effect on
expressive grammar captured through standardized grammar
measures. However, effects on measures of grammar com-
prehension were modest compared to expressive grammar.
General Discussion
Results from the current study support and build upon
findings in the literature. Finestack (2018) demonstrated
the efficacy of explicit–implicit instruction using novel
morphemes, suggesting that the experimental approach may
yield quicker gains, and improvement closer to mastery
compared to existing implicit-only intervention procedures.
Furthermore, Finestack called for an evaluation of treat-
ment effectiveness using true English morphemes across
measures of maintenance and generalization to progress the
clinical applicability of research findings. Calder et al. (2018)
piloted the intervention with a small group of early school-
aged children diagnosed with DLD. Findings suggested
intervention implemented over 5 weeks, twice per week with-
out predefined dosage, improved –ed production of untrained
verbs and standard measures of expressive and receptive
grammar. The authors concluded maintaining the consis-
tent dosage (i.e., 50 trials) and extending the duration (i.e.,
10 weeks) may improve production on untrained verbs
and discern optimal dose to allow replication for clinical
practice.
The current study applied recommended changes to
intervention dose and intensity, and predictions were sup-
ported. Furthermore, using measures of verbs trained in
session and those from previous sessions allowed the analysis
of within- and between-session gains (e.g., Finestack, 2018).
We saw that children showed greater and more rapid im-
provement on trained verbs probed within and between
sessions compared to untrained verbs. However, gains in
standard measures of receptive grammar were not observed
to the extent reported in Calder et al. (2018). It is likely that
reduced improvement on the measure is attributable to the
baseline performance of the participants from the current
study. That is, the baseline scores of the current group of
participants were higher than those reported in Calder et al.,
which may suggest fewer gains were to be made on such a
measure. This finding is consistent with literature suggesting
that receptive grammar is less amenable to improvement
when compared to expressive grammar (Ebbels, 2014).
From a theoretical perspective, limited improvement
on receptive measures may be due to the status of inter-
nal representations of language remaining relatively fixed.
However, increased production practice may establish new
representations, such as those practiced within sessions,
which are generalizable to similar targets, such as other verbs
marked for –ed or 3S. This pattern was observed with two
participants (P2 and P4, respectively), so future research is
needed to explore this claim further. Alternatively, the current
standard measures of receptive grammar may fall short of
their aim. Recently, Frizelle, Thompson, Duta, & Bishop
(2019) found multiple-choice grammar tasks may underesti-
mate children’s abilities compared to truth-value tasks. In
the current study, probing grammaticality judgment of
trained and untrained verbs allowed investigation of im-
provement of obligatory tense marking as a specific behav-
ior, although improvement was limited across participants.
This may provide evidence of the persistent nature of lan-
guage disorder (e.g., Dale et al., 2018). Alternatively, the
task may be implicated by other cognitive factors, such as
phonological short-term memory. Regardless, further re-
search is needed to unpack effective methods to treat recep-
tive language difficulties.
Current findings are comparable to recent studies
targeting –ed marking in children with DLD. For example,
in a study using similar procedures to the current study,
Smith-Lock et al. (2015) demonstrated explicit rule instruc-
tion coupled with a systematic cueing hierarchy was more
effective in improving morphosyntax in preschool children
with DLD when compared to recasting alone. A key differ-
ence to intervention procedures reported in this study is
the inclusion of visual metalinguistic training and the explicit
use of the cueing hierarchy. That is, cues in this study were
presented to highlight that the targeted behavior was not
observed, and so the children were encouraged to reflect
on the rule they had just been taught with the support of
visuals and to self-correct. Furthermore, the current study
implemented over double the cumulative intensity than Smith-
Lock et al. (2015), although trials were not specified in that
study, so it is challenging to make direct comparisons.
Finally, Van Horne et al. (2017) reported positive treatment
outcomes following intervention targeting –ed production.
Importantly, the primarily implicit intervention procedures
outlined in Van Horne et al. were effective in improving –ed
for both studied groups following 36 sessions, which is
markedly longer than dose duration reported here and by
Smith-Lock et al. (2015), suggesting that explicit inter-
ventions may be more time efficient in improving expressive
310 Language, Speech, and Hearing Services in Schools • Vol. 51 • 298–316 • April 2020
grammar outcomes. Future research is needed to compare
the superiority of the two approaches to intervention.
This study further extends on a body of research eval-
uating the efficacy and effectiveness of explicit interventions
using visual support strategies to improve grammatical
knowledge for children with language difficulties, specifi-
cally the SHAPE CODING system (Ebbels, 2007). Positive
results of use of the system have been reported with older
children with DLD (Ebbels et al., 2014, 2007; Kulkarni et al.,
2013), younger children with DLD (Calder et al., 2018),
and children with complex learning needs (Tobin & Ebbels,
2019). It should be noted that positive results were reported
by Finestack (2018) where metalinguistic training without
visual support was efficacious in improving grammar in
young children with DLD. Continued research in this area
will discern the extent to which the visual aspect of the
SHAPE CODING system is responsible for positive treat-
ment effects.
We saw that children showed greater and more rapid
improvement on verbs trained in session when compared
to untrained verbs, suggesting children with DLD may have
difficulty generalizing grammar skills, particularly those
relying upon sequence learning, such as finiteness marking.
Therefore, we are more likely to see immediate improvement
in verbs trained via intervention compared to untrained
verbs. We also expected there might have been improvement
on verbs marked for 3S; however, this was not widespread
across participants, with P6 improving during intervention
and three (P1, P2, and P4) improving postintervention. This
finding suggests that, generally, grammar targets should
be taught directly, even if they are linguistically related to
existing intervention targets for children with DLD. Further-
more, production practice did not seem to affect grammati-
cality judgment; however, metalinguistic training may have.
That is, regardless of practice trials being held consistent,
children for whom “silly sentences” were introduced (P1, P2,
P3, P4, P5, P7) appeared to perform better on repeated
measures of grammaticality judgment (see Supplemental
Materials S10, S11, and S12). Therefore, introducing the
subactivity at the onset of treatment, rather than awaiting
the 80% accuracy criterion, may result in improvement of
grammaticality judgment.
Other factors to consider when evaluating treatment
effectiveness are environmental. For example, the partici-
pant with the lowest performance in general (P6) had
attended the specialist school for the least amount of time,
compared to P2 and P4, the strongest performers who were
in their third year at the specialist school. It could be that
these children were primed to learn during language-based
tasks more so than P6. However, P6 also had the lowest
pre-intervention language scores and received fewer trials
throughout the intervention phase. Nonetheless, P6 still im-
proved significantly despite these potential barriers. Through
SCEDs, evaluating individual treatment responses allows
researchers and clinicians to extricate factors related to re-
sponsiveness to intervention that may otherwise be lost in
group treatment studies (Plante, Tucci, Nicholas, Arizmendi,
& Vance, 2018).
Limitations
There are limitations to this study. Firstly, generaliz-
ability of results using SCED must be applied with caution.
Although the methodology allows for analysis of treatment
effects for individuals, the lack of a control group and rela-
tively small sample size inhibit the ability to make causal
inferences regarding treatment effectiveness in relation to
the general population. Furthermore, within-participant
analysis does not control for the influence of external factors,
such as classroom instruction, when compared to robust
randomized group comparison studies. Nonetheless, SCEDs
provide a useful methodology for establishing an early
evidence base for newly developed interventions (Fey &
Finestack, 2008). In fact, Horner et al. (2005) suggest re-
sults from a minimum of five studies totaling at least 20 par-
ticipants across three different research teams are necessary
to determine intervention efficacy using high-quality SCEDs
prior to effectiveness being tested using clinical trials. The
current study was designed using guidelines developed by
Kratochwill et al. (2012) and Tate et al. (2016) to meet
minimum standards for SCED to interpret treatment efficacy.
Note that an independent rater did not collect repeated
measures within the baseline and intervention phases as
per Kratochwill et al.’s recommendation. However, strong
interrater reliability values addressed potential observer
bias. Secondly, the current study used convenience sampling
to recruit participants from a specialized school designed to
provide intensive language and literacy support to young
children with DLD. While nonverbal IQ was not directly
measured as part of this study, all participants were enrolled
into an educational program for children with DLD in the
presence of average nonverbal IQ. Furthermore, the socio-
economic status of participants was unknown, and the
majority (8/9) of participants were male. Therefore, the
current sample may not be representative of the population
of children with DLD at large. Lastly, the current efficacy
study was limited to the analysis of –ed production and
grammaticality judgment and standard expressive and re-
ceptive grammar scores. More naturalistic measures, such
as narrative or conversation sampling, may better serve
as true measures of generalization in future studies.
Clinical Implications
A recent survey of U.S. speech pathologists investi-
gating current clinical practices for grammar intervention
found that, although a regular component of practice, spe-
cific aspects of grammatical interventions are not well un-
derstood (Finestack & Satterlund, 2018). Furthermore, –ed
marking is often targeted as a treatment goal, and explicit
presentation is often used in intervention procedures. How-
ever, relatively little research has been reported using ex-
plicit intervention for teaching –ed to early school-aged
children. Fey and Finestack (2008) proposed a framework
for conceptualizing intervention components. The current
intervention is summarized in Table 5. This framework
may serve as a point of reference for clinicians planning to
Calder et al.: Grammar Intervention in Young Children With DLD 311
implement intervention to improve production of –ed for
early school-aged children with DLD. Clear intervention
procedures and maintaining consistent dose throughout the
intervention phase also allow clinicians to replicate findings.
It appears generally that this intervention is less efficacious
for improving grammaticality judgment of –ed, with only
a small intervention effect (0.26) observed. However, a sim-
ilar effect (0.22) was observed for grammaticality judgment
of 3S but not for the production or grammaticality judg-
ment of ’s. Since 3S was not targeted directly but is linguis-
tically related, perhaps improvement for some children was
due to the phonological saliency of /z, s/ compared to –ed
/d, t/, providing a learning advantage to the morpheme when
combined with metalinguistic training.
Conclusions
Results continue to support the efficacy of explicit
grammar interventions to improve –ed marking in early
school-aged children. Future research should continue to
evaluate the efficacy of similar interventions, for example,
using more clinically relevant dosage (e.g., one session per
week). It is also important to determine whether explicit
grammar interventions can improve other aspects of gram-
matical difficulty for younger children with DLD, such
as copula/auxiliary use or wh-questions. Overall, findings
contribute to the understanding of efficacious intervention
procedures for early school-aged children with DLD, sug-
gesting children are able to apply knowledge acquired
through explicit instruction.
Acknowledgments
The authors acknowledge the contribution of an Australian
Government Research Training Program Scholarship in supporting
this research.
The authors thank the specialized school, participants, and
student speech-language pathologists Taylor Gartner, Kelly Mackean,
Jenni Brennan, Becky Balchin, and Siobhan Kavanagh involved
in this study. They also thank Lizz Hill as the blinded assessor and
Karen Smith-Lock for supporting the use of the Grammar Elicitation
Test and sharing intervention sessions to adapt for the purpose of this
study.
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Intervention component Experimental intervention
Children Children with DLD aged 5;10–6;8
Goals Regular past tense (–ed) production and grammaticality judgment
Service delivery 1:1 with a speech-language pathologist in clinical contexts (within
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Appendix A
Checklist for Scoring Intervention Procedure Fidelity
Step Explanation 1/0
1. Explicit teaching Remind the child of the goal of the session.
1a. Activate prior knowledge ❒
1b. Explain goals ❒
ACTIVITY 1
2. Check vocabulary Child asked to label materials from session linked to subject/object nouns ❒
3. Goal Demonstrate 3× SV/O sentences using one exemplar from each of the allomorphic categories.
Introduce “left down arrow cues” each alongside its corresponding shape.
❒
4. Practice 25 trials to produce past tense –ed with systematic cueing
4a. Coding Lay large shapes on the floor and student to use as cues to produce SV/O sentences. ❒
4b. Trials 22–28 trials achieved ❒
4c. Cueing Are errors cued appropriately? ❒
5. Consolidation At the end of the session, review the 3× SV/O sentences using one exemplar from each of the
allomorphic category.
5a. Comprehension task Student to produce subjects, verbs, and objects following comprehension questions ❒
5b. Production Student says phrase ❒
5c. Repeat without shapes Student says phrase (cue as necessary) ❒
ACTIVITY 2
6. Check vocabulary Child asked to label materials from session linked to subject/object nouns ❒
7. Goal Demonstrate 3× SV/O sentences using one exemplar from each of the allomorphic categories.
Introduce “left down arrow cues” each alongside its corresponding shape.
❒
8. Practice 25 trials to produce past tense –ed with systematic cueing
8a. Coding Lay large shapes on the floor and student to use as cues to produce SV/O sentences. ❒
8b. Trials 22–28 trials achieved ❒
8c. Cueing Are errors cued appropriately? ❒
9. Consolidation At the end of the session, review the 3× SV/O sentences using one exemplar from each of the
allomorphic category.
9a. Comprehension task Student to produce subjects, verbs, and objects following comprehension questions ❒
9b. Production Student says phrase ❒
9c. Repeat without shapes Student says phrase (cue as necessary) ❒
10. Summarize Remind the child of the goal of the session. ❒
Total: /19
Percentage accuracy: %
Note. SV/O = subject–verb–object.
Calder et al.: Grammar Intervention in Young Children With DLD 315
Appendix B
List of Supplemental Materials
S1: Expressive raw scores of participants on trained past tense verbs within-session.
S2: Expressive raw scores of participants on trained past tense verbs between-session.
S3: Expressive raw scores of participants on untrained past tense verbs.
S4: Expressive scores of participants on third-person singular (extension).
S5: Summary of Tau-U analyses for expressive repeated measures baseline versus treatment phase contrasts on untrained
third-person singular targets (extension).
S6: Graph of % correct on expressive third-person singular repeated measures (extension).
S7: Expressive raw scores of participants on possessive ’s (control).
S8: Summary of expressive repeated measures baseline versus treatment phase contrasts on untrained possessive ’s
targets (control).
S9: Graph of % correct on expressive possessive ’s repeated measures (control).
S10: Grammaticality judgment raw scores of participants on trained past tense verbs within session.
S11: Grammaticality judgment raw scores of participants on trained past tense verbs between-session.
S12: Grammaticality judgment raw scores of participants on untrained past tense verbs.
S13: Summary of grammaticality judgment repeated measures baseline versus treatment phase contrasts on trained and
untrained targets.
S14: Graph of % correct on grammaticality judgment within-session repeated measures.
S15: Graph of % correct on grammaticality judgment between-session repeated measures.
S16: Graph of % correct on expressive untrained repeated measures.
S17: Grammaticality judgment raw scores of participants on third-person singular (extension).
S18: Summary grammaticality judgment repeated measures baseline versus treatment phase contrasts on untrained
third-person singular targets (extension).
S19: Graph of % correct on grammaticality judgment third-person singular repeated measures (extension).
S20: Grammaticality judgment raw scores of participants on possessive ’s (control).
S21: Summary of grammaticality judgment repeated measures baseline versus treatment phase contrasts on untrained
possessive ’s targets (control).
S22: Graph of % correct on grammaticality judgment possessive ’s repeated measures (control).
316 Language, Speech, and Hearing Services in Schools • Vol. 51 • 298–316 • April 2020
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